key: cord-300656-56sd6pnn authors: welle, luke; medoro, amanda title: tainted hand sanitizer leads to outbreak of methanol toxicity during sars-cov-2 pandemic date: 2020-07-08 journal: ann emerg med doi: 10.1016/j.annemergmed.2020.07.011 sha: doc_id: 300656 cord_uid: 56sd6pnn nan tainted hand sanitizer leads to outbreak of methanol toxicity during sars-cov-2 pandemic to the editor, we feel it is timely to notify the membership of an emerging public health crisis which parallels the ongoing fight against the sars-cov-2 virus. the coronavirus pandemic has resulted in a severe supply-demand mismatch of many products, particularly personal protective equipment and sanitization products. consumers and healthcare entities alike are turning to alternative sources including the online marketplace to purchase products for workplace and personal safety. instances of misrepresented materials purchased by governments and healthcare systems have become frequent in the news. the most recent example in the american southwest is an outbreak of methanol poisonings from tainted hand sanitizer products. hand sanitizers typically containing high concentrations of ethanol or isopropanol have become increasingly recognized as a substance of abuse due to low cost and availability relative to conventional drinking alcohols. 1 hand sanitizer products have recently been indicated in methanol poisonings causing blindness in two and death in seven new mexicans. although methanol outbreaks are historically well-established, associations to hand sanitizer consumption have been poorly reported in the peer-reviewed literature. outbreaks tend to occur when access to alcohol is limited as seen in the prohibition-era and in resource-poor populations turning to alternative alcohol sources. 2 the food and drug administration issued an advisory on 6/19/2020 to notify the public about the dangers of nine formulations of hand sanitizers marketed by a manufacturer in mexico. these products were found to contain up to 81% methanol, which was not listed as an ingredient. 3 at the time of letter submission, our cases appear to align with hand sanitizer consumption, but not to products specifically identified thus far by the food and drug administration. 4 as such, non-commercial sources of hand sanitizer and drinking alcohol are also being considered. emergency physicians must have a heightened awareness for methanol toxicity in at-risk populations given the possibility of this outbreak to spread geographically in this time of the online marketplace and heightened product demand. methanol toxicity has been observed in doses as small as 15 ml and may lead to blindness and death if not promptly treated. since methanol is less lipophilic than ethanol, toxicity can present without the typical intoxicating features of ethanol. an anion gap metabolic acidosis is commonly seen in large ingestions, but like serum osmolar gap, does not rule out toxic alcohol poisoning. 5 as soon as the diagnosis is suspected, treatment with fomepizole in tandem with poison center consultation is imperative. ethanol is second-line for treatment when fomepizole is unavailable and has been shown to improve prehospital outcomes with hemodialysis often necessary for toxin elimination. 2, 5 the rising incidence of intentional ingestion of ethanol-containing hand sanitizers use of out-of-hospital ethanol administration to improve outcome in mass methanol outbreaks fda advises consumers not to use hand sanitizer products manufactured by eskbiochem. u.s. food & drug administration we urge the emergency medicine community to remain vigilant to this developing threat. key: cord-320862-ua69gcxv authors: giacalone, serena; bortoluzzi, paolo; nazzaro, gianluca title: the fear of covid‐19 infection is the main cause of the new diagnoses of hand eczema: report from the frontline in milan date: 2020-05-20 journal: dermatol ther doi: 10.1111/dth.13630 sha: doc_id: 320862 cord_uid: ua69gcxv nan the center for disease control and prevention (cdc) asserted that hand washing and surface decontamination are primary measures to reduce covid-19 propagation [1] . in parallel, recent studies revealed an increased incidence of hand eczema (he) in health care workers [2] , as well as among general population [3] . during the period corresponding to italian lockdown, from march 9 to may 4 2020, 24 cases of new he were detected (the equivalence of 11.8% -24/203-of all urgent and deferred consultations provided by our dermatologic unit) [4] . women exceed male (17 vs 7) and the median age was 51 (range 16-63). the diagnosis was made on history and clinical observation: irritant contact dermatitis (icd) prevailed on allergic contact dermatitis (acd), that was suspected in 5 people. about 13 patients (54.1%) complained occasionally itching. none of the patients was a health care worker. detailed anamnesis revealed that all of them washed hands more than 10 times a day and used often alcohol gel sanitizing. we asked patients to describe their hygiene routine and emerged some repetitive and obsessive actions not required by proper procedures. for example, more than one reported to use gel sanitizing after hand washing with soap. others believed that hot water or harsh soap are strategies more effective for virus inactivation. more than two-thirds used cleaners without gloves. moreover, 15 patients (62.5%) asserted during the visit to be particularly anxious about possible contagious of relatives. in regard of suspicious cases of acd we reported some common aspects: fragrance and/or quaternary ammonium-presenting sanitizers, long term or additional layers latex gloves used. this group of patients is waiting to perform patch tests. fourteen patients received 1-week treatment with 0.1% betamethasone plus 2% fusidic acid bid. the remaining ten patients were suggested two or three daily applications of reparative hand cream this article is protected by copyright. all rights reserved. mainly composed by shea butter, stearic acid, ceramide 3 and cholesterol. after three weeks, most of them showed an improvement. above all, we focused our attention on giving information about rational of hand hygiene and preventing clinical relapses with daily application of moisturisers in association with barrier creams [5] . on may 4, a new government decree came into force replacing the strict lockdown rules and giving people back more liberties. our dermatological unit hypothesizes a rising incidence of cutaneous adverse effect related to hygiene measures. because it has been demonstrated that a damaged skin barrier could be a gateway for covid-19 [6] , to preserve a high compliance in cdc actions recommended for the prevention of person-to-person viral transmission, dermatologist have the role to educate people to maintain "healthy hands". this article is protected by copyright. all rights reserved. coronavirus disease 2019 how to protect yourself & others skin damage among healthcare workers managing coronavirus disease-2019 overzealous hand hygiene during covid 19 pandemic causing increased incidence of hand eczema among general population what is the role of a dermatologist in the battle against covid-19? the experience from a hospital on the frontline in milan interventions for preventing occupational irritant hand dermatitis tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis legend fig 1. hand eczema in 16 years old women before (a) and after (b) two weeks of hand cream application twice daily and interruption of excessive washing key: cord-333840-r5bfebsp authors: alzyood, mamdooh; jackson, debra; aveyard, helen; brooke, joanne title: covid‐19 reinforces the importance of handwashing date: 2020-05-14 journal: j clin nurs doi: 10.1111/jocn.15313 sha: doc_id: 333840 cord_uid: r5bfebsp nan are not available is the first line of defence in stopping the spread of infection (cdc 2020) . there is ample evidence, however, that many years before the epidemic handwashing among healthcare workers (hcw) remained an area that needed improvement (cdc 2019, erasmus et al., 2010) . our hands are a critical vector for transmitting microorganisms (edmonds-wilson, nurinova, zapka, fierer, & wilson, 2015) . the cross-transmission of these organisms to others occurs when we fail to wash hands effectively. within healthcare systems and services, there have been almost continual awareness campaigns in place to encourage handwashing among health service personnel, patients and visitors. for instance, the international campaign, "my five moments for hand hygiene" defines the key moments at which hcws should comply with hygiene rules while making contact with patients or their surroundings (sax et al., 2009) . the "cleanyourhands campaign" was a national campaign launched in the uk aiming to reduce the risk associated with hospital-acquired infections via enhanced hand hygiene compliance among hcws (stone et al., 2012) . the campaign included a message "it's ok to ask" to encourage patients to ask hcws to wash their hands (stone et al., 2012) and supports patient involvement to prompt handwashing and to work together with nurses and other hcws to reduce the transmission of infection (alzyood, jackson, brooke, & aveyard, 2018) . the current covid-19 pandemic has seen a focus of education and information on handwashing aimed both at people working within the health sector as well as to the general public. there has been a proliferation of public health messages through various sources about the importance of handwashing, and the correct techniques for handwashing. memes and short videos aimed at reaching people on their handheld devices, as well as through social media, and mainstream television, radio, print ads and billboards are all in use, and all with the same message that effective handwashing is crucial to stopping the spread of covid-19. in addition to a greater presence on social media platforms and other advertising outlets, the importance of handwashing is now frequently seen on daily news reports, as handwashing initiatives are taken on by service users, politicians, public figures and many others. it is commendable to see greater and more widespread efforts to raise handwashing awareness and a notable increase in people speaking up and talking about the importance of handwashing. as nurses, we are aware that handwashing has not always been taken as seriously as it should, with compliance and adherence in clinical settings far from optimal over time (bezerra et al., 2020; pittet, 2001) . multiple reports from different countries have shown that hand hygiene compliance rate has been estimated at only 40% (erasmus et al., 2010) while the rate of adherence in critical care units was only 46.25% (bezerra et al., 2020) . although this is a simple and lifesaving task, it is not, regrettably, always undertaken (doronina, jones, martello, biron, & lavoie-tremblay, 2017) . the current pandemic has made handwashing the focus of attention. we must now ensure that this focus continues. once this pandemic is over, nurses must continue to promote handwashing with the same enthusiasm and commitment not only within the healthcare arena but widely throughout communities and populations. the significant growth of interest in promoting handwashing behaviours since the start of covid-19 pandemic should be harnessed and continued well after this outbreak is contained. thus, nurses can support the protection of their communities against this and the many other infectious agents that pose a threat. an integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting adherence to hand hygiene in critical sectors: can we go on like this hand hygiene in healthcare settings covid-19): faq on hand hygiene a systematic review on the effectiveness of interventions to improve hand hygiene compliance of nurses in the hospital setting review of human hand microbiome research systematic review of studies on compliance with hand hygiene guidelines in hospital care improving adherence to hand hygiene practice: a multidisciplinary approach the world health organization hand hygiene observation method evaluation of the national cleanyourhands campaign to reduce staphylococcus aureus bacteraemia and clostridium difficile infection in hospitals in england and wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study key: cord-270313-k0cj209s authors: erdem, yasemin; altunay, ilknur kivanc; aksu çerman, aslı; inal, sena; ugurer, ece; sivaz, onur; kaya, hazel ezgi; gulsunay, ilayda esna; sekerlisoy, gul; vural, osman; özkaya, esen title: the risk of hand eczema in healthcare workers during the covid‐19 pandemic: do we need specific attention or prevention strategies? date: 2020-06-07 journal: contact dermatitis doi: 10.1111/cod.13632 sha: doc_id: 270313 cord_uid: k0cj209s nan china in late 2019. apart from the respiratory droplets, contact transmission was announced to play an important role both in the spreading of the disease. therefore, hand hygiene became an important building block for prevention; who has recommended using water and soap, or alcohol-based hand disinfectant before and after the contact with patients and/or their body fluid. 1 independent from covid 19, healthcare workers (hcw) have an increased risk for hand eczema (he). 2.3 skin damage due to intensive hand hygiene measures during the covid-19 pandemic in hcw has recently been reported, 4, 5 as well as he among hcw during the pandemic. 5 therefore, we aimed to investigate the frequency, risk factors, and clinical features of he among healthcare workers during the covid-19 pandemic. between may 15 to 25, 2020, a total of 107 hcw involved in covid-19 patient care units of our hospital were enrolled to the study. all individuals were examined by a team of dermatologists. demographic and clinical findings were filled in a detailed form. hand eczema severity index (hecsi) scoring system was used in the standardization of he severity. 6 he was detected in 54 of 107 (50.5%) participants. the overall demographic and clinical parameters, and the comparison of these parameters between groups with and without he are summarized in online supplemental table 1a (table 3) . moisturizing hand cream was used in 26 (57.8%) patients before, and in 36 (80%) patients after the development of he. topical corticosteroids were used only in 16 (35.6%) after he has developed. the frequency of handwashing and the use of alcohol-based disinfectants did not change before and after he (table 1b) . the frequency of he was 50.4% among healthcare workers at covid-19 patient care units in this study. the he prevalence in pre-covid-19 era varied between 12%-50%. 2, 7 lan et al reported a high share of 70.4% hand skin damage due to frequent hand hygiene and longer times of using gloves in healthcare workers managing covid-19. 4 recently, guertler et al published a questionnaire-based study among healthcare workers at covid-19 units. the vast majority of the study population (90.4%) reported symptoms associated with acute hand dermatitis whereas the prevalence of selfreported he was only 14.9%. 5 previous reports have demonstrated that personal or familial atopy, >20 handwashing per day, using occlusive gloves, and long working years are independent risk factors for he. 3 on the other hand, he frequency was lower in individuals using moisturizers, and the use of moisturizers has been recommended for preventing he. 3, 8 the increased risk of he with frequent handwashing >20 per day was in line with the literature from pre covid-19 era. in contrast to the literature, however, the increased use of moisturizing hand cream was independently associated with he in the present study. this might suggest that patients with he used moisturizing creams with a therapeutic intent after the development of he, rather than for prevention. it was interesting that only 1/3 of patients used topical corticosteroids after the development of he, and that a majority (80%) increased the frequency of moisturizer use instead. although the use of moisturizers before he development was reported as 57.8% among patients with he, we cannot assume whether the moisturizs had been used appropriately. the limitation of this study was its small sample size. however, the diagnosis of he based on dermatological examination during covid-19 pandemic was the strength of the study. in conclusion, because hand hygiene is one of the key factors to prevent covid-19 transmission, preventive strategies are rapidly needed in order to reduce he risk related to hand hygiene. this article is protected by copyright. all rights reserved. online supplemental table 1a .94 online supplemental history of hand eczema in the past year <.001 18. 5 3.82-89.9 prevalence of hand dermatitis in inpatient nurses at a united states hospital prevalence and risk factors of hand eczema in hospitalbased nurses in northern china skin damage among healthcare workers managing coronavirus disease-2019 onset of occupational hand eczema among healtcare workers during the sars-cov-2 pandemic-comparing a single surgical site with a covid-19 intensive care unit. contact dermatitis the hand eczema severity index (hecsi): a scoring system for clinical assessment of hand eczema. a study of inter-and intraobserver reliability hand eczema among healthcare professionals in the netherlands: prevalence, absenteeism, and presenteeism guidelines for diagnosis, prevention and treatment of hand eczema clinical characteristics of hand eczema ⁋ according to patient's history of a confirmed diagnosis by patch testing in the past hecsi: hand eczema severity index §hecsi 0-11 points: mild eczema, 12-27 points: moderate eczema dyshidrotic/vesicular, n (%) erythema-squamatous, n (%) hyperkeratotic/rhagadiform, n (%) combined morphology, n (%) localizations palm, n (%) dorsum, n (%) finger webs, n (%) sides of finger, n (%) periungual eczema and nail eczema, n (%) key: cord-284532-b6tsjmfs authors: thampi, n.; longtin, y.; peters, a.; pittet, d.; overy, k. title: it’s in our hands: a rapid, international initiative to translate a hand hygiene song during the covid-19 pandemic date: 2020-05-06 journal: j hosp infect doi: 10.1016/j.jhin.2020.05.003 sha: doc_id: 284532 cord_uid: b6tsjmfs nan sir, the novel coronavirus disease-2019 (covid-19) continues to affect the global community deeply and rapidly, with more than 200 countries impacted at the time of writing (may 2, 2020). in order to manage the extent of this pandemic, there is a need to develop, disseminate and implement infection prevention and control strategies in both healthcare settings and the community. early on in the outbreak, there were general recommendations to frequently wash hands to reduce the spread of infection. with the current, relentless global scale of covid-19, international compliance with handwashing frequency and technique is more important than ever. a prominent strategy to improve hand hygiene, developed by the world health organization (who), includes an effective six-step handwashing technique and has led to broad uptake through the use of a multimodal approach; however encouraging consistent compliance can be challenging [1] . in addition to needing to remember all six steps of the technique and needing to wash hands for the required duration of time, there can be a lack of awareness regarding the importance of handwashing technique on reducing the microbial burden on hands. this lack of awareness may not be surprising, as most hand hygiene promotion campaigns focus on indications for action ("when to clean hands") rather than on technique ("how to clean hands") [2] . thus, continuing to promote correct handwashing technique is currently of utmost importance to the world population, especially given the disproportionate burden of covid-19 on older adults, and emerging evidence of asymptomatic shedding [3, 4] . in order to assist children with remembering the effective six-step technique, we recently published a musical mnemonic to the tune of the well-known nursery rhyme frère jacques, or brother john [2, 5] . this memory aid reinforces inclusion of all six handwashing steps using self-instruction, via engaging with the familiar melody and singing (or imagining singing) the lyrics ( figure 1a ). in the context of the 3/6 evolving covid-19 pandemic, the near-ubiquitous melody of brother john provided an opportunity for international, interdisciplinary collaboration to translate and rapidly disseminate the musical mnemonic globally. on 19 th march, drawing on our combined network of music neuroscience researchers, music education specialists and healthcare professionals, we invited approximately 40 international colleagues to create a new version of the handwashing song that a) included all six who handwashing steps; b) worked musically in the new language; and c) had been checked by a healthcare professional for accuracy. each translator was also invited to submit an audio or video file of the translated song. we brother john is an ideal tune to use in this context: it is widely known across cultures; the melody involves very simple, repeating patterns; the vocal range centres around a small interval of a sixth (e.g. middle c to a), which is easy to sing even by non-musically trained individuals; and the duration, when sung at a steady tempo, is between 20 and 25 seconds. singing is a highly sequential, structured activity and has been used throughout history to remember text or coordinate movement, from ballads and religious scriptures to work songs and children's action songs. experimentally, music has been shown to facilitate verbal and motor learning in a variety of contexts, likely using neural resources shared between music, language and motor networks [6] [7] [8] . in practice, we have observed that, once the handwashing song becomes highly familiar through repetition and rehearsal, a missed step is immediately noticed, leading to important self-correcting behavior. a clear advantage of this six-step handwashing song is that it highlights the importance of correct technique, in addition to the recommended 20-second duration (such as singing "happy birthday" twice, another popular approach). a demonstration, prior to introducing the song, will ensure full understanding of each step. in launching these translated songs during a pandemic that underlines our global interconnectedness, and to highlight 2020 world hand hygiene day on 5 th may, we have made these songs available at www.cleanhandssavelives.org/hand-washing-song/, hoping this mnemonic will inspire individuals to take matters into their own hands and reduce their risk of acquiring or spreading covid-19. music is known to have the capacity to entertain, bring joy and be a powerful, positive shared experience; the 28 languages included here allow access to this musical mnemonic to more than half of the world's population in their native language. global implementation of who's multimodal strategy for improvement of hand hygiene: a quasi-experimental study hygiene: why, how & when? in: who characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention virological assessment of hospitalized patients with covid-2019 longtin y wash your hands cognitive and neural mechanisms underlying the mnemonic effect of songs after stroke singing can facilitate foreign language learning schaefer rs auditory rhythmic cueing in movement rehabilitation: findings and possible mechanisms figure 1: who six-step handwashing technique 1 and handwashing song lyrics, set to the tune of brother john. (a) visual handwashing aid, lyrics and musical notes for each step. figure (b) 28 translations of the handwashing song additional thanks go to tom howey for the figures and to giuliano avanzini and maria majno for sparking and facilitating this initiative, respectively. a b key: cord-320133-q26jiv17 authors: sadr, mr a h; gardiner, miss s; burr, mrs nikki; nikkhah, mr d; jemec, miss barbara title: managing hand trauma during the covid-19 pandemic using a one-stop clinic date: 2020-05-22 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.05.026 sha: doc_id: 320133 cord_uid: q26jiv17 nan short correspondence: jpras the covid-19 pandemic has shifted clinical priorities and resources from elective and trauma hand surgery with general anaesthesia (ga) to treat the growing number of covid patients. at the time of this correspondence, the pandemic has affected over 2 million people resulting in 129045 deaths worldwide, with 12868 uk deaths, with numbers still climbing. this has particularly affected our hand trauma services which serves north london, a population of more than 2 million. we receive referrals from a network of 8 hospitals in addition to 3 emergency departments of the royal free group of hospitals and numerous gp practices and urgent care centres. in the first week following the british government lockdown, which commenced march 23rd, we experienced a 75% drop in referrals, from 25 to 6 a day. subsequently, numbers have been steadily rising to 12-14 a day by 6 th of april. the british association of plastic, reconstructive and aesthetic surgeons, the british society for surgery of the hand and the royal college of surgeons of england, have all issued guidance: both encouraging patients to avoid risky pursuits, which could result in accidental injuries and to members how to prioritise and optimise services for trauma and urgent cancer work. we have adapted our hand trauma service to a 'one stop hand trauma and therapy' clinic, where patients are assessed, definitive surgery performed and offered immediate post-operative hand therapy where therapists make splint and give specialist advice on wound care and rehabilitation including an illustrated hand therapy guide. patients are categorised based on the bssh hand injury triage app. we already have a specific 'closed fracture' hand therapy led clinic, to manage the majority of our closed injuries. we combined this clinic with the plastic surgeons' led hand trauma clinic, and improved its efficiency further by utilising the mini carm fluoroscope within the clinic setting. this enabled us to immediately assess fractures and perform fracture manipulation under simple local anaesthesia. we have successfully been able to perform 95% of our operations for hand trauma under wide awake local anaesthesia no tourniquet (walant) (1). prior to the pandemic, we used walant for selected elective and trauma hand surgical cases. in infected cases, where local anaesthesia is known to be less effective, we have used peripheral nerve blocks. previous data showed 50% of our trauma cases were conducted under ga, 33% under la, and 17% under brachial or peripheral nerve blocks (2). we have specifically modified our wound care information leaflets to minimise patient hospital attendance. afterwards patients receive further therapy phone consultations and encouragement to use the hand therapy exercise app developed by the chelsea and westminster hand therapists. the patient is given details of a designated plastic surgery nhs trust email address, for direct contact with the plastic surgery team: for concerns, questions and transfers of images. we have to date received 39 emails, of which 21 have been from patients directly, and the remainder from referring healthcare providers. the majority of inquiries are followed up via a telephone consultation and only complex cases or complications, attend face-to-face follow-up. this model has successfully combined assessment, treatment and post-op therapy into a one-stop session, which has greatly limited patient exposure to other parts of the hospital, such as the radiology and therapy departments. the other benefit of such clinic is an improved outcome through combined decision making (3) . there is also a cost saving benefit compared to our traditional model of patient care. we have treated 31 patients based on this model so far, who have been suitable for remote monitoring. on average we have saved 2 plastics dressing clinic (pdc) visits for wound checks per patient, as a very minimum. we have previously calculated the cost of pdc at our centre at £155 per visit (4) and for our 31 patients this translates to an approximately saving of £9000 per month just on pdc costs. if 30 patients each month could be identified for remote monitoring, this could potentially lead to an annual saving of more than £110,000. in addition, the estimated cost-saving by converting the mode of anaesthesia from ga to walant has been shown to cause a 70% reduction (5) . how the wide awake tourniquet-free approach is changing hand surgery in most countries of the world.lalonde dh, tang jb. hand clin hand trauma service: efficiency and quality improvement at the royal free nhs foundation trust one -stop" clinics in the investigation and diagnosis of head and neck lumps the implications of cosmetic tourism on tertiary plastic surgery services; the need for a national reporting database cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures the concept of a one-stop clinic has already been successfully implemented in the treatment of head & neck tumours, following introduction of nice guidelines in 2004 (3) and the covid-19 pandemic has made us redesign a busy metropolitan service for hand injuries along the same lines. we believe this model is a good strategy and combining this with more widespread use of the walant technique, technology such as apps and telemedicine, as well as encouraging greater patient responsibility in their post-operative care and rehabilitation; is the way forward.we hope sharing this experience will result in improved patient care at this time of crisis. key: cord-271360-2s6h4u8p authors: gon, giorgia; dancer, stephanie; dreibelbis, robert; graham, wendy j.; kilpatrick, claire title: reducing hand recontamination of healthcare workers during covid-19 date: 2020-04-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.111 sha: doc_id: 271360 cord_uid: 2s6h4u8p nan to the editor-worldwide, the response to the covid-19 pandemic requires hand hygiene compliance by everyone, as highlighted in the who #safehands campaign and numerous documents. hand hygiene is particularly critical for frontline healthcare workers (hcws) who are overstretched and for whom this key routine task must be easy to complete and effective. 1 however, a neglected aspect of hand hygiene, even in the absence of a global pandemic, is the risk of touching surfaces or objects that could recontaminate hands after hand rubbing or washing, whether gloves are worn or not. infection prevention is key during this pandemic, and reducing hand recontamination is important to ensuring patient and hcw safety at all times. avoiding recontamination is implicit in the who hand hygiene guidelines for health facilities. 2 failure to comply with hand hygiene can result from not washing or rubbing hands at the right time or from subsequent hand or glove recontamination. in a recent study in tanzania during which 781 hand hygiene indications were observed, approximately half of the times when birth attendants rubbed or washed their hands, they then recontaminated their hands on potentially unclean surfaces before performing an aseptic procedure. 3 similar findings come from obstetric wards in nigeria and ghana. 4, 5 recontamination is not only a problem in low-income settings. a us study demonstrated microbiological recontamination of hands at the point of care despite high levels of self-reported hand hygiene compliance. 6 reports from the united kingdom and australia show that hcws touch privacy curtains between hand hygiene and touching a patient. 7 the tanzanian study also suggested that hand rubbing or washing and glove recontamination are underpinned by different behavioral determinants. 8 without targeting these 2 behaviors separately, hand hygiene initiatives during this pandemic may be undermined. hcws are able to prioritize patient needs when providing routine care. however, the covid-19 pandemic has introduced significant uncertainty into the care environment and thus workflow, including timing of necessary procedures, anticipating and managing patient volumes, and rapidly evolving guidelines on patient management. during this crisis, hand hygiene, along with other infection control activities, may be compromised, not because it is not a priority but rather because staff may be too busy or uncertain on how to implement hand hygiene in this outbreak setting. in their ethnography of infection prevention in australia, hor et al 9 state that understanding the "boundaries of what is clean" is not straightforward in hospital departments and that hcws have different perceptions over whether certain surfaces could potentially lead to cross transmission. recontamination may be an indication that staff fail to understand the definition of the who hand hygiene recommendations or how those apply in rapidly changing healthcare settings. 3 an understanding of surfaces that are safe to touch depend upon assumptions about appropriate cleaning of surfaces, cleaning frequencies, established methods, and sufficient trained cleaning staff. in spite of amazing efforts from all staff, including environmental cleaning staff, standards are not always optimal in the united kingdom, as in many other countries. 10 surface contamination played a plausible role in sars, mers, and pandemic influenza transmission in healthcare settings. emerging evidence suggests that the virus responsible for the current pandemic (sars-cov-2) can survive on common surfaces for days, but viral demographics and characteristics have yet to be sufficiently studied. 11 recontamination of hands is a consequence and a source of poor surface cleanliness (fig. 1, steps 5 and 7) . we call for greater attention to the risk from hand recontamination and the opportunity for its prevention through empowering hcws and strengthening cleaning of the care environment. for those managing covid-19 cases, these actions will improve their own and coworkers' safety as well as that of all patients and visitors. like so much in the covid-19 response, behavior change plays a key part. behavior change needs to be tailored and targeted. following michie's principles for behavior change during the covid-19 pandemic, 1 we recommend the following: fig. 1) , in relation to hand hygiene, especially before a clean or aseptic procedure. 2. social norms: managers and their colleagues should lead by example by demonstrating appropriate hand hygiene including avoiding recontamination. hand hygiene protocols should be followed by everyone involved in patient care. 3. emotion: the importance of recontamination in patient and hcw safety needs to be clearly emphasized. 4. replace the behavior to stop the habit: "keep hands off unsafe surfaces" rather than "do not touch unsafe surfaces." 5. make it easy: create a user-friendly environment that facilitates hand hygiene and reduces opportunities for recontamination. the environment needs to account for the workflow for patient management, allowing for minimal opportunities to recontamination when collecting equipment or moving between patients. the environment should also include appropriate cues to remind and trigger hand hygiene, such as strategic placement of handrub dispensers. slowing down the covid-19 outbreak: changing behaviour by understanding it who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care hand washing, glove use, and avoiding recontamination before aseptic procedures at birth: a multicenter time-andmotion study conducted in zanzibar hygiene during childbirth: an observational study to understand infection risk in healthcare facilities in kogi and ebonyi states, nigeria obstetric infection control in a developing country hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission antimicrobial resistance & infection control website behavioural determinants of hand washing and glove recontamination before aseptic procedures at birth: a timeand-motion study and survey in zanzibar labour wards beyond hand hygiene: a qualitative study of the everyday work of preventing cross-contamination on hospital wards measuring the effect of enhanced cleaning in a uk hospital: a prospective cross-over study aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 key: cord-334377-khqvezmu authors: ling, moi lin; how, kue bien title: impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections date: 2012-03-23 journal: antimicrob resist infect control doi: 10.1186/2047-2994-1-13 sha: doc_id: 334377 cord_uid: khqvezmu background: during the severe acute respiratory syndrome (sars) outbreak, high compliance in healthcare workers to hand hygiene was primarily driven by fear. however, the post-sars period confirmed that this practice was not sustainable. at the singapore general hospital, a 1,600-bedded acute tertiary care hospital, the hand hygiene program was revised in early 2007 following singapore's signing of the pledge to the world health organization (who) "clean care is safer care" program. findings: a multi-prong approach was used in designing the hand hygiene program. this included system change; training and education; evaluation and feedback; reminders in the workplace; and institutional safety climate. hand hygiene compliance rate improved from 20% (in january 2007) to 61% (2010). improvement was also seen annually in the compliance to each of the 5 moments as well as in all staff categories. healthcare-associated mrsa infections were reduced from 0.6 (2007) to 0.3 (2010) per 1000 patient-days. conclusions: leadership's support of the program evidenced through visible leadership presence, messaging and release of resources is the key factor in helping to make the program a true success. the hospital was recognised as a global hand hygiene expert centre in january 2011. the who multi-prong interventions work in improving compliance and reducing healthcare associated infections. the who multimodal hand hygiene improvement strategy comprising a guide to implementation and a range of tools constructed to facilitate implementation of each component was used in a 1600-bedded acute tertiary care general hospital in singapore [1] . the objective is to change healthcare workers' behavior and improve hand hygiene compliance. during the severe acute respiratory syndrome (sars) outbreak in 2003, a high compliance of close to 90% in healthcare workers to hand hygiene was achieved. however, this was primarily driven by fear for transmission of pathogens to self. following the closure of the sars outbreak globally, we noted that the hand hygiene compliance decreased to that of the baseline before the sars outbreak i.e. the high hand hygiene compliance was not sustainable. the hand hygiene program was revised in early 2007 following singapore's signing of the pledge to the world health organization (who) "clean care is safer care" program. the multi-prong approach used includes: (v/v) in the procurement of hand hygiene alcohol hand products. this implies the use of a higher content of alcohol than before. from july 2009, 4% chlorhexidine handwash agent bottles were removed from the clinical areas except for the operating theatres, endoscopy unit and treatment rooms. this was done to reduce the incidence of dryness or skin irritation resulting from concomitant use of both alcohol and chlorhexidine [1] . hand moisturizer was provided freely for healthcare workers' use. they are encouraged to use it as often as possible to protect their hands. a. who training dvds were used to illustrate clinical scenarios of hand hygiene opportunities to all healthcare workers. although these were in french, they provided clear teaching on the 5 moments to the staffs. b. creative educational tools were also used to teach healthcare attendants and junior nurses. teddy bears dusted with glo-germ were used as patient models in teaching healthcare workers the importance of hand hygiene as well as the who 5 moments (figure 1 ). c. powerpoint slides with detailed explanation of the 5 moments were created for doctors, nurses and allied health. these were uploaded on the hospital intranet for easy access by the staffs. 3. evaluation and feedback: feedback surveys are conducted annually amongst staffs to gather feedback and comments on products used or issues faced during practice. the last survey done in november 2010 confirmed that the use of posters have helped to remind staffs and public on the messages of hand hygiene. 4. reminders in the workplace: more than 150 posters were designed from march 2007 for display at lifts and walkways (figures 2 and 3) . giant posters on hand hygiene messaging were designed to convey the hospital's commitment to the public (figures 4 and 5) . shuttle ling and how antimicrobial resistance and infection control 2012, 1:13 http://www.aricjournal.com/content/1/1/13 buses, floor surfaces and lift doors are used to display reminders to both staffs and public (figures 6, 7 and 8) . 5. institutional safety climate: leadership's support and commitment was clearly visible at events and meetings. the chief executive officer (ceo) led the hospitals staffs in november 2009 in a pledge of commitment to the hand hygiene program (figure 9 ). hand hygiene compliance rate improved from 20% (in january 2007) to 61% (2010) (figure 10) . improvement was also seen annually in the compliance to each of the 5 moments as well as in all staff categories ( figure 11 and figure 12 ). although hand hygiene compliance was lowest in the doctors category, it is encouraging to note that improvement was also seen year to year in this job category ( figure 12 ). the hand hygiene program was an integral part also of an ongoing mrsa reduction program in the hospital, which includes the implementation of the mrsa bundle. the "mrsa bundle" includes five components of care. this bundle was first introduced by the institute of healthcare improvement (ihi) in 2006 in their "protecting 5 million lives from harm" campaign. it comprised the following elements [3]: most of the elements were routine practices in the hospital except for active surveillance cultures, which were implemented hospital-wide for high risk patient groups from 2008. healthcare-associated mrsa infections were noted to reduce from 0.6 (2007) to 0.3 (2010) per 1000 patient-days ( figure 13 ). leadership's support of the program evidenced through visible leadership presence, messaging and release of resources is the key factor in helping to make the program a true success. the hospital was recognised as a global hand hygiene expert centre in january 2011 ( figure 14) . the use of the who multi-prong interventions is successful in improving hand hygiene compliance with concomitant reduction in healthcareassociated infections. who guidelines on hand hygiene in healthcare guidelines on hand hygiene in healthcare million lives campaign: getting started kit: reduce methicillin-resistant staphylococcus aureus (mrsa) infection how-to guide cambridge, ma: institute for healthcare improvement cite this article as: ling and how: impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections authors' contributions mll was the advisor to the hand hygiene program. kbh was the coordinator in the hand hygiene program. all authors have read and approved this manuscript for publication. we have received support of our hand hygiene program from the following companies: key: cord-325222-wuqekxxc authors: hanna, sandra; zwi, karen; tzioumi, dimitra title: morbidity in the covid‐19 era: ethanol intoxication secondary to hand sanitiser ingestion date: 2020-08-05 journal: j paediatr child health doi: 10.1111/jpc.15017 sha: doc_id: 325222 cord_uid: wuqekxxc nan we report on a 6-year-old child diagnosed with ethanol poisoning due to ingestion of hand sanitiser. this occurred in the midst of the covid-19 pandemic in australia, when public messaging had been to encourage the use of frequent handwashing or hand sanitiser to protect against infection. a 6-year-old girl was brought by her carer to the emergency department (ed) of a local hospital with a decreased glasgow coma scale (gcs), diplopia and slurred speech. the history provided was that about 1 h and 15 min after she had been playing alone, she reported to her mother feeling dizzy and was noted to have slurred speech. her older sister commented that her breath smelled like hand sanitiser. on arrival to ed she vomited twice (described as 'sweet smelling'). she had a patent airway, respiratory rate of 17 breaths/ min, heart rate of 77 beats/min and blood pressure 92/59 mmhg. her gcs was initially 13 (eye response 4, motor response 5, verbal response 4). within 30 min, she had increased vomiting and dropped her gcs to 9 (e2, m4, v3). her pupils were 3 mm bilaterally and responsive to light. she had widespread decreased tone, but no focal neurological deficit. there were no visible injuries on examination. the patient's medical history included one previous seizure at 14 months of age. she had normal development, was fully immunised and was not on any regular medications. venous blood gas revealed a metabolic acidosis (ph 7.31, base excess −2, bicarbonate level 20 mmol/l, lactate 2.5, co2 48); blood sugar level was 7.9 mmol/l. she was hypokalaemic with potassium of 3.3 mmol/l. other electrolytes, full blood count examination, c-reactive protein, kidney and liver function tests, were normal. a non-contrast computed tomography scan of her brain did not reveal an acute intracranial pathology. a toxicology screen, performed due to the non-specific and unexplained presentation, was negative for salicylates and paracetamol. however, her serum ethanol concentration was found to be 41.1 mmol/l or 0.19% (nsw legal blood ethanol limits for driving <10.9 mmol/l or 0.05%). considering the drop in gcs and persistent vomiting, her airway was assessed as being at risk, and she was intubated and ventilated in the ed. she was not clinically assessed to be septic or dehydrated by the treating physicians at the time; however, she was prophylactically treated with one dose of intravenous ceftriaxone and transferred to a tertiary paediatric intensive care unit. her sedation was rapidly weaned, and she was extubated within 3 h of arriving in the intensive care unit. subsequent serum ethanol level performed 6 h later showed a level of 14 mmol/l (0.06%). her gcs returned to 15 and her neurological examination was normal. thorough history obtained from the parent confirmed that there were no alcoholic drinks in the house. once awake, the patient disclosed that she had often tasted the hand sanitiser over the last few months and had done so the previous night. she was unable to report the volume that she consumed but the nsw poisons information centre estimated it to be in the region of 50 ml. she reported liking the smell and taste of the hand sanitiser, which her mother noted had been missing for a few days. the particular brand of hand sanitiser ingested contains between 62 and 70% ethanol, which is standard for most alcohol-based hand sanitisers sold in australia. the child remained well and was discharged home 24 h later. due to the current covid-19 pandemic, alcohol-based hand sanitisers (abhs) have rapidly become commonplace within households, health-care setting, schools, shops and other areas frequented by children. the important message of hand hygiene in reducing the transmission of covid-19 has been widely disseminated. the cdc reports that abhs formulations that contain 80% ethanol or 75% isopropanol work to inactivate sars-cov-2. 1 1 alcohol-based hand sanitisers are appealing in taste and smell to young children and hence dangerous ingestion can occur. 2 paediatric patients presenting with ethanol intoxication need to be closely monitored for potentially life-threatening hypoglycaemia. 3 prevention of unintentional hand sanitiser ingestion in young children through appropriate product safety and enforcement strategies and increased public awareness is required. the nsw poisons centre has seen a two-fold increase in hazardous exposure to hand sanitiser over the 3 months of the pandemic (personal communication, nsw poisons information centre) compared to this time last year. a published review of embase and ovid medline revealed that paediatric ingestion of household products containing ethanol is becoming an increasing occurrence world-wide. 2 there have been two published reports of children requiring intensive care admission after ingestion of abhs, one of whom required intubation and ventilation for airway protection. 3, 4 unfortunately the dangers of abhs in the paediatric population have not been widely disseminated considering the toxic and potentially lethal effects of this easily accessible, everyday product. ethanol intoxication in paediatric patients can pose a clinical challenge and be difficult to identify without an explicit history. absorption and distribution of ethanol in children differ from adults, with the threshold for clinically significant and lifethreatening intoxication far lower. serum ethanol levels of >11 mmol/l or >0.05% can be lethal in children with ethanolinduced hypoglycaemia a key feature. physicians also need to be mindful of any child protection issues including intentional exposures, abuse and neglect. 5 the paediatric population was particularly susceptible to unintentional exposures to abhs, even prior to the pandemic. between 2011 and 2014, 70 669 exposures to both alcohol and non-alcohol-based hand sanitisers were reported to the national poison data system in america. almost all (90%) were among children aged 0-5 years, with the majority through oral ingestion. alcohol rather than non-alcohol-based hand sanitisers accounted for 92% of exposures, and was more likely to be associated with adverse events and worse outcomes. 6 the epidemiology in adults highlights that it is intentional ingestion that has been rising in north america, particularly in people with a history of mental health disorders and substance abuse, with toxic and lethal effects. 7 this is thought to be due to the accessibility and affordability of abhs. in an era where hand hygiene and abhs are critically important, our case highlights that children are able to consume sufficient volume to result in toxic and potentially lethal intoxication. prevention strategies are urgently required. these could include product safety strategies such as child-proof packaging, legislation about taste and smell being used as a deterrent, and health education campaigns to increase public and health professional awareness regarding the importance of keeping these items out of reach of children. the use of a common bittering agent, denatonium benzoate, as an additive to ethylene-based engine coolants and methanol-based windshield washer liquids has been recognised as a method to protect against accidental ingestions of these products. 8 public health strategies to explore similar methods with abhs should be urgently considered whilst we increase public health campaigns to protect children from toxic ingestion. hand hygiene recommendations, guidance for healthcare providers about hand hygiene and covid-19 paediatric ingestions of house hold products containing ethanol: a review alcohol-based hand sanitiser: a potentially fatal toy acute ethanol poisoning in a 4-year-old as a result of ethanol-based hand-sanitizer ingestion ethanol intoxication of young children reported adverse health effects in children from ingestion of alcohol-based hand sanitizers-united states the rising incidence of intentional ingestion of ethanol-containing hand sanitizers bittering agents: their potential application in reducing ingestions of engine coolants and windshield wash the authors acknowledge genevieve adamo, senior specialist in poisons information, nsw poisons information centre. key: cord-273021-9t66ygoj authors: prsic, adnan; boyajian, michael k.; snapp, william k.; crozier, joseph; woo, albert s. title: a 3-dimensional-printed hand model for home-based acquisition of fracture fixation skills without fluoroscopy date: 2020-06-19 journal: j surg educ doi: 10.1016/j.jsurg.2020.05.027 sha: doc_id: 273021 cord_uid: 9t66ygoj objective: to design a low cost ($40), realistic and fluoroscopy-free percutaneous kirschner wire hand fracture fixation training instrument kit for home-based skill acquisition during the covid-19 pandemic. design: a 3d-printed hand was designed from a computed tomography scan of a healthy hand. these data were used to create replaceable hand and wrist bones and reusable silicone molds for a replica of the soft tissue envelope. the model is currently being integrated into the simulation curriculum at 2 integrated plastic surgery residency programs for training in percutaneous wire fixation of hand fractures. setting: brown university, warren alpert medical school of brown university. department of surgery, division of plastic and reconstructive surgery. large academic quaternary referral institution. yale university, yale school of medicine. department of surgery, division of plastic and reconstructive surgery. large academic quaternary referral institution. participants: pgy 1-4 plastic surgery residents preparing to meet acgme accreditation for graduate medical education hand surgery specific milestones. results: a realistic and durable 3d model with interchangeable bones allows trainees to practice the key motor skills necessary for successful fixation of hand and wrist fractures with k-wires in a home-based setting. conclusions: a low cost, realistic and durable 3d hand model with interchangeable bones allows easy integration into any home-based hand surgery curriculum. with 3d printers and programming becoming more prevalent and affordable, such models offer a means of low-cost and safe instruction of residents in fracture fixation with no harm to patients. graduated responsibility is the hallmark of modern-day surgical training. however, with increasing restrictions on work-hours, an increasing percentage of graduating residents lack adequate readiness for the work force. 1 given the covid-19 pandemic the number of residents participating in patient care has decreased at our institutions. hand surgery volume has decreased with only emergent surgeries being performed. given reduced number of cases and resident participation, alternative means of resident education and progress are essential during this time. to track progress of clinical skills, the milestone project in plastic surgery was established between 2011 and 2014. specifically, it was created "to define training outcomes and measure progress as a trainee progresses from novice to expert." 2 the levels are graded from 1 to 5. one requirement for the level 3 milestone is the performance of routine procedures, such as the repair of hand fractures. kirschner wire (k-wire) fixation of bones is a complex procedure, requiring the acquisition of 3d spatial skills as well as utilizing haptic and visual feedback to obtain a successful result. given such complexities, achieving a level 3 skill level can be a challenge in training programs with a low volume of hand surgery. the opportunity to practice these skills independently and supplement clinical practice can be difficult to come by. it has been demonstrated that practicing prior to surgical interventions "enable[s] the trainee to maximize learning episodes and trainers more likely to delegate surgical training." 3 given limited simulation tools for hand fracture fixation and the absence of commercially available 3d hands that replicate the tactile feel of bone and soft tissue, we focused on developing an affordable and durable model for resident training. while previous reports have cited costs over $100 per hand, we have achieved this under $50 per hand. 4 with 3d printers becoming more affordable and ubiquitous at academic centers, it is our goal to share our knowledge and increase access to easy production of 3d-printed models for resident training. at the same time, it is our goal to make simulation available at home and outside of the hospital. our 3d-printed hand model consists of 2 distinct parts: a 3d-printed set of bones and a silicone soft tissue envelope. the 3d-printed stereolithographic file is created from a computed tomography scan of a hand. to replicate haptic feedback into the model, the cortical surface and the medullary canal of the bones were made with variable fill patterns of the material, in our case acrylonitrile butadiene styrene (abs) (fig. 1) . after printing, the bones are set into an abs mold and covered with silicone. transparent silicone is used for beginners and skin-colored silicone for advanced learners (figs. 2 and 3). fracture patterns can be created at the time of practice or at time of printing. bones can be individually printed and easily interchanged for repeat use (fig. 4) . intrinsic properties of the silicone allow it to be used repeatedly without compromising soft tissue feel and creating damage from k-wires. our model is designed with a cost goal of under $50. we have used materials specifically selected to replicate the tactile feedback of "bone" and "soft tissue envelope." our <$50 include the materials and manufacturing of a 1-time hand mold, silicone for soft tissue replication and abs material for bones. cost breakdown per hand is shown in table 1 . the overhead, not included in the cost of the hand, includes 3d printing space, 3d printing machines and available personnel. our laboratories at yale university and brown university have 3d printers and materials available at no cost to the user. our 3d-printed hand model allows trainees to practice basic and complex fracture fixation with a multitude of attempts, precise bony anatomy and haptic feedback. the nature of the silicone soft tissue allows the fingers to be naturally flexed and the hand positioning to be manipulated during use. the option to replace bones also gives our model the added benefit of allowing novices and experienced trainees to practice fixation of simple and complex fracture patterns. the model is the size of an average human hand and is easily portable. fractures can be fixed with operating room quality k-wire drivers or with a home power drill. using the power drill reduces overall cost and allows trainees to practice fixation in their own home. our model does not require fluoroscopy and avoids unnecessary radiation exposure to the trainee. however, if trainees wish to practice incorporating fluoroscopy feedback, the 3d-printed bones are radiopaque. limitations of our model are the availability of a 3d printer, the price of overhead costs associated with purchase and maintenance of the printer, and the time for construction of the silicone mold. stereolithographic files can be easily shared across institutions. the printing time of hand bones can vary based on the quality of 3d printer available. however, once the soft tissue molds have been printed, pouring the silicone and placing the bones require no specific training. the other limitation is the upfront cost of the 3d printers and materials for the molds. however, in our experience, there are many facilities (including universities and local libraries) that hold workshops and allow community members access to 3d printers for a small fee. another limitation is the limited number of attempted fixations of the "bone." for example, our "bones" can be used to drill up to 6 to 8 different entry points, on metacarpal head radial and ulnar sides each, before the entry points coalesce into a large hole. we expect novice learners to require more attempts compared to advanced learners, and therefor require varying number of "bones" to complete an exercise. our individual bones can be manufactured for $2 and are exchangeable. with the covid-19 pandemic we have begun integration of 3d-printed hand fracture fixation into our educational curriculum. written instructions on fracture fixation have been created for residents in postgraduate years 1 to 4 and focus on visuospatial coordination, tactile feel of bony fixation, and proper use of the k-wire drivers. zoom sessions have been utilized to facilitate interaction among trainees and provide real-time instruction. trainees have expressed an extremely positive impact on their visuospatial orientation and tactile feedback with the use of 3d-printed hand for fracture fixation simulation. we will begin a formal program in evaluating improvements in basic fracture fixation skills. a concerted effort to prepare plastic surgery residents for practice and enable them to meet all milestones as set forth by the accreditation for graduate medical education acgme prior to graduation should be made during the covid-19 pandemic. we believe that our 3d hand-printed model can assist trainees in the acquisition of tangible fracture fixation skills with the use of a lowcost 3d-printed hand. journal of surgical education volume 00 /number 00 month 2020 entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy the plastic surgery milestone project how educational theory can inform the training and practice of plastic surgeons a high-fidelity tactile hand simulator as a training tool to develop competency in percutaneous pinning in residents key: cord-305500-uit5k7qs authors: elsner, peter; fartasch, manigé; schliemann, sibylle title: dermatological recommendations on hand hygiene in schools during the covid‐19 pandemic date: 2020-07-12 journal: j dtsch dermatol ges doi: 10.1111/ddg.14170 sha: doc_id: 305500 cord_uid: uit5k7qs nan dear editors, the covid 19 pandemic brings new requirements for hygiene to professions and spheres of life, which, unlike the health care system, have in the past been less visible as a focus of public health efforts on infection prevention. this applies particularly to schools, in addition to all professions with exposure to the public. though children have been reported to have more asymptomatic covid-19 infections, milder illnesses, faster recovery and a better prognosis than adults [1], transmission through close contact in schools remains possible, and there have been preventive closures of schools in many states despite unclear evidence for such measures in containment of the covid-19 pandemic [2] . the gradual reopening of schools in germany after the march/april 2020 shutdown is to be based on individual school hygiene plans in accordance with the specifications of the ministries of education. these hygiene plans envisage -in analogy to the prevention recommendations of the robert koch institute (rki) -frequent "thorough hand hygiene by handwashing with soap for 20-30 seconds". washing of the hands is deemed sufficient for infection prophylaxis and should be the preferred method "within the framework of resource conservation". hand disinfection is only recommended as an exception if "thorough hand washing is not possible". there is no mention of skin care in the hygiene plans. these hygiene plans pose great challenges for schools, since in the past such plans were often not drafted, adapted or updated in the respective schools, and since hygiene in the sanitary areas was often only monitored by the health authorities on a case-related basis, whereby "complaints made could usually be confirmed" [3] . health authority inspection criticized the frequent lack of soap and disposable towels [4], which make proper hand hygiene impossible [3] . wash basins in classrooms are often less well equipped than in school toilets [4] . on the other hand, intervention studies have confirmed the importance of hand hygiene in schools, showing that appropriate intervention can lead to a decreased number of days of absence due to illness, especially caused by gastrointestinal, but also respiratory infections [5, 6] . however, health education campaigns such as the "hygiene tips for kids" show that targeted training measures, in particular those including teachers and parents, are necessary for the effective use of hygiene facilities, beyond their mere provision [7] . educational material developed during this project could also be used for instruction on hand hygiene in covid-19 infection [7] . there is no scientific evidence on the preventive effectiveness of hand hygiene for covid-19 infection; the robert koch institute, with regard to preventive measures in health care facilities, refers to the recommendation of the commission for hospital hygiene and infection prevention (krinko) [8] , which in turn refers to its recommendation on hand hygiene from 2000 [9] . in its 2016 recommendation on hand hygiene in health care facilities, krinko points out that viricidal disinfectants should be used depending on the type of viruses expected, whereby enveloped viruses, including covid-19, are affected by all alcohols in a concentration-dependent manner [10] . the rki regularly publishes a list of tested and approved disinfectants and procedures for hygienic hand disinfection [11] . the medical indications for hygienic hand disinfection (immediately before direct patient contact, immediately before aseptic procedures, immediately after contact with potentially infectious material, after contact with the immediate patient environment and after direct contact with the patient) [10] can only be applied to a limited extent to hand washing/disinfection in schools. regarding the frequency of hand hygiene, the rki refers to the federal center for health education (www.infektionsschutz.de), which recommends, without substantiating evidence, washing hands with soap and water for at least 20 seconds in the following circumstances to prevent covid-19 infection: -upon coming home, -after blowing one's nose, sneezing or coughing, -before preparation of meals, -before eating and after using the bathroom, -before and after contact with other people, especially if they are ill, -before putting on and after taking off the mouth-and-nose cover. for hand hygiene in schools, any skin contact with potentially virus-contaminated surfaces should be added as an additional circumstance. although from a dermatological viewpoint there are hardly any studies on the effects of different approaches to hygiene on children's skin health, a broad body of evidence from occupational dermatology does exist that can be transferred to the hygiene plans of schools. there is consensus from numerous epidemiological and skin physiological studies that repeated exposure to detergents in the form of frequent hand washing significantly increases the risk of hand eczema [12] . the use of alcohol-based disinfectants is less irritating than skin cleansing with common this is an open access article under the terms of the creative commons attribution-noncommercial-noderivs license, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. correspondence clinical letter detergents [13] [14] [15] . working in damp conditions, defined by the technical rules for hazardous substances (trgs) 401 as an activity that is hazardous to the skin, includes activities in which a worker frequently or intensively cleans his or her hands; under such conditions, a worker must be provided with suitable protective measures [16] . the awmf guideline "occupational skin products" summarizes the available evidence on skin protection, skin care and skin cleansing in the occupational context [17] ; it states that a preventive effect of skin protection and skin care products on the epidermal barrier in case of detergent-induced irritation can be proven both in epidemiological intervention studies and in experimental skin physiological investigations. with regard to training measures for skin protection, skin care and skin cleansing, extensive competence, of which schools may avail themselves, is available both in the training and advice centers of the accident insurance institutions [18] and in the skin protection centers [19] [20] [21] managed by dermatologists. a negative impact on the hygienic effect of an alcohol-based disinfectant by the subsequent application of a skin care product has not been proven. specific recommendations for skin care products for use after washing/disinfection are not possible due to a lack of relevant study-based evidence; more research is needed here. a dermatological recommendation for the hygiene plans of schools regarding covid-19 prevention, grounded in the application of the outlined occupational dermatological and skin physiological evidence, is that these should include a concept for the maintenance of the students' skin health. this is all the more important as up to 30% of children suffer from atopic eczema or an atopic disposition [23] and thus face an increased risk of hand eczema. from a dermatological viewpoint, the following recommendations can be made: 1. in the absence of visible contamination of the hands, disinfection with a virucidal alcohol-based hand sanitizer should be given priority over washing with soap or washing lotions (detergents) since alcohol-based disinfectants affect the epidermal barrier less. 2. in order to enable infection control by hand disinfection in schools comprehensively, sanitizer dispensers should be installed not only in washrooms but also in classrooms and corridors (especially in front of canteens, sports rooms), especially since the capacity of school toilets and washrooms is limited due to the distance requirement in covid-19 prevention. 3. after each washing and disinfection, a skin care product that supports regeneration of the skin barrier should be applied. 4. children with atopic eczema should follow the same hygiene recommendations as normal persons; however, greater attention should be paid to consistent skin care after washing and disinfection. 5. for hand washing/disinfection/skin care to be effective, it has to be done correctly; this requires health education instruction, for which sufficiently competent consultants are available in germany through hygiene institutes, health authorities, training and advice centers of accident insurance providers and skin protection centers. finally, students and parents should be advised that upon the occurrence of hand eczema as a result of intensified hand hygiene, students should be given prompt dermatological care. according to the current escd guidelines for diagnosis, prevention and treatment of hand eczema [24] , guideline compliant treatment should be carried out promptly to prevent chronicity. schools: a prospective cohort study the effect of handhygiene interventions on infectious disease-associated absenteeism in elementary schools: a systematic literature review infektionsprävention im rahmen der pflege und behandlung von patienten mit übertragbaren krankheiten mitteilung der kommission für krankenhaushygiene und infektionsprävention am robert koch-institut empfehlung der kommission für krankenhaushygiene und infektionsprävention (krinko) beim robert koch-institut (rki) liste der vom robert koch-institut geprüften und anerkannten desinfektionsmittel und -verfahren exposures related to hand eczema: a study of healthcare workers effects of disinfectants and detergents on skin irritation tandem application of sodium lauryl sulfate and n-propanol does not lead to enhancement of cumulative skin irritation hand disinfection in hospitals -benefits and risks gefährdung durch hautkontakt ermittlung -beurteilung -maßnahmen. trgs 401 s1 guideline on occupational skin products: protective creams, skin cleansers, skin care products (icd 10: l23, l24)-short version das hautschutzprogramm in den schulungs-und beratungszentren der berufsgenossenschaft für gesundheitsdienst und wohlfahrtspflege rehabilitation bei berufsdermatosen prävention im hautschutzzentrum -ein konzept zur erfolgreichen vermeidung von berufsunfähigkeit haut optimal" -abgestufte hautschutzberatung am telefon, mittels beratungsmobil und seminar effect of hand lotion on the effectiveness of hygienic hand antisepsis: implications for practicing hand hygiene pathophysiology of atopic dermatitis guidelines for diagnosis, prevention and treatment of hand eczema key: cord-262886-irmwqjfh authors: beiu, cristina; mihai, mara; popa, liliana; cima, luiza; popescu, marius n title: frequent hand washing for covid-19 prevention can cause hand dermatitis: management tips date: 2020-04-02 journal: cureus doi: 10.7759/cureus.7506 sha: doc_id: 262886 cord_uid: irmwqjfh coronavirus disease 2019 (covid-19) continues to spread globally, outpacing the capacity and resources of health systems worldwide. a therapeutic vaccine is not yet on the rise, and preventive measures are the current approach to restraint the transmission of cases. as the virus is highly contagious via respiratory route (droplets from infected persons, widely spread by coughing or sneezing) and via contact with contaminated surfaces, community transmission and spread can be decreased through the practice of regular and diligent hand hygiene. frequent hand washing implies a prolonged exposure to water and other chemical or physical agents and may induce several pathophysiologic changes, such as epidermal barrier disruption, impairment of keratinocytes, the subsequent release of proinflammatory cytokines, activation of the skin immune system, and delayed-type hypersensitivity reactions. adverse dermatologic effects, such as excessive skin dryness or even contact dermatitis (particularly the irritant subtype and, to a lesser extent, the allergic subtype), can occur, especially in individuals with a history of atopic dermatitis. these skin conditions are perfectly manageable, and applying a moisturizer immediately after washing hands or after using a portable hand sanitizer is the cornerstone in preventing the development of eczematous changes in the hands. in the current global context, the potential occurrence of these dermatological adverse events should in no way cause people to deviate from strict hand hygiene rules. covid-19 stands for "coronavirus disease 2019," and it refers to an outbreak of acute respiratory infection caused by a novel coronavirus. the specific coronavirus strain was initially referred to as 2019-ncov (2019 novel coronavirus) and finally designated as sars-cov-2 (severe acute respiratory syndrome coronavirus 2). it was first identified in late 2019 in the city of wuhan, hubei province of china, and it rapidly spread throughout other eastern countries (e.g. south korea, japan, iran) as well as europe and the united states [1] . on march 2020, the who (world health organization) declared the covid-19 outbreak a global pandemic and all countries were urged to undertake effective measures for reducing transmission [2] . vaccines active against covid-19 are not available, and ongoing prospects in formulating and developing preventive or therapeutic vaccines against sars-cov-2 are limited [3] . in this context, public health actions to prevent transmission are crucial in slowing the spread of the pandemic. one of the essential recommendations that the who has issued for the populous is to wash their hands frequently and correctly. in the process, intensified hand washing may generate various changes in skin texture and even hand dermatitis. this article aims to review the potential dermatological adverse effects that may arise due to frequent hand washing, as well as practical tips for preventing these uncomfortable skin reactions. all clinical images included in the review section of the article were taken in the department of oncologic dermatology of emergency university hospital "elias" in bucharest, using a digital camera (nikon d3300; nikon corporation, tokyo, japan). frequent hygienization of hands may generate various changes in skin texture, ranging from the development of cutaneous xerosis (dryness of the skin) up to irritant contact dermatitis (icd) or, rarely, even allergic contact dermatitis (acd). overall, these skin disorders are induced by various physical, chemical, and immunological mechanisms. when measures of diligent hand hygiene are implemented, these mechanisms may be activated mainly by the following circumstances. 1. prolonged skin exposure to water and humid environment: it creates extensive swelling of stratum corneum (the skin's outermost layer) and disruption in the ultrastructure of intercellular lipids, and heightens the skin's permeability and sensitivity to physical or chemical irritants [4] . in addition, prolonged wearing of protective gloves can generate excessive sweating and increased humidity, thus further increasing the inflammatory response elicited towards irritants. 2. repeated use of soaps, surfactants, detergents, or solvents: these substances used for domestic cleaning are weak irritants and are usually very well tolerated. nevertheless, repeated exposure to these substances can lead to chronic cumulative icd (figure 1) , mainly due to their capacity to remove skin surface lipids, damage skin proteins, denature epidermal keratin, and even induce alteration of the cell membrane of keratinocytes [5] . furthermore, patients with a personal or family history of atopic dermatitis have a chronically dysfunctional cutaneous barrier that increases their sensitivity to skin irritants ( figure 2 ) [6] . rarely, some individuals may even develop acd (figure 3) , a t-cell-mediated, delayed-type hypersensitivity reaction, to an ingredient in a hand hygiene-related product, such as soaps or detergents [7] . the patient initiated preventive hand washing measures two months ago, without hydrating the hands afterward and developed severe skin dryness, fissuring (white arrow), and scaling. also the irritant-induced changes have progressed to hyperkeratosis and acanthosis (black arrows), highlighting the cumulative exposure. confluent, erythematous, scaly itchy patches, with small vesicles (highlighted in the white circles), on the hands of a patient with allergic reaction induced by chemicals in detergents and soaps. 3. repeated use of alcohol-based hand sanitizer: the who states that using hand rubs that contain at least 60% alcohol is a reasonable alternative if water and soap are not available, and as long as the hands are not visibly dirty [8] . frequent use of these products can also result in skin dryness and irritation. on the other hand, allergy against alcohol itself is unknown and acd attributable to other compounds added to alcoholic hand gels is extremely rare. this was illustrated by the experience of a large hospital in switzerland where health workers routinely used a commercial alcohol-based hand sanitizer for 10 years, without reporting any allergic reactions to the product [9] . in these times, it is very important to adapt our hand washing habits to ensure efficient protection against the spread of covid-19 while lowering the risk of skin adverse reactions. in this respect, we find very useful the adoption of the following protective measures. 1. as the who recommends, hands should be washed thoroughly (including fingernails, interdigital web spaces, wrists) for at least 20 seconds, using lukewarm water and soap, particularly after being in public areas, before meals, after coughing or sneezing, after using the toilet, and whenever the hands are dirty. 2. after washing, we advise rinsing the hands by using gentle maneuvers, without causing a physical irritation to the skin. 3. applying moisturizing skin care products after hand cleansing is the essential step in keeping the skin hydrated and preventing further abnormal skin reactions. these hydrating products should be liberally applied, multiple times per day, particularly immediately after hand washing. 4. there are several subtypes of moisturizers but to efficiently improve the quality of the skin barrier it is largely indicated to combine humectants with occlusive emollients. humectants (e.g., topical urea, propylene glycol) are capable of attracting water to the stratum corneum from the environment and from the deeper layers of the skin. occlusive emollients (e.g., petrolatum-based products, lanolin, mineral and vegetable oils, waxes) prevent water loss and alleviate irritation. a combination of the two is useful for attracting and sealing water at the level of the corneum layer and soothing the skin. 5. thick greasy creams and ointments (e.g., petroleum jelly) provide higher protection against xerosis than lotions. to reduce the risk of contact sensitization, it is highly recommended to use fragrance-free and hypoallergenic products. 6. when soap and water are not available, the cdc advises that the use of alcohol-based hand sanitizers (that contain at least 60% alcohol), is an effective alternative in destroying the virus. since these can be irritating, it is important to hydrate the skin immediately after. applying a moisturizing cream afterward does not interfere in any way with the properties and efficiency of this type of sanitizers. 7. for individuals working with protective gloves, it is highly recommended to wash hands and apply moisturizer whenever gloves are taken off. also, to lower the humidity, they should be changed systematically and applied only on dry hands. 8. for people with highly sensitive skin, which easily develop disturbing forms of dermatitis, short courses of topical corticosteroids may be used to reduce the signs and symptoms of inflammation. covid-19 and italy: what next? who declares covid-19 a pandemic sars-cov-2 and covid-19: the most important research questions water disrupts stratum corneum lipid lamellae: damage is similar to surfactants effects of four soaps on skin trans-epidermal water loss and erythema index tolerability and cosmetic acceptability of a body wash in atopic dermatitis-prone subjects methylisothiazolinone in rinse-off products causes allergic contact dermatitis: a repeated open-application study can we contain the covid-19 outbreak with the same measures as for sars? replace hand washing with use of a waterless alcohol hand rub in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. compliance with hand hygiene recommendations is essential in preventing the spread of covid-19 and, under no circumstances, should be diminished by the eczematous changes that may occur in the hands. in this context, the potential development of hand dermatitis is preventable and manageable by using the appropriate skin care products. regular skin hydration is a key component in preventing hand dermatitis as a consequence of frequent washing. key: cord-295034-em6z8mlu authors: daverey, achlesh; dutta, kasturi title: covid-19: eco-friendly hand hygiene for human and environmental safety date: 2020-11-11 journal: j environ chem eng doi: 10.1016/j.jece.2020.104754 sha: doc_id: 295034 cord_uid: em6z8mlu the coronavirus disease-2019 (covid-19) outbreak is caused by a highly pathogenic novel coronavirus (sars-cov-2). to date, there is no prescribed medicine for covid-19. frequent handwashing with soap and the use of alcohol-based hand sanitizers is recommended by who for hand hygiene and to prevent the spread of covid-19. however, there are safety concerns associated with the use of soaps and alcohol-based hand sanitizers. therefore, the review aims to highlight the health and environmental concerns associated with the frequent use of soaps/detergents and alcohol-based hand sanitizers amid covid-19. the potential of some of the natural detergents and sanitizing agents as eco-friendly alternatives to petrochemical-based soaps and alcohol-based hand rubs for hand hygiene are discussed. the market of soaps and hand sanitizers is expected to grow in the coming years and therefore, future research should be directed to develop eco-friendly soaps and hand sanitizers for human and environmental safety. coronavirus diseases 2019 (covid19) , which was first reported in wuhan city (china) j o u r n a l p r e -p r o o f hydrogen peroxide (0.125% v/v as a preservative to inactivate bacterial spores) and glycerol (1.45% v/v as a humectantmoisturizing agent) diluted with sterilized distilled water or boiled water (who, 2010). in commercial products, propylene glycol is being used as a humectant. a viscosity enhancer such as alkyl acrylate cross-polymer, tetrahydroxypropyl-ethylenediamine, etc. is usually added in alcohol-based hand-rub gels. the cost of alcohol-based liquid and gel sanitizers is ranged around us$ 2.5-5.4 and us$ 8, respectively (who, 2010). the mechanism of killing the microorganisms by soaps or detergents relies on the fact that they disrupt the lipophilic membrane of the cell wall of bacteria and other microorganisms including enveloped viruses (ijaz et al., 2020) . similarly, alcohol also dissolves the lipid membrane of microorganisms. literature suggests that ethanol is highly effective (within 30 s) against almost all clinically relevant enveloped viruses including coronaviruses (sars-cov i.e. severe acute respiratory syndrome coronavirus and mers-cov i.e. the middle east respiratory syndrome coronavirus, which belong to the same class of viruses as sars-cov-2), and influenza viruses (kampf, 2018; golin et al., 2020) . therefore, alcohol-based hand sanitizers with alcohol content >60% v/v are popular and recommended by who and other national organizations such as cdc (centers for disease control and prevention), usa (cdc, 2020). the recent study by kratzel et al. (2020) reports that sars-cov-2 was efficiently inactivated by ethanol and 2-propanol at a concentration of >30% v/v and by the two preparations recommended by who in 30 s. that's why frequent hand washing with soaps and hand hygiene with alcohol-based hand sanitizers has been recommended. the simplified mechanism of soaps/detergents and alcohol-based hand sanitizers are presented in fig. 1 . pandemic is yet to be quantified. the general safety issues associated with alcohol-based hand sanitizers are flammability of alcohol and toxicity due to the accidental ingestion of the sanitizer. in a recent review by though the key components of hand sanitizers, alcohol and h 2 o 2 are in general not toxic externally, there is a concern of skin damage due to excessive use of hand sanitizers, which can lead to an inability of the skin to protect against other microorganisms or viruses (mahmood et al., 2020). younger kids (12-year-old children or younger) are at high risk due to accidental ingestion. in children, even a small dose of alcohol can cause alcohol poisoning. therefore, the american association of poison control center (aapcc) regarded hand sanitizers as emerging hazards. in the first six months (january to june 2020), 11,363 cases of exposure due to hand sanitizer have been reported according to aapcc (https://aapcc.org/track/hand-sanitizer). methanol contamination has also been found in hand sanitizers probably due to the high demand for ethyl alcohol and isopropyl alcohol during this pandemic. fda (u.s. food & drug administration) found methanol contamination in several tested hand sanitizers (77 products as on july 23, 2020) and advises consumers not to use hand sanitizers from certain manufactures (fda, 2020). therefore, there is a dire need to replace alcohol-based hand sanitizers with nontoxic or low-toxic hand sanitizers for human and environmental safety. antimicrobial resistance due to the rampant use of antibiotics and other antimicrobial agents has become one of the major concerns worldwide. apart from antimicrobials (antibiotics, antivirals, and antiparasitics), excessive use of surfactants, alcohol, and hydrogen peroxides are also known to cause resistance to microorganisms (singer et many microorganisms (bacteria, yeasts, and fungi) and plants produce surface-active agents called biosurfactants. chemically they are amphiphilic compounds i.e. have both lipophilic and hydrophilic moieties in their structure. the biosurfactants possess similar properties as their chemical counterpart. for example, they efficiently reduce the surface and interfacial tensions between two phases, act as emulsifiers, and have foaming properties. therefore, biosurfactants are potential agents to replace synthetic surfactants in soaps and detergents. based on their chemical structure microbial biosurfactants are classified as glycolipids, in the kumaun region of uttarakhand (india) 22 plant species have been used as traditional soaps and detergents. different plant parts such as seeds, seed coats, barks, leaves, and young shoots, roots, ash have been used for washing and bathing purposes by the local people (mehta and bhatt, 2007) . overall, all these properties of plant-derived natural soaps and detergents have the potential to replace the synthetic detergents and alcohol-based sanitizers. however, in-vitro j o u r n a l p r e -p r o o f activities of these natural biosurfactants against coronaviruses and sars-cov-2 has to be tested before using for hand hygiene. propylene glycol is the most commonly used humectant in hand sanitizers due to its low cost. a viscosity enhancer such as carbomer hydroxyethyl cellulose, sodium carboxymethyl cellulose, etc. is also added in the hand rubs. aloe vera gel, a transparent mucilaginous jelly-like material (lin et al., 2017) . lemon balm oilan essential oil, which inhibits the enveloped herpes simplex virus and phenolic compounds from the isatis indigotica, which inhibits coronavirus, could also inactivate sars-cov-2 (jahan and ahmet, 2020). however, the low-yield of essential oils and phenolic compounds could be a major factor for their commercial application in hand-sanitizers. the main raw material used in soaps and hand sanitizers is petrochemicals based surfactant and good hand hygiene prevents the spread of various diseases including covid-19. handwashing with soaps and the use of hand sanitizers to clean hands have increased immensely during the covid-19 pandemic. the global market of detergents and hand sanitizers is expected to grow in the coming days. however, considering the harmful effects of chemical detergents and hand sanitizers, it is high time to replace them with eco-friendly natural agents. several microbial j o u r n a l p r e -p r o o f biosurfactants and plant secondary metabolites possess detergent, antimicrobial and antiviral activities. being non-toxic and biodegradable, these eco-friendly agents have tremendous potential to replace conventional soaps and hand sanitizers. economical production of biosurfactants and extraction of bioactive antimicrobial agents from the plants will play a crucial role in their commercial application and sustainability as eco-friendly soaps and hand sanitizers and therefore further research is needed in this direction. covid-19: critical discussion on the applications and implications of chemicals in sanitizers and disinfectants antiviral effect of phytochemicals from medicinal plants: applications and drug delivery strategies demonstrating the persistent antibacterial efficacy of a hand sanitizer containing benzalkonium chloride on human skin at 1, 2, and 4 hours after application biological activity of sophorolipids and their possible use as antiviral agents skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel occurrence of surfactants in wastewater: hourly and seasonal variations in urban and industrial wastewaters from seville (southern spain) hand hygiene recommendations: guidance for healthcare providers about hand hygiene and covid-19 design of sustainable lip gloss formulation with biosurfactants and silica particles covid-19 and frequent use of hand sanitizers; human health and environmental hazards by exposure pathways anti-influenza triterpenoid saponins (saikosaponins) from the roots of bupleurum marginatum var. stenophyllum fda updates on hand sanitizers with methanol low-toxic and nonirritant biosurfactant surfactin and its performances in detergent formulations plant-based natural saponins for escherichia coli surface hygiene management. lwt -food science and technology biosurfactants: production and potential applications in microbial enhanced oil recovery (meor) hand sanitizers: a review of ingredients, mechanisms of action, modes of delivery, and efficacy against coronaviruses optimisation of saponin extraction conditions with camellia sinensis var. assamica seed and its application for a natural detergent application of rhamnolipid biosurfactant for bio-detergent formulation increased use of quaternary ammonium compounds during the sars-cov-2 pandemic and beyond: consideration of environmental implications microbicidal actives with virucidal efficacy against sars-cov-2 potentials of plant-based substance to inhabit and probable cure for the covid-19 valorization of selected fruit and vegetable wastes as bioactive compounds: opportunities and challenges use of wastes for sophorolipids production as a transition to circular economy: state of the art and perspectives hand sanitizers: a review on formulation aspects, adverse effects, and regulations efficacy of ethanol against viruses in hand disinfection inactivation of severe acute respiratory syndrome coronavirus 2 by who-recommended hand rub formulations and alcohols evaluation of surfactant removal efficiency in selected domestic wastewater treatment plants in poland antiviral natural products and herbal medicines effective inhibition of mers-cov infection by resveratrol nonantibiotic antimicrobial triclosan induces multiple antibiotic resistance through genetic mutation the therapeutic properties and applications of aloe vera: a review traditional soap and detergent yielding plants of uttaranchal benzalkonium chlorides: uses, regulatory status, and microbial resistance heavy use of hand sanitizer boosts antimicrobial resistance aloe vera (l.) burm. f. as a potential anti-covid-19 plant: a mini-review of its antiviral activity the role of surfactants in wastewater treatment: impact, removal and future techniques: a critical review bioactive phenolic compounds from agri-food wastes: an update on green and sustainable extraction methodologies microbial biosurfactants for oil spill remediation: pitfalls and potentials increasing tolerance of hospital enterococcus faecium to handwash alcohols characterization and authentication of commercial cleaning products formulated with biobased surfactants by stable carbon isotope ratio polyphylla saponin i has antiviral activity against influenza a virus quillaja saponin characteristics and functional properties antiviral activity obtained from aqueous extracts of the chilean soapbark tree (quillaja saponaria molina) review of antimicrobial resistance in the environment and its relevance to environmental regulators biosurfactant production: emerging trends and promising strategies production, formulation and cost estimation of a commercial biosurfactant mechanism of inactivation of enveloped viruses by the biosurfactant surfactin from bacillus subtilis guide to local production: who-recommended handrub formulations coronavirus disease (covid-19) advice for the public potential changes in soil properties following irrigation with surfactant-rich greywater surfactin inhibits membrane fusion during invasion of epithelial cells by enveloped viruses new sustainable alternatives to reduce the production costs for surfactin 50 years after the discovery surfactants at environmentally relevant concentrations interfere the inducible defense of scenedesmus obliquus and the implications for ecological risk assessment key: cord-254886-fl5ar971 authors: arav, y.; klausner, z.; fattal, e. title: understanding the indoor pre-symptomatic transmission mechanism of covid-19 date: 2020-05-17 journal: nan doi: 10.1101/2020.05.12.20099085 sha: doc_id: 254886 cord_uid: fl5ar971 discovering the mechanism that enables pre-symptomatic individuals to transmit the sars-cov-2 virus has a significant impact on the possibility of controlling covid-19 pandemic. to this end, we have developed an evidence based quantitative mechanistic mathematical model. the model explicitly tracks the dynamics of contact and airborne transmission between individuals indoors, and was validated against the observed fundamental attributes of the epidemic, the secondary attack rate (sar) and serial interval distribution. using the model we identified the dominant driver of pre-symptomatic transmission, which was found to be contact route, while the contribution of the airborne route is negligible. we provide evidence that a combination of rather easy to implement measures of frequent hand washing, cleaning fomites and avoiding physical contact decreases the risk of infection by an order of magnitude, similarly to wearing masks and gloves. during the months following the emergence of the covid-19 pandemic in december 2019, it became evident that sharing an indoor space is the major sars-cov-2 infection risk (1) (2) (3) . these studies also found that the members of the same households has the highest risk of infection among people in different modes of close contact. this conclusion is based on the secondary attack rate (sar), the percentage of household contacts who were later confirmed to be infected with sars-cov-2. estimates of the sar made in china, south korea, taiwan and the united states ranges between 10.2 − 16.2% (2) (3) (4) (5) (6) . due to the fact that most of these estimates were made in countries that lead a public health policy of immediate isolation of cases upon symptoms' onset, these estimates represent the effect of pre-symptomatic carrier transmission. in fact, pre-symptomatic transmission was recently referred to as the achilles' heel of covid-19 pandemic control, as symptom-based detection of infection is less effective in comparison to the control of the sars epidemic in 2003 (7) . however, the question of understanding the mechanism that enables seemingly healthy individuals to transmit the virus, was left unsolved. this is the motivation of this study. generally, respiratory viruses, such as sars-cov-2, spread via three transmission routes: contact, droplet and aerosol transmission. in contact transmission an infected person gets virus on his hands and transfers this virus either directly, e.g., via a handshake, or indirectly via an intermediate object, to the hands of an infectee, who then places his hand into his facial membranes, thus exposing himself to the contamination on his hands. transmission of virus through the air can occur via droplets or aerosol. droplets generated in a cough or a sneeze travel less than 1.5m before they settle on close contacts or environmental surfaces (8) . aerosols remain suspended in the air and may infect a susceptible individual once they deposit in his upper or lower respiratory tract. the commonly accepted cutoff is 5µm (9) . however, droplets that are smaller than approximately 100µm evaporate to their droplet nuclei size before they hit the ground (8) . following (8) , we assume that the respiratory fluid is a physiological saline solution with anion and cation concentration of about 0.9%w/v. therefore, the droplet shrinks to about 3 √ 0.009 ≈ 0.2 of its original size. thus, a 100µm droplet would reduce to a droplet nuclei of 20µm before reaching the ground. here we have used a cutoff size of 100µm between droplets and aerosol. this cutoff size results in an conservative estimation of the contribution of the aerosol transmission route as larger volume of aerosols is considered. the relative importance, if any, of these routes differ for each infectious disease, depending on its specific parameters. in the current study, we model the mechanism of indoor transmission with an individualbased stochastic mechanistic model ( figure 1 ). the model describes the basic interaction of two individuals, a pre-symptomatic primary (infetor) and a secondary (infectee) individuals. 3 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. face. in addition, the primary sneezes and coughs in a rate characteristic to healthy individuals (11, 12) . we have performed each until the primary developed symptoms in order to address the question of pre-symptomatic transmission, and in accordance with the public health policy that isolates the primary when his symptoms appear. that is, the duration of each realization is the primary's incubation time, that distributes log-normally with a mean of 5 days and standard deviation (sd) of 0.45 days (13) . we assumed an exponential growth law of the viral load with time (10) which reaches its maximal level when the symptoms appear (14) . the probability that the secondary will be infected is inferred from the dose-response curve that was reported for sars-cov-1 (15) . we relied on the recent available literature to-date to determine empirically plausible values for the model parameters. a complete list of the model parameters and their values is presented in table s1 . the reference simulation uses parameters that describe a normal, pre-epidemic, behaviour (see table 1 ). details and sensitivity analysis on key parameters such as the dose response, viral loading and shedding, room dimensions, transfer coefficients 4 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. a necessary validation criteria for a model such as the one described in this study is to correctly simulate the sar and the distribution of the serial interval. the serial interval is the time period between the symptoms' onset of primary and the secondary. its distribution is closely associated with the estimation of the reproductive number and key transmission variables in epidemic models as well as important in the optimization of quarantine and contact tracing (16, 17) . the serial interval distribution of covid-19 was estimated in many countries and was usually found to be gamma distributed with mean between 4.03 to 6.3 days and standard deviation between 3 and 4.2 days ( figure 1a , shaded area) (2, (18) (19) (20) . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. we have also analyzed the contagious period of pre-symptomatic patients by examining the cumulative sar over time ( figure 2c ). as seen, the contagious period begins approximately 30 hours before symptoms' onset, with increasing probability as the onset of the symptoms approaches. this result is consistent with the estimation of he et al. (14) that inferred from data of 77 transmission pairs (i.e., primary and secondary) a contagious period of approximately 2 days before symptoms' onset. the fact that contact transmission is the main route of pre-symptomatic transmission, suggests that the hygienic and behavioral measures (hbms) advised to the public should focus on hbms to diminish the contamination on the hands or somehow interrupt the virus transfer from the hand to the facial membranes. we decided to examine five hbms: washing hands, cleaning fomites, maintaining social distancing (i.e avoiding physical contact), wearing a mask and 6 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. . https://doi.org/10.1101/2020.05.12.20099085 doi: medrxiv preprint gloves. naturally, conservative precautions measures would be to implement all these at once. however, strict adherence to all these hbms would be hard to endure and persist on doing over a long period of time. therefore, we have tried to sort out few combinations of hbms that will enable practical implementation by the public, while significantly lowering the risk of infection. as the sar is a proportion, it is appropriate to compare the hbms in terms of odd ratio (or), i.e., the odds that the secondary will be infected when a given combination of hbms is taken, compared to the reference scenario in which no hbm is applied. generally, any hbm that results in or less than 1 decreases the risk of infection (i.e., provide smaller sar than the reference) (23) . however, in practice the lower the or, the better hbm combination is at lowering the risk. the values brought here are in terms of or alongside with 95% confidence interval (95% ci) washing hands is known to remove the viruses from the hands of both individuals and it is the simplest measure to implement. our simulations show that washing hands every hour rather than 3 times a day, as in the reference simulation (table 1) , results in or of 0.71 (95% ci 0.62-0.8) ( figure 3a, column h) . this result is consistent with intervention studies that have shown that increased hand washing decreased respiratory illness by 20%, albeit different viruses were studied (24) . this phenomenon seems counter intuitive, as we found that more than 99% of the viruses are transmitted through the hands and it was expected that washing it would remove the contamination. in order understand the reason for the relatively limited effect of hand hygiene, we have examined the dynamics of the virus concentration on the hands of the secondary individual ( figure 3b ). this concentration exhibits a periodic behaviour, that is governed by touching events in fomites and the face. spectral analysis reveals that the hand concentration cycle is characterized mainly by frequencies that are with time scale of 50 minutes (see supplementary text). therefore, hand washing is expected to dramatically reduce the risk for infection if it occurs at at higher frequency than 50 min. unfortunately, such frequent 7 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. . washing is unrealistic. cleaning the fomites more frequently reduces the virus repositories that are available for intake. cleaning of the fomites 10 times a day rather then 2 times a day, as in the reference simulation, results in or of 0.82 (95% ci 0.72-0.93), rather similar to washing hands more 8 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. (figure 3a , column m+g). this result is surprising, as it was expected that protecting the hands and mouth will provide as the best hbm combination. the fact that the combination of all other hbms provided better or means that following these hbms meticulously may save people the discomfort and limitation that is associated with having to wear constantly a mask and gloves in indoor scenarios. our analysis, as with all modeling exercises, has several limitations and requires certain assumptions. at this point, the model does not account for contact patterns that prevail in households with young children and does not take into account the diurnal cycle of activity. the model parameters, such as the dose response curve, the viral shedding coefficients and 9 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 17, 2020. . transfer coefficients were chosen on the basis of prior knowledge of the sars, other strains of coronavirus or other bacteria (15, 30) . although the model is stable to variations in these parameters, more information on the key characteristic of the disease would considerably reduce uncertainties. to conclude, we have analyzed the possible routes of pre-symptomatic transmission in indoor scenarios. using a validated model, we were able to identify the main transmission mechanism as contact associated, mostly directly but also mediated by fomites. frequent hand washing and fomite cleaning coupled with avoiding physical contact result in a similar risk for infection as wearing gloves and a mask. our findings can provide an important tool for decision makers while advising the public of the hbms that are necessary to impede the epidemic. as it seems that the initial wave of pandemic may be closing to its end, many countries are gradually lifting the restrictions on society, such as the re-opening of schools and workplaces. however, recurrent outbreaks (the so called second wave) may occur in the coming year (31) . under such reality, the model presented in this study can be used to quantify the contribution of different measures in mitigating the risk of infection in workplaces or schools scenarios. transmission routes of respiratory viruses among humans air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient include acknowledgments of funding, any patents pending, where raw data for the paper are deposited, etc. key: cord-303468-95btvr1v authors: verran, joanna; jackson, sarah; scimone, antony; kelly, peter; redfern, james title: biofilm control strategies: engaging with the public date: 2020-07-30 journal: antibiotics (basel) doi: 10.3390/antibiotics9080465 sha: doc_id: 303468 cord_uid: 95btvr1v there are few peer-reviewed publications about public engagement with science that are written by microbiologists; those that exist tend to be a narrative of an event rather than a hypothesis-driven investigation. however, it is relatively easy for experienced scientists to use a scientific method in their approach to public engagement. this short communication describes three public engagement activities hosted by the authors, focused on biofilm control: hand hygiene, plaque control and an externally applied antimicrobial coating. in each case, audience engagement was assessed using quantitative and/or qualitative methods. a critical evaluation of the findings enabled the construction of a public engagement ‘tick list’ for future events that would enable a hypothesis-driven approach with more effective communication activities and more robust evaluation. it is increasingly being recognised by 'experts' that science literacy is of key importance for the public [1] . at a time where antimicrobial resistance (amr) continues to pose significant public health threats (or indeed, at a time of a global pandemic), an understanding of statistics, epidemiology and microbiology is even more desirable. as a subject, microbiology offers many topics with which we can engage non-experts, such as microbial diversity (including fungi, algae, protozoa and viruses as well as bacteria), beneficial microbes (for example, probiotics, fermented foods, the human microbiome), and messages that can influence behaviour in a positive manner (including vaccination, hand hygiene, antimicrobial stewardship) [2] [3] [4] . biofilms (an assemblage of microbial cells that are irreversibly associated with a surface-not removed by gentle rinsing-and enclosed in a matrix of primarily polysaccharide material [5] ) are of great importance to microbiologists, but also to many other professionals (such as engineers, biocide manufacturers, architects), and are found in a variety of environments (water distribution systems, industrial processing, hospitals). biofilm research is multi-disciplinary, extensive and significant, with many applications. there are several research centres which focus on biofilm, such as the us-based centre for biofilm engineering (http://www.biofilm.montana.edu/) and the uk-centred national biofilm innovation centre (https://www.biofilms.ac.uk/), and conferences about biofilm are regular and not uncommon. some individual researchers, research groups and research centres are keen to engage with external public audiences through outreach activities, although evidence of such activities (websites, articles, learning materials and other peer-reviewed outputs) is not easy to find. but why do we want the public to know about biofilms? and what does the 'public' need to know about biofilms? 'now wash your hands' was developed as part of a university faculty family fun day during national science and engineering week/healthcare science week in the uk. the aim was to raise awareness of effective handwashing, whilst also engaging the participants in a discussion about the skin microbiome/biofilm. this event guarantees an audience of predominantly families who are likely to have an existing interest in science. hand hygiene activities are well established as interactive learning activities with demonstrable public health impact (for example, as an intervention in reducing the spread of coronavirus [6] ). in this activity, demonstrators (academic staff and student volunteers) engaged audiences to demonstrate surface contamination and effective handwashing ( figure 1 ). thus, visitors at this activity (in a walkway area) had their hands 'contaminated' with a uv hand gel (www.hand-washing.com). this kit uses a fluorescent dye and ultraviolet light to illustrate the transmission of 'germs' from hands to other surfaces (and vice versa) and the importance of handwashing. in addition, the participants were invited to press their hands onto large agar plates for subsequent incubation to reveal the culturable microorganisms present on their skin. of course, they were unable to see the results of this work until after incubation, thus images of plates pre-inoculated with microorganisms present on hands and mobile phones [7] were available to view, and post-incubation images of their own plates were uploaded to flickr, a social media site that hosts images (http://tinyurl.com/howcleanareyourhands, figure 2 ). within a week from results going online, almost 100 downloads were recorded (the participants were provided with a card/web address), equivalent to the number of plates inoculated. from this, we deduced that visitors demonstrated interest and engagement with the activity. throughout the activity, conversations were ongoing. it was unfortunate that these interactions were not noted in some form: informal observations revealed points of interest from the participants such as their inability to clean hands effectively (especially the adults!) and amazement at the mobile phone contamination. the handprint technique has been used as an engagement tool for other events, such as an art installation called 'hands across the cultures' for registrants to a qualitative research conference and as part of the 'bioselfies' project (https://blogs.bl.uk/science/2020/02/introducing-bio-selfies-11-february-2020.html) initiated by the university of salford. flickr has been used for other events that require incubation of plates [8, 9] , and download numbers have on occasion exceeded the number of images posted, showing that the participants may have been sharing the findings with others. the fluorescent hand technique was used to illustrate person-to-person transmission by handshaking prior to a screening of the movie contagion (directed by soderbergh, 2011). one person 'contaminated' his/her hands, shook the hand of their neighbour, who shook her/his neighbour's hand and so on. thus, the passing-on of fluorescence was used to illustrate the transmission of infection through poor hand hygiene, reinforcing the message as to how the movie pandemic was initiated (hand contact). hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing techniques are employed. explanation regarding the presence or importance of the antibiotics 2020, 9, 465 4 of 12 skin microbiome/biofilm are likely rare (especially if the results are not available until a later date): the activity is inevitably more focused on the removal of temporary contaminants and on the importance of good handwashing. some discussion could take place regarding the hygiene-versus-cleanliness hypothesis [10, 11] . the flickr method used for posting images and monitoring downloads at least gives an indication of interest, but much more could be made of this activity. it would also be interesting to know if the 'good handwashing' messages are retained and employed in the future. however, longitudinal studies are rare in this type of public engagement, probably because of the significant advanced planning required in terms of gaining approval for personal data access (e.g., emails) and also because only short-term awareness raising tends to be the primary aim of the activity. the plaque biofilm is one of the best-known medical biofilms [12, 13] , and oral hygiene advertising frequently provides cartoons of plaque being removed to demonstrate the effectiveness of a paste, mouthwash or brush. it is known that good toothbrushing helps to remove plaque [14] and should be carried out regularly. different dentifrices claim varying activities, but virtually all formulations include fluoride (to 'strengthen the teeth') [15] , and many contain antimicrobial agents (to reduce the number of microorganisms, with claims around gum health) [16] . 'plaque attack!' was a laboratory-based activity designed for children and their parents, taking place during manchester science festival's family fun day at manchester metropolitan university. the aim of the event was to encourage good oral hygiene but also to captivate visitors with the components of the plaque biofilm as well as the laboratory and its equipment. being time-consuming and space-limited, the participants had to register for the event, were limited to 3 groups of 20 participants, be escorted to the laboratory, provided with appropriate clothing and instruction and supervised at all times. oral microbiology is a key research area in our laboratories, and the delivery team thought it would be valuable for visitors to encounter activity in a working (teaching) laboratory. the delivery team comprised phd students, technical staff and an academic. several activities were conducted as part of a 'round-robin' activity: sampling plaque (microscopy demonstration and take-home photo [zip mobile printer, polaroid]); disclosing plaque (using commercially available disclosing tablets), with photographs taken before and after cleaning teeth (in a wash area adjacent to the laboratory); looking at cultures of oral bacteria on agar plates; investigating biofilm structure/building a biofilm (using 'model magic' [crayola bedford uk], a white air-drying modelling clay) ( figure 3a ); and destroying a biofilm (using a water pistol to remove plaque (whose microorganisms were pre-constructed from fimo, a multi-coloured clay which can be hardened in the oven [www.staedtler. com]) hampered by plaque matrix (a translucent hair gel) [17] (figure 3b ). the participants were provided with a basic information sheet on plaque and oral hygiene, onto which they could attach their polaroid images. they were also given a bag containing complimentary toothbrush and toothpaste (courtesy of unilever [www.unilever.co.uk]). at the end of the activity, they were asked for free text feedback on what they thought of the event, and the information was coded into categories to allow for comparison [18, 19] (figure 4) . the participants were particularly engrossed in the microscopy demonstration, being able to see their own plaque at high magnification. they also clearly had fun 'destroying' the biofilm but were less interested in the more passive/less exciting activity (agar plates demonstration, building a biofilm). the free text provided by the participants (allowing more thorough insight compared to multiple-choice or leading questions such as 'give three things you have learned', or 'smiley face/sad face' evaluations [18, 20] ) gave valuable qualitative information that was used to inform subsequent activities. (a/top) participants at the 'plaque attack!' event were encouraged to create their own oral bacteria flora from modelling clay, which was assembled into the oral biofilm representation here shown. (b/bottom) participants were encouraged to 'destroy a biofilm' by removing bacteria (coloured plastic pieces) encased in biofilm extracellular matrix (hair gel) with a spray bottle filled with water. there was a total of 19 comments that were coded based on their focus-with each comment possibly being coded into more than one category. our research into titanium dioxide coatings included a range of laboratory-based studies that compared different titanium dioxide concentrations in paint formulations [21] . the work described . themes identified from 'plaque attack!' feedback. there was a total of 19 comments that were coded based on their focus-with each comment possibly being coded into more than one category. our research into titanium dioxide coatings included a range of laboratory-based studies that compared different titanium dioxide concentrations in paint formulations [21] . the work described in this paper was to see whether the effect of a photocatalyst in paint could be detected by the human eye. thus, as part of a phd project investigating the activity of photocatalytic surfaces, one of the external walls of the university was used to illustrate the effectiveness of titanium dioxide paints in terms of self-cleaning and reduction of the formation of biofilm on the wall material. photocatalytic material such as titanium dioxide can exhibit self-cleaning, anti-fouling and antimicrobial properties in the presence of light, which makes these materials excellent candidates for incorporation into urban buildings and infrastructure [22] [23] [24] . the self-cleaning properties stem from their superhydrophilic nature-as, for instance, that of a liquid (e.g., rain) rolling off the surface of a continuous body. this sheeting carries away dirt and debris, cleaning the surface in the process-as seen in the sydney opera house [25] . thus, biofilm formation on the surface is delayed or prevented. in our study, the wall, comprising concrete panels (smaller panels 190 cm × 76 cm, larger panels 406 cm × 76 cm) on a 1970s university building, was west-facing (location on chester street, manchester, uk m1 5gd). six of the panels were painted with a siloxane external paint formulation that contained or lacked the photoactive pigment (kindly provided by tronox, www.tronox.com). our aim was to inform the passing public about our research (an interpretation panel was affixed to the wall), and on occasion, we encouraged passers-by to participate in a longitudinal subjective assessment of the impact of titanium dioxide-containing paint on the perceived cleanliness of the panel. this engagement activity was done directly by interview and indirectly using photographs at specific times over a 44-month period. initially there was no apparent difference in the brightness of the painted panels (figure 5a ). members of the public attending a manchester science festival event (october 2014) were asked to rank the painted panels in order of cleanliness/whiteness, with 1 being most clean, and 6 being least clean (n = 18). the experiment was also conducted via a social media platform (facebook), with participants asked to assess whiteness using photographs (n = 48). the direct assessment was repeated after three years (n = 21). in all cases, the participants ranked two or three of the photocatalytic panels as the 'whitest'. in 2014, around 60% of the participants selected the three photocatalytic panels correctly. in 2017, this figure rose to 78%. after six years, the test-paint panels appeared whiter than the control panels ( figure 5b, may 2020) . the presence of the wall with its accompanying information panel at the side of the university science and engineering building provided a useful pointer to introduce visitors to some of the research ongoing in the faculty. the use of the public to assess the cleanliness of the wall proved unnecessary within a few months, when the impact of the test paint was apparent. the fact that almost all participants could discriminate between the panels after less than 12 months was also of interest. this approach might therefore be useful in the future for the assessment of test formulations. figure 5 . images of the wall at manchester metropolitan university used in the study of photocatalytic paint (panels labelled 1-6). panels 1, 3 and 6 were painted with photocatalytic paint, whilst panels 2, 4 and 5 were painted with paint that did not contain the photocatalytic agent. the image on the top (a) was taken in 2014, eight months following the application of the paint: whiteness/brightness difference between the two paint types is hard to distinguish. the lower image (b) was taken six years later (2020); panels painted with photocatalytic paint are visibly brighter compared to control paint panels. antibiotics 2020, 9, 465 9 of 12 much was learned from each event (as noted above), particularly through observation, in terms of what components participants like and engage with when discussing biofilm. in addition, quantitative evidence of engagement was derived from the 'now wash your hands' event; qualitative evidence of enjoyment and engagement was obtained from 'plaque attack', and the potential for acquisition of research data was indicated by the photocatalytic wall activity. these various outcomes informed how subsequent events for the public would take place, with more focus on design, delivery and evaluation. more recently, there has been increasing effort to ensure that these criteria for effective public engagement are met. microbiology has a particularly dynamic approach to public engagement, and many teams are now publishing the outcomes of their public engagement research in peer-reviewed journals, magazines or online. yet, in a review of public engagement activity around amr, a rich bedrock of activity was found only through personal contacts and communication rather than through a literature search [4] . it is even more important when talking to audiences about biofilms that intended messages are clear. thus, we describe in table 1 the planning of a hypothetical public engagement event designed to inform a large number of adults about biofilm and amr. our focus was on the combination of the two phenomena, which occurs, for example, when biofilms on medical devices present increased resistance to antibiotics [26] . in order to address this combined effect, it was first necessary to define the two phenomena separately. we particularly wished to avoid intrusive aspects of evaluation, relying instead on observation and other (subjective and objective) indicators from participants. we hope that this checklist may be useful for others who might wish to engage audiences with their biofilm/antibiotic research. the national biofilm information centre has recognised the importance of public engagement and is providing a hub for the dissemination of biofilm-focused outreach and engagement activities, which will enable, over time, ideas, expertise and outcomes to be shared and developed, in order to improve the effectiveness of engagement encounters for scientists and their audiences alike. we hope that our experiences in the area are of interest in this context. public engagement activities can be designed with clear aims that enable effective evaluation using both quantitative and qualitative methods. this is particularly important for complex phenomena such as biofilms and amr. the urgent need for microbiology literacy in society simfection: a digital resource for vaccination education practical microbiology in schools: a survey of uk teachers raising awareness of antimicrobial resistance among the general public in the uk: the role of public engagement activities. jac-antimicrob role of hand hygiene in healthcare-associated infection prevention the microbial contamination of mobile communication devices fitting the message to the location: engaging adults with antimicrobial resistance in a world war 2 air raid shelter spreading the message of antimicrobial resistance: a detailed account of a successful public engagement event rsph and ifh call for a clean-up of public understanding and attitudes to hygiene 99th dahlem conference on infection, inflammation and chronic inflammatory disorders: darwinian medicine and the 'hygiene' or 'old friends' hypothesis composition of in vitro denture plaque biofilms and susceptibility to antifungals dental biofilm: ecological interactions in health and disease power toothbrushes: a critical review comparison of the effect of fluoride and non-fluoride toothpaste on tooth wear in vitro and the influence of enamel fluoride concentration and hardness of enamel antimicrobial efficacy of different toothpastes and mouthrinses: an in vitro study blast a biofilm: a hands-on activity for school children and members of the public transforming a school learning exercise into a public engagement event: "the good, the bad and the algae refreshing the public appetite for 'good bacteria': menus made by microbes research methods in education photoinactivation of escherichia coli on acrylic paint formulations using fluorescent light. dyes pigment photoinduced reactivity of titanium dioxide photocatalytic construction and building materials: from fundamentals to applications effect of process parameters on the photocatalytic soot degradation on self-cleaning cementitious materials the authors declare no conflict of interest antibiotics 2020, 9, 465 antibiotics 2020, 9, key: cord-294595-9qcu0wts authors: berardi, alberto; cenci-goga, beniamino; grispoldi, luca; cossignani, lina; perinelli, diego romano title: analysis of commercial hand sanitisers amid covid-19: are we getting the products that we need? date: 2020-10-15 journal: aaps pharmscitech doi: 10.1208/s12249-020-01818-6 sha: doc_id: 294595 cord_uid: 9qcu0wts the covid-19 pandemic has caused a sudden spike in demand and production of hand sanitisers. concerns are rising regarding the quality of such products, as the safeguard of consumers is a priority worldwide. we analyse here the ethanolic content of seven off-the-shelf hand sanitiser gels (two biocides and five cosmetics) from the italian market, using gas chromatography. the who recommends that products containing ethanol should have 60–95% (v/v) alcohol. four of the tested hand gels have ethanolic contents within the recommended range, while three products (all cosmetics) contain < 60% (v/v), i.e. 52.1% (w/w), ethanol. the product with the lowest alcoholic content has 37.1% w/w ethanol. toxic methanol is not found in any of the hand sanitisers. we show, in addition, that products with the highest ethanolic content have generally greater antibacterial activity. in conclusion, all tested products are complying with the eu regulations, as the three “substandard” products are classified as cosmetics, whose purpose is cleaning and not disinfecting. nevertheless, if such hand cleaners were inappropriately used as hand disinfectants, they might be ineffective. thus, consumer safety relays on awareness and ability to distinguish between biocidal and cosmetics hand gels. the obtained results might sensitise the scientific community, health agencies and ultimately consumers towards the risks of using hand sanitisers of substandard alcoholic concentration. if the wrong product is chosen by consumers, public health can be compromised by the inappropriate use of “low-dosed” cosmetic gels as disinfectants, particularly during the period of the covid-19 pandemic. [image: see text] electronic supplementary material: the online version of this article (10.1208/s12249-020-01818-6) contains supplementary material, which is available to authorized users. at the beginning of 2020, a new coronavirus, namely sars-cov-2, has started to spread worldwide leading to the so-called covid-19 pandemic (1) . considering that sars-cov-2 is an air-born pathogen but can also spread through surfaces, hand sanitisation has become a primary infection prevention measure (2) . as health agencies around the world have started to recommend the use of alcohol-based hand rubs (abhrs), the demand and sale of such products skyrocketed, leading to sudden shortages of this commodity in most markets (3) . in europe, many businesses have increased their production of abhrs, while others have even shifted their manufacturing lines to abhrs (4) . in this run to produce hand sanitisers, the risk of substandard products being introduced into the market could be a reality. the european community (ec) stated that "a steep increase in the submission to the cosmetics product notification portal" was notified to the ec, urging the issue of a clear guidance on legislation for production of leave-on hand cleaners and hand disinfectants (4) . it is emphasised in this guidance that hand sanitisers aiming at protecting public health by disinfecting should follow the legislation of biocidal products. cosmetic alberto berardi and beniamino cenci-goga are co-first authors. electronic supplementary material the online version of this article (https://doi.org/10.1208/s12249-020-01818-6) contains supplementary material, which is available to authorized users. hand sanitisers are instead supposed to clean and not disinfect. thus, companies must be aware that "hand disinfectants" are subject to rules established under the biocidal products-and not cosmetics products-regulation. individuals from the general public are unlikely to distinguish between cosmetic and biocidal hand sanitisers. if a cosmetic abhr is used improperly for the purpose of disinfection, then this product becomes, practically, a substandard product. disinfection in abhrs is dependent on alcoholic concentration. health agencies recommend that hand disinfectants must contain 60-95% (v/v) ethanol (5) (6) (7) . keeping this alcoholic range as the reference concentration to ensure disinfection efficacy there is a risk that cosmetic products, which are not disinfectants but might be improperly used as disinfectants, do not need to have the alcoholic concentration stated in the label and could contain ethanol in concentrations lower than the aforementioned range. in this case, the product may not be effective in killing pathogenic microorganisms. we reached this conclusion in our recently published review on hand sanitisers (3), provoking further questions that inspired the current original research. these new questions that we address here are as follows: (i) do biocidal hand sanitisers contain as much ethanol as stated in the label? and (ii) what is the actual ethanolic content in cosmetic hand sanitisers (being not mandatorily reported in the label)? is the ethanolic content within or below the range recommended by health agencies to ensure disinfection? in view to ultimately safeguard consumers, we probe here the concentration of ethanol in seven commercial ethanol-based hand sanitiser gels purchased in the italian market, two biocides and five cosmetic products, comparing the obtained results with label claims. we also assess their antibacterial properties as a preliminary result of their potential disinfection ability. the ethanol concentration (% w/w) and the antimicrobial activity of seven different abhrs was evaluated. the composition (according to label claims) and regulatory classification of the analysed alcohol gels are reported in table i . all products were purchased from a local pharmacy, except for gel 4, which was purchased in a local supermarket. ethanol was extracted from samples by headspace solidphase microextraction (hs-spme) using a fibre coated with 85-μm polyacrylate film (supelco, bellefonte, pa, usa). before use, the fibre was conditioned following the instructions of the manufacturer. an aliquot (500 mg) of each sanitising gel sample (1-7) and calibration standards was transferred to an 8-ml screw-capped amber vial with a ptfelined silicone septum. the vial was thermostated for 1 min at 30°c before spme extraction. the spme fibre was inserted into the headspace of the vial through the septum on the screw cap, then it was exposed to the headspace of the vial for 20 s at 35°c. after the extraction, spme fibre was removed from the vial and inserted into the gas chromatograph (gc) injection system for the analysis. a dani 1000 dpc (norwalk, ct, usa) gc provided with a split-splitless injector and a flame ionisation detector (fid) was used. the injector was set in splitless mode for 5 min and maintained at 250°c. a fused silica capillary column, supelcowax-10 (60 m × 0.25 mm i.d., 0.25 μm f.t.; supelco, bellefonte, pa, usa), was used for the chromatographic separation. the initial oven temperature, 65°c, was raised at 6°c/min to 155°c, and then at 20°c/min to 250°c. the detector temperature was 260°c. the carrier gas was helium with a flow rate of 1 ml/min. the chromatograms were acquired and processed using clarity integration software (dataapex ltd., prague, czech republic). the external calibration curve for the quantification of ethanol was obtained by analysing standard gel samples at a different concentration of ethanol (40-70% w/w). these gels were prepared by dispersing carbopol ® 974 (1% w/w) to the corresponding hydro-alcoholic mixture under stirring. the dispersions were left under stirring for 24 h and, then ph was adjusted to 7.0 using triethanolamine. the antimicrobial activity was tested against two different bacterial strains: staphylococcus aureus atcc 29213 for gram positive and a clinical isolated escherichia coli for gram negative. each strain was grown aerobically in nutrient broth (nb; oxoid, uk) at 37°c for 24 h. a preliminary assay was prepared in order to assess (i) the non-toxicity of the liquid culture media used for dilutions (maximum recovery diluent, mrd, oxoid, uk) of bacterial suspension, (ii) the non-toxicity of the neutraliser (d/e neutralising broth; liofilchem, italy) and (iii) the non-toxicity of the different gels after neutralisation. in order to do so, bacterial suspensions and the different diluents were left in contact at 37°c for the test period. after this, decimal dilutions were performed, samples were inoculated in triplicate on nutrient agar (na; oxoid, uk) and incubated at 37°c for 24 h. counting was performed and the total viable cell count was calculated. vitality reduction activity was tested according to the bs en 1040:2005 (european committee for standardization [ecs] , 2005) as modified by grispoldi et al. (8) , using the tested neutraliser to stop the antibacterial activity of the gels at any given time. for the assay, sterile tubes were prepared with solutions of bacterial suspension and the hand sanitisers were diluted to different v/v concentrations (33%, 50%, 66% and 75%). the solution was left in contact with the diluted abhrs for 8 min. then, the appropriate volume of neutraliser was added. after 5 min, the mixture decimal dilutions were prepared. samples were inoculated in triplicate on na and incubated at 37°c for 24 h. counting was performed and the total viable cell count was calculated. only the plates showing a number of colonies included in a 1.5 10 2 -3.0 10 3 (maximum deviation of 10%) were used to perform the result calculation (9) . a simple and rapid analytical method, hs-spme in combination with gc/fid, has been used for the extraction and quantification of ethanol in commercial hand sanitiser gels. the quantification of ethanol has been successfully performed by external standard method, with good precision and linearity. values of inter-assay coefficients of variation lower than 7.8% indicate that the technique is reproducible, while the calibration curve prepared by analysing standard gels with known content of ethanol shows linear relationship with highly significant (p < 0.01) correlation (r = 0.9971) (fig. 1a) . the concentration of ethanol (% w/w) in the tested hand sanitiser gels ranges from 37.1 ± 1.9% w/w (gel 6) to 66.1 ± 2.0% w/w (gel 5). three gels (gels 3, 4 and 6) have an average ethanolic content below the lower limit (60% v/v, i.e. 52.1% w/w) of the who recommended range (5), while four are within the recommended range. the highest ethanol concentration (≥ 60% w/w) was determined for gels 1, 2 and 5. among these, gel 2 and gel 5 are those authorised as biocides (table i) . no methanol was detected in any of the analysed gels (data not shown). after validation of the antimicrobial assay (for more information, see the supporting information), the antibacte-rial efficacy of the commercial gels was evaluated. the bactericidal activity of dilutions (from 33% v/v to 75% v/v) of the seven commercial gels upon 8 min contact with s. aureus and e. coli is shown in fig. 2 . at a concentration of 33% v/v, vitality reduction for s. aureus ranged between 0.25 cfu ml −1 (gel 4) and 4.91 cfu ml −1 (gel 2); the total viable cell count at the same concentration for e. coli was 0 for gel 2 and 7, while the vitality reduction ranged between 0.2 cfu ml −1 (gel 1) and 0.46 cfu ml −1 (gel 5) for the other gels. at a concentration of 50% v/v, the total viable cell count for s. aureus was 0 for gel 2 and 7, while the vitality reduction ranged between 0.24 cfu ml −1 (gel 3) and 7.53 cfu ml −1 (gel 5) for the other gels; at the same concentration, the total viable cell count for e. coli was 0 for gels 1, 2, 4, 6 and 7, while the vitality reduction was 0.5 cfu ml −1 for gel 3 and 8.11 cfu ml −1 for gel 5. at a concentration of 66% v/v, viable cells were observed only for s. aureus in gels 3 and 4, while no viable cells were counted for the other gels; no viable cells were counted at the same concentration for e. coli. at a concentration of 75% v/v, a complete reduction was observed for all the gels for both bacteria. *the percentage of ethanol is w/w for the products authorised as biocide, while the unit is unknown, since not reported, for the cosmetic ones **alcohols, as well as other ingredients with potential antimicrobial activity, are highlighted in bold ***n/r not reported the result of our analysis reveals that three of the seven abhrs tested have ethanolic content below the range recommended by regulatory agencies (60 to 95% v/v) (5-7). however, one of these gels, i.e. gel 3, contains , also isopropyl alcohol (table i) in addition to 52% ethanol; thus, the overall alcoholic content of this product is likely to be within the expected range for disinfection. the eu regulations for biocides (10) require that the concentration of the active (e.g. ethanol) should be stated in the label. of the two tested biocides, gel 5 has ≈ 66% (w/w) ethanol, against a label claim of 70% (w/w), and gel 2 contained ≈ 64% (w/w) ethanol, against 74% (w/w; with (1-7) . mrd is the maximum recovery diluent used as negative control ethanol 96%, corresponding to ≈ 71% with absolute ethanol) of the label claim. despite some discrepancy with the label claim, both biocides contain alcohol well within the range recommended by the health agencies. on the other hand, products containing "substandard" (< 60% v/v) concentrations of ethanol, i.e. gels 3, 4 and 6, are all cosmetics (table i) . eu regulations on cosmetics require that all ingredients should be reported in the label (11) , in descending order of weight, while there is no requirement to report the concentration of alcohol. thus, also gels 3, 4 and 6 comply with eu regulations. such products are, however, cosmetics to be used solely for cleansing purposes and not suitable for hand disinfection. a question arises to whether consumers would be able to distinguish between two basically identical hand product types, which are biocidal hand gels and cosmetics hand gels (differing only for the label). most probably many consumers are unable to choose the right product for the right purpose, with high chance that "under-dosed" (i.e. < 60% v/v of ethanol) cosmetic gels are improperly used by individuals who intend to disinfect their hands amid the covid-19 pandemic. this risk that cosmetic hand sanitisers might be sold and used inappropriately in place of disinfectants is not remote amid the covid-19 health crisis. indeed, in april 2020, after witnessing a sharp increase in the submissions to the cosmetics product notification portal, a clarification for economic operators was deemed "urgently needed" by the european commission (4). the "guidance on the applicable legislation for leave-on hand cleaners and hand disinfectants (gel, solution, etc.)" was thus promptly issued. it is worth noting that none of the abhrs tested contains any trace of methanol. the issue of methanol contamination in abhrs has been recently raised by the us fda, which has issued a list of nearly 90 "do-not-use" dangerous hand sanitisers containing methanol. among the tested products, methanol content ranged between 1 and 80% (12) . given the stringent safety measures and difficulty in sourcing and handling sars-cov-2 virus, the antibacterial test of fig. 2 aimed to provide some preliminary results on the intrinsic disinfection power of the tested abhrs. it is worth noting that to better discriminate on the antibacterial activity, hand gels were tested diluted. in agreement with their high ethanolic content and regulatory classification, both biocides (gels 2 and 5) elicit strong antibacterial activity. among the five cosmetics, the antibacterial activity is variable between products and not always directly related to the concentration of ethanol. for example, gel 7, which ranks fourth out of the seven gels in terms of ethanolic content, showed strong antibacterial effect. this can possibly be attributed to the presence of other ingredients in the formulations (e.g. preservatives and organic acids) that can have antimicrobial activity. for instance, citric acid (present in gel 7) can substantially increase viricidal activity of alcohol-based hand sanitisers (13) and it has also antibacterial activity (14) . overall, although ingredients other than alcohol can have an adjuvant antimicrobial effect, safe hand disinfection should rely exclusively on alcohol content. health agencies discourage the use of all products other than those containing at least 60% (v/v) alcohol (5) . scientists, as well, suggest not adding bactericidal agents to abhrs as they do not add clear benefits (15) , while some may increase the risk of antibiotic resistance (16) . if and once virus-like particles of sars-cov-2 will be ready available, future experimental work shall focus on the evaluation of the stability of these non-infectious viral mimics upon exposure to biocidal and cosmetics hand sanitisers. in conclusion, we propose to answer the provocative question raised in the title of this article, i.e. to whether the hand sanitisers available in the market fulfil quality needs. we demonstrated that: & the tested products fulfil the regulatory requirements specific to the class to which they belong (i.e. biocide or cosmetic). & yet, some cosmetic hand sanitisers, which alcoholic concentration is not stated in the label, contain ethanol (e.g. ≈ 40%) well below the range of concentrations recommended by health agencies for infection prevention, thus following below expected standards of disinfection. in the era of the covid-19 pandemic, when hand disinfection is deemed as a crucial infection prevention measure (3), having off-the-shelf cosmetic hand gels with sub-disinfecting concentrations of ethanol is concerning. how many from the general public are inadvertently using gels containing ≈ 40% ethanol as those tested here, expecting efficient disinfection? such problem could perhaps be mitigated by awareness campaigns, appropriate pharmacists counselling and revisions of current regulations. a system could be introduced to require manufacturers of cosmetic abhrs to add, for example, an extra label which states "not for disinfection" in a large and easily readable size. a novel coronavirus from patients with pneumonia in china aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 hand sanitisers amid covid-19: a critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand guidance on the applicable legislation for leave-on hand cleaners and hand disinfectants (gel, solution, etc show me the science -when & how to use hand sanitizer in community settings temporary policy for manufacture of alcohol for incorporation into alcohol-based hand sanitizer products during the public health emergency (covid-19) guidance for industry world health organization. who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. world health organization how to assess 371 in vitro probiotic viability and the correct use of neutralizing 372 agents effects of uv irradiation in a continuous turbulent flow uv reactor on microbiological and sensory characteristics of cow's milk. j food protinternational association for food protection regulation (eu) no 528/2012 of the european parliament and of the council of 22 may 2012 concerning the making available on the market and use of biocidal products regulation (eu) no 1223/2009 of the european parliament and of the council of covid-19) update: fda reiterates warning about dangerous alcohol-based hand sanitizers containing methanol, takes additional action to address concerning products efficacy of ethanol against viruses in hand disinfection efficacy of citric acid and sodium hypochlorite as disinfectants against mycoplasma bovis lack of sustained efficacy for alcohol-based surgical hand rubs containing 'residual active ingredients' according to en 12791 biocidal agents used for disinfection can enhance antibiotic resistance in gram-negative species publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations ab is grateful to dr. hamid a. merchant for sparking the motivation to develop this project. key: cord-327888-4g3x5dje authors: yuan, c. t.; dembry, l. m.; higa, b.; fu, m.; wang, h.; bradley, e. h. title: perceptions of hand hygiene practices in china date: 2009-02-28 journal: journal of hospital infection doi: 10.1016/j.jhin.2008.09.017 sha: doc_id: 327888 cord_uid: 4g3x5dje summary hand hygiene is considered one of the most important infection control measures for preventing healthcare-associated infections. however, compliance rates with recommended hand hygiene practices in hospitals remain low. previous literature on ways to improve hand hygiene practices has focused on the usa and europe, whereas studies from developing countries are less common. in this study, we sought to identify common issues and potential strategies for improving hand hygiene practices in hospitals in china. we used a qualitative survey design based on in-depth interviews with 25 key hospital and public health staff in eight hospitals selected by the chinese ministry of health. we found that hospital workers viewed hand hygiene as paramount to effective infection control and had adequate knowledge about proper hand hygiene practices. despite these positive attitudes and adequate knowledge, critical challenges to improving rates of proper hand hygiene practices were identified. these included lack of needed resources, limited organisational authority of hospital infection control departments, and ineffective use of data monitoring and feedback to motivate improvements. our study suggests that a pivotal issue for improving hand hygiene practice in china is providing infection control departments adequate attention, priority, and influence within the hospital, with a clear line of authority to senior management. elevating the place of infection control on the hospital organisational chart and changing the paradigm of surveillance to continuous monitoring and effective data feedback are central to achieving improved hand hygiene practices and quality of care. healthcare-associated infections (hcais) are a significant cause of morbidity and mortality among hospitalised patients, affecting more than 1.4 million people worldwide at any time. 1 although hand hygiene (i.e. hand washing with soap and water or the use of a waterless, alcohol-based hand rub) has long been considered one of the most important infection control measures for preventing hcais, compliance rates by healthcare workers with recommended hand hygiene procedures generally fall below 50%. 2 poor adherence to recommended hand hygiene procedures by healthcare workers has been shown to be related to system constraints as well as to individual, group and community behaviour. 3e5 experts in quality improvement have suggested that a multidisciplinary strategy is necessary to improve hand hygiene, including improved training, protocols, engineering controls and equipment, and routine observation and feedback. 6, 7 despite the extensive discussion in the literature about potential interventions to improve hand hygiene in the usa and europe, research from developing countries is less common. given the limited resources available in many hospital settings in developing countries, improving hand hygiene, while critical to reducing hospital-acquired infection rates, may be particularly challenging. 8 specific barriers and hence potential strategies to change healthcare workers' behaviour regarding hand hygiene in resource-poor settings remain unclear. therefore we undertook the current study to identify common issues and potential strategies for improving hand hygiene practices in hospitals in china as an example of a developing country. improving hand hygiene practices globally is a priority of the world health organization, which recently highlighted the worldwide problem of insufficient hand hygiene practices in hospitals and the need for implementation of guidelines. 1 as a developing country, improving hand hygiene in china may be particularly challenging due to resource constraints. by conducting in-depth interviews of infection control directors and key staff, we sought to describe issues of adherence to current people's republic of china's hand hygiene guidelines. we also aimed to describe potential ways of improving hand hygiene practices in the hospital from the perspectives of staff who had been involved with improvement efforts in infection control. we used a qualitative study design based on indepth interviews with key hospital and public health staff. we chose a qualitative study design because it is well-suited to exploratory studies when there is limited previous literature, and to studies seeking to describe in detail causal factors in human behaviour and organisational change that are central to improving hand hygiene in the hospital setting. 9, 10 we conducted in-depth interviews and site visits with a purposeful sample of eight hospitals identified by the chinese ministry of health (moh) as having extensive experience with improvement efforts aimed at infection control and hand hygiene. the interviewees were identified by directors of infection control as having been involved with improvement efforts. we selected hospitals and staff with experience in improvement efforts as 'information rich' sites and individuals who had adequate experience and personal knowledge of the barriers and challenges to improving hand hygiene practices, as recommended by experts in in-depth interviewing. 9 the hospitals were located in beijing (n ¼ 2), shanghai (n ¼ 3), and guangdong (n ¼ 3). a total of 25 healthcare workers of various disciplines were interviewed, including 17 formal, in-depth interviews and eight less formal discussions with physicians and nurses on patient care units. as recommended by experts in qualitative research, in-depth interviews were conducted using a standardised discussion guide consisting of openended questions and probes to encourage greater detail or clarity. 9, 11, 12 examples of questions included: 'how would you characterise hand hygiene practices among the nurses and patient care assistants here at the hospital?'; 'what about among the physicians?'; 'what have you found to be the biggest challenges in improving hand hygiene here at the hospital?'; 'how have you addressed those challenges?'. the interviews were conducted on-site by a single person who was fluent in both mandarin and english. interviews lasted between 120 and 180 min and were transcribed, translated, and then typed to facilitate formal analysis by the research team. we employed the constant comparative method of qualitative data analysis to summarise key themes that emerged from the interview and site visit data. 13, 14 data from the transcribed interviews were reviewed line-by-line by all members of the research team and coded into key concepts. all transcripts were coded by two or more researchers, first independently and then jointly, with differences resolved through negotiated consensus. the code structure was developed iteratively and was reviewed three times by the full research team to ensure its breadth and comprehensibility. hospital staff viewed proper hand hygiene as important for quality and safety both hospital and government officials stated that infection control practices were of primary importance to the quality of their hospital care. furthermore, all participants recognised the fundamental role of hand hygiene in infection prevention. hospital workers noted that hand hygiene was important for their own safety as well as the patients' well-being. as one hospital president reflected: hands are a major link to transmission of antibioticresistant microorganisms, which then cause difficulty in clinical treatment, and also waste medication and money. therefore, infection control management is very important. hospital staff also viewed the process of improving hand hygiene as having ancillary benefits, stating that the systems and strategies for improving hand hygiene could have positive 'spillover' effects for other infection control practices. these staff suggested that hand hygiene might bring about greater focus on additional behaviour changes such as use of personal protective equipment and more regular and thorough equipment decontamination practices by healthcare workers. hospital workers were knowledgeable about hand hygiene practices participants were generally well-informed about recommended hand hygiene practices, and several officials described that this knowledge had improved substantially since the severe acute respiratory syndrome (sars) outbreak. as one hospital infection control director commented: during the sars outbreak and avian flu prevention period, we had dedicated orientations for educating healthcare workers about hand hygiene. since sars, there are many more hand hygiene training sessions, and people's consciousness in this area has increased. although there was some variation among healthcare workers in their knowledge and practices regarding hand hygiene, in general, interviewees suggested that compliance had improved substantially in the previous few years since the sars outbreak. some suggested that the knowledge of hand hygiene guidelines was greater among young hospital staff or among the more educated public. whereas healthcare workers both appreciated the importance of hand hygiene and understood the recommended practices, many reported that proper practices often did not occur due to limited equipment to support hand hygiene efforts. staff remarked on inadequate budgets for the infection control department, which was viewed as a source of cost rather than as a source of revenue generation. equipment gaps included running water and soap, clean towels, and gloves. the issue of inadequate equipment and resources was highlighted by this hospital infection control director who said: even if healthcare workers' sense to do hand hygiene is strong, facilities and equipment need to improve, like having paper towels for instance. no one is willing to use publicly shared towels. they all wipe their hands on their lab coats. a primary issue that healthcare workers reported as hindering improvements in hand hygiene practices was inadequate organisational authority vested in hospital infection control departments. limited numbers and qualification of hospital infection control staff was also cited as a challenge, but the lack of organisational influence of the departments and their staff were most problematic. typically, infection control departments were managed by nurses or junior physicians, who were viewed as 'outside' the more powerful spheres of senior physicians and hospital management. despite the participants' acknowledgement of the importance of having links to senior management, in many hospitals infection control directors did not report organisationally to hospital administration. like hospital staff interviewed, several government officials also stated that infection control staff needed to have the authority to monitor and then follow up on problems with other staff in order to be effective. without adequate senior level commitment to these goals, infection control functions were unlikely to be able to make any substantial improvements in practices. as one city quality control association representative said: infection control personnel do not have power to enforce infection control guidelines: no funding, no administrative power, and no financial budgeting power. in addition to statements about infection control having inadequate access to senior management, participants also highlighted the importance of having physicians, not just nurses, represented in hospital infection control departments. participants noted the importance of physician-tophysician communication about hand hygiene in order to change behaviour. they indicated that having nurses, who may be informed about infection control, talk with physicians was unsuccessful in influencing changes in physician hand hygiene practices due to the power differentials between physicians and nurses. the physician perspective was described as important for all aspects of infection control: developing hospital policies about hand hygiene, monitoring staff adherence with policies, and providing surveillance data about hand hygiene performance to physicians. for example, one hospital infection control director commented: most infection control personnel are nurses. the hierarchical gap between physicians and nurses is important. physicians would not follow nurses' suggestions, and don't even mention their criticism. despite the obvious need for physicians in infection control departments, physician participants stated that they were not eager to work in or with infection control departments due to the lack of respect afforded to infection control clinicians by other physicians and the lower pay in such positions. an added challenge for infection control departments was their lack of autonomy from other clinical departments in the hospital. although the moh guidelines were described as recommending that the infection control departments should be independent from hospital clinical departments, many infection control staff were housed within other clinical departments and hence faced some conflicts of interest in monitoring and reporting non-adherence to hand hygiene guidelines by colleagues. one hospital infection control director made this conflict clear: we have an independent infection control department now, but soon it will be allocated to another department. it will be difficult to manage surveillance and criticism of this other department because they pay our salary and our bonus. although all hospitals had surveillance systems for monitoring hand hygiene, no system was designed to enhance adherence to recommended hand hygiene practices. several aspects of both the moh and hospital internal surveillance approaches were problematic. first, surveillance focused on outcomes such as infection rates and bacteria counts, rather than on the process of proper hand hygiene. some participants noted that data on adherence to recommended hand hygiene processes which were known to improve outcomes (reduced hcais) would provide concrete targets for improvement. however, participants also said that monitoring of hand hygiene practices was not done routinely in any hospital. the focus was on bacterial counts on sampled hands of workers. second, data were rarely actionable as they were produced from random checks and reported in unidentified ways months after the measurement. subsequently, while the data could show trends in infection rates at the hospital, they were too generalised to foster quality improvement efforts on particular patient care units. as a chinese center for disease control and prevention (cdc) representative commented: the surveillance system is primordial. the outcomes are not very sensitive to result-based surveillance of disinfection agents and sample of hands. it is more useful to get results from process-based surveillance, but it is difficult to implement in hospitals. participants also said that individual hospitals would be unlikely and perhaps unable to initiate improved data monitoring unless directed by the government, citing that there was limited understanding of quality improvement and data feedback techniques in their hospitals. participants suggested that a government mandate to do increased surveillance at the hospital level would be the best strategy to change behaviour. as one hospital infection control director noted: in china, the government's mandate is the most powerful tool. if anything has to be promoted or implemented fast, you must obtain government's administrative order first. a small minority of participants supported the development of a hospital accreditation system that might include surveillance of infection control practices, although details of how this might dovetail with existing governmental monitoring by moh or by increased government mandates were not discussed. findings from this study suggest that the primary challenges in improving hand hygiene in china are the limited authority of infection control departments in hospitals, the lack of essential resources, and the ineffective use of data monitoring and feedback to hospital staff. these insights are important as previous studies have attributed poor hand hygiene practices to individuals' knowledge and attitudes, and typical strategies to improve hand hygiene involve staff training. 15, 16 based on our study, the reasons for inadequate hand hygiene are more complicated, and strategies to address this behaviour require greater understanding of the organisational culture and systems of accountability that exist in hospitals in china. a major decision is where the hospital infection control department is on the organisational chart. in our study hospitals, infection control staff often reported within general medicine and not to senior administration. this was problematic for two reasons. first, access to senior management, who set overall goals for the hospital and who determined the allocation of resources in part, was limited or non-existent. the infection control budget was typically under the departmental level. as department heads were evaluated in part by their financial outcomes, they were less willing to allocate budget to infection control since it did not generate revenue. as a result, infection control was not included in the strategic or financial discussions of priorities in the hospital, and the infection control department director was unable to discuss directly with senior management in order to request resources for the department. second, as a result of its reporting to the same department that it was monitoring, often general medicine, some infection control directors had conflicts of interest in performing surveillance on peers within the same department, especially when in some cases they depended on the head of general medicine for their departmental budget. while this could be effective in integrating infection control in a clinical department, given that many infection control staff were nurses, their ability to influence physician behaviour was limited. based on our findings, having the infection control director report to senior management and allowing the department some independence from medicine might provide the context in which the necessary resources and organisational attention could be directed at improving hand hygiene practices. in addition to building greater management support for infection control, more modern methods of hand hygiene surveillance were needed. data monitoring and feedback is central to quality improvement techniques and has been shown to be effective in a number of clinical areas including hand hygiene. 17e19 previous studies on hand hygiene adherence have shown that, with respect to processes that staff can control, consistent and timely data feedback provide for greater accountability and improvements in the monitored process. 20e23 however, the participants in this study indicated that surveillance for hand hygiene was focused on bacterial counts on hand samples, which were randomly checked in the hospital. monitoring of observed hand hygiene practices was not generally conducted, limiting the ability to provide timely data on the action needing improvement. instruments exist to facilitate a simple process of observation and data feedback to staff on hand hygiene. 24 using the principles of quality improvement, hospitals could set targets for hand hygiene practices, implement observation-based data monitoring, and provide feedback to staff about performance. although such monitoring does require resources and attention, it can be far more effective than random checks of hand bacteria. if done in a non-punitive, learning environment, such data feedback can drive substantial and sustained improvements in healthcare worker practices. these findings should be interpreted in light of the study limitations. this was a qualitative, exploratory study in which we sought to understand in depth the reasons for inadequate hand hygiene practices in china. interviews and observations were conducted at hospitals that had had previous experience in improvement efforts directed at infection control practices and therefore may not represent the experiences in other hospitals. in addition, although we ensured that the interviewer was fluent in mandarin and was embedded in the hospitals to reduce misunderstandings and mistrust, participants may have withheld information. given the types of responses received and the guaranteed anonymity, however, we believe that participants were forthcoming. furthermore, the sample was relatively small, which is common with qualitative studies. 9 we did achieve theoretical saturation, suggesting that we obtained a comprehensive view of the issues. 9, 13 however, a broader sample with more diverse participants may have generated additional themes. finally, this was a hypothesis-generated study about the possible causes of inadequate hand hygiene in hospitals. we did nonetheless employ several strategies recommended by experts to enhance the rigor and validity of qualitative studies, including the consistent use of a discussion guide, use of researchers from diverse disciplines to conduct the analysis, and sampling until the point of theoretical saturation. 9e14 future research should test whether changes in these factors result in significant improvements in hand hygiene practices. as we strive to improve quality of hospital care, resource-poor settings present particular challenges. china, with all its economic growth, is on the verge of enormous expansion and the quality of hospital care will be a critical factor in supporting a healthy and productive population. infection control practices are of critical importance to overall quality of care and safety of healthcare workers and their patients, as well as the communities we share. despite international engagement in improving hand hygiene, all countries struggle to sustain proper hand hygiene practices in healthcare. 1 our study suggests that the core issues are about the degree to which the infection control department and its staff are given adequate attention, priority and influence within the hospital with a clear line of authority to senior management. elevating the place of infection control on the hospital organisational chart and changing the paradigm of surveillance to continuous monitoring and effective data feedback are central to achieving improved hand hygiene practices and quality of care. who guidelines on hand hygiene in health care (advanced draft): a summary e clean hands are safer hands. world alliance for patient safety. geneva: world health organization influence of role models and hospital design on hand hygiene of healthcare workers hand hygiene among physicians: performance, beliefs, and perceptions determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns behavioural considerations for hand hygiene practices: the basic building blocks improving adherence to hand hygiene practice: a multidisciplinary approach guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force. society for healthcare epidemiology of america/association for professionals in infection control/infectious diseases society of america the evolution: handwashing to hand hygiene guidance qualitative research and evaluation methods qualitative methods: what are they and why use them? the long interview basics of qualitative research: techniques and procedures for developing grounded theory the discovery of grounded research: strategies for qualitative research qualitative data analysis for health services research: developing taxonomy, themes, and theory behavioral interventions to improve infection control practices why healthcare workers don't wash their hands: a behavioral explanation out of crisis quality control handbook data feedback efforts in quality improvement: lessons learned from us hospitals increasing handwashing in an intensive care unit increasing icu staff handwashing: effects of education and group feedback teaching hospital medical staff to handwash effectiveness of a hospital-wide programme to improve compliance with hand hygiene promotion of hand hygiene techniques through use of a surveillance tool none declared. key: cord-261595-c69vfs8q authors: allegranzi, benedetta; memish, ziad a.; donaldson, liam; pittet, didier title: religion and culture: potential undercurrents influencing hand hygiene promotion in health care date: 2008-10-03 journal: am j infect control doi: 10.1016/j.ajic.2008.01.014 sha: doc_id: 261595 cord_uid: c69vfs8q background: health care–associated infections affect hundreds of millions of patients worldwide each year. the world health organization's (who) first global patient safety challenge, “clean care is safer care,” is tackling this major patient safety problem, with the promotion of hand hygiene in health care as the project's cornerstone. who guidelines on hand hygiene in healthcare have been prepared by a large group of international experts and are currently in a pilot-test phase to assess feasibility and acceptability in different health care settings worldwide. methods: an extensive literature search was conducted and experts and religious authorities were consulted to investigate religiocultural factors that may potentially influence hand hygiene promotion, offer possible solutions, and suggest areas for future research. results: religious faith and culture can strongly influence hand hygiene behavior in health care workers and potentially affect compliance with best practices. interesting data were retrieved on specific indications for hand cleansing according to the 7 main religions worldwide, interpretation of hand gestures, the concept of “visibly dirty” hands, and the use of alcohol-based hand rubs and prohibition of alcohol use by some religions. conclusions: the impact of religious faith and cultural specificities must be taken into consideration when implementing a multimodal strategy to promote hand hygiene on a global scale. health care-associated infection is a major patient safety problem worldwide, affecting hundreds of millions of patients each year. 1 hand hygiene is considered the leading measure to reduce the impact of health care-associated infections and prevent pathogen transmission in health care settings, 2,3 but compliance with hand hygiene measures remains poor overall. 4, 5 the world health organization's (who) global patient safety challenge, ''clean care is safer care,'' a core component of the who's world alliance for patient safety, 6 is dedicated to tackling the issue of health care-associated infection worldwide. 1, 7 the central strategy for achieving the goals of the challenge focuses on the development of who guidelines on hand hygiene in health care 8 and their implementation in a pilot-test phase. these guidelines consider new aspects of hand hygiene promotion, including behavioral and transcultural issues. within this framework, the present article reflects the findings of the who's task force on religious and cultural aspects of hand hygiene. the task force was created to explore the potential influence of transcultural and religious factors on attitudes toward hand hygiene practices among health care workers and to identify some possible solutions for integrating these into strategies for improving hand hygiene. research into religious and cultural factors influencing health care delivery has been conducted previously, but mostly in the field of mental health and in countries with a high influx of immigrants, where unicultural care is no longer appropriate. 9, 10 in a recent world conference on tobacco use, the role of religion in determining health beliefs and behaviors was raised and deemed a potentially strong motivating factor to promote tobacco control interventions. 11 a recent review has listed various potential positive effects of religion on health as shown by studies demonstrating its impact on disease morbidity and mortality, behavior, and lifestyle, as well as the capacity to cope with medical problems. 12 beyond these particular examples, the complex association between religion and culture and health-particularly hand hygiene practices among health care workers-remains a lightly explored, speculative area. an exhaustive literature search of the us national library of medicine's pubmed database from january 1966 to october 2007 was conducted without language restrictions. the key search terms used were ''religion,'' ''culture,'' ''hand hygiene,'' ''hand washing,'' ''hygiene,'' ''alcohol-based hand rub,'' ''buddhism,'' ''christianity,'' ''hinduism,'' ''islam,'' ''judaism,'' ''orthodox christianity,'' and ''sikhism.'' bibliographies of retrieved articles were also hand-searched for additional studies. relevant books on culture and health were consulted as well. leaders from the most important religions affiliated with the world council of churches (a fellowship of churches associated in an ecumenical movement to promote christian unity) and the muslim world league (an islamic nongovernmental organization that promotes islamic unity) were individually consulted to gather knowledge regarding the importance of hygiene, hand hygiene, and alcohol prohibition within the precepts and holy texts of their faiths. a total of 2332 articles were retrieved through the medline search. many of the articles referred to ''culture'' in the microbiological sense and had to be eliminated, together with numerous articles restricted to mental health. of the remaining articles, only 27 referred to cultural and/or religious aspects influencing health, in particular hygiene, hand hygiene practices, and alcohol prohibition according to the most important religions; these were retained for review. the literature review and consultation with religious leaders were performed by 2 of the authors (b.a. and d.p.), who identified the relevant issues to be considered and then brought these to the attention of the task force members through a formal consensus process. the task force comprised experts in infection control and behavioral theories, as well as anthropologists and psychiatrists. they met in april 2005 and were consulted by e-mail and telephone in 2006 and 2007 to finalize the article after an additional literature search. of the vast number of religious faiths worldwide, only the most widely represented were considered in this study (fig 1) . 13 for this reason, this review cannot be considered exhaustive by any means. some ethnoreligious aspects, such as practices of local, tribal, animistic, or shamanistic religions, also were evaluated. based on the literature review and the consultation of religious authorities, the most important topics identified by the task force 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 hand rubs in the light of alcohol prohibition by some religions. according to behavioral theories, 14, 15 hand cleansing patterns are most likely to be established in the first 10 years of life. this imprinting subsequently affects the attitude toward hand cleansing throughout life, particularly ''inherent hand hygiene,'' which reflects the instinctive need to remove dirt from the skin. the attitude toward hand cleansing in more specific opportunities, called ''elective hand hygiene practice,'' more frequently corresponds to the indications for hand hygiene during health care delivery. 2, 8 in some populations, both inherent and elective hand hygiene practices may be deeply influenced by cultural and religious factors, although establishing whether a strong inherent attitude toward hand hygiene directly determines an increased elective behavior has proven difficult. hand hygiene can be practiced for hygienic reasons, for ritualistic reasons during religious ceremonies, and for symbolic reasons in specific everyday life situations (table 1) . islam, judaism, and sikhism have precise rules for handwashing specified in holy texts, and this practice punctuates several crucial times of the day. in the sikh culture, hand hygiene is not only a holy act, but also an essential element of daily life. islam places great emphasis on cleanliness 10 in both its physical and spiritual aspects, and the qu'ran gives clear instructions as to how this should be carried out (table 1) . 16, 17 with the exception of the ritual sprinkling of holy water on hands before consecration of the bread and wine and the washing of hands after touching the holy oil (the latter in the catholic church), the christian faith does not include definite indications for hand cleansing. in general, the indications given by christ's example refer more to spiritual behavior, but the emphasis on this specific viewpoint does not imply that personal hygiene and body care are not important in the christian way of life. similarly, the buddhist faith has no specific indications regarding hand hygiene in daily life or during ritual occasions, apart from the hygienic act of washing hands after each meal. culture also may be an influential factor regardless of religious background. in certain african countries (eg, ghana and some other west african countries), hand hygiene is commonly practiced in specific situations of daily life according to ancient traditions; for instance, hands always must be washed before raising anything to one's lips. furthermore, it is customary to provide facilities for hand aspersion (a bowl of water with special leaves) outside the house door to welcome visitors and allow them to wash their face and hands before even inquiring of the purpose of their visit. unfortunately, the hypothesis that community behavior influences health care workers' professional behavior has been corroborated by only scanty scientific evidence. in particular, we found no data on the impact of religious norms on hand hygiene compliance in health care settings in which religion is very deep-seated. this topic merits further research from a global perspective to identify the most effective components of hand hygiene promotion in these communities. hand use and specific gestures are universal but have considerable significance in certain cultures. 18 the most common popular belief regarding the hands in african, hindu, jewish, and muslim cultures is to consider the left hand ''unclean'' and reserved solely for ''hygienic'' reasons, with the right hand used for offering, receiving, eating, and gesticulating. in the sikh culture, as in mahayana and tibetan buddhism, a specific cultural meaning is given to the habit of folding the hands together as a form of greeting, in prayer, or as a mark of respect. studies have demonstrated the importance of the role of gestures in teaching and learning, and there is certainly a potential advantage to considering this in the teaching of hand hygiene, particularly in its representation in pictorial images for different cultures. 19, 20 in multimodal strategies to promote hand hygiene, posters placed in key points in health care settings have proven to be very effective tools for reminding health care workers to cleanse their hands. 2, 8, 21 efforts to consider specific hand uses and gestures according to local customs in visual posters, including education and promotion material, may help convey the intended message more effectively. this area also merits further research. both the centers for disease control and prevention 2 and the recent who guidelines 8 recommend that health care workers wash their hands with soap and water when visibly soiled. otherwise, rubbing the hands with an alcohol-based formulation is recommended as the preferred practice for all other hand hygiene indications during patient care, because it is faster, more effective, and better tolerated by the skin. but infection control practitioners find it difficult to precisely define the meaning of ''visibly dirty'' and to provide practical examples when teaching hand hygiene. from a transcultural perspective, finding a common understanding of this term is even more difficult; for example, a spot of blood or other proteinaceous material is more difficult to see on very dark skin. furthermore, in a hot and humid climate, the need to wash the hands with fresh water also may be driven by the feeling of sticky or humid skin. according to some religions, the concept of dirt is not strictly visual and reflects a wider meaning, referring to interior and exterior purity. 22, 23 among some health care workers, such a perspective may lead to the perceived need to wash the hands with water when feeling ''impure'' and may be an obstacle to the use of alcohol-based hand rubs. the cultural issue of feeling cleaner after handwashing rather than after hand rubbing actually was raised recently during a widespread hand hygiene campaign in hong kong and may underlie the inability to sustain the excellent hand hygiene compliance attained during the recent severe acute respiratory syndrome (sars) pandemic (w.h. seto, personal communication). from a global perspective, the foregoing considerations underscore the importance of making every possible effort to consider the concept of ''visibly dirty'' in accordance with racial, cultural, and environmental factors, and to adapt it to local situations with appropriate strategies to promote hand hygiene. based on scientific evidence, the use of alcoholbased hand rubs is considered the gold standard for hand hygiene in health care. 2, 3, 8, 16, 24, 25 for this purpose, who recommends specific alcohol-based formulations that take into account antimicrobial efficacy, local production, distribution, safety, and cost issues at a country level worldwide. 7 in some religions, alcohol use is prohibited or considered an offense requiring a penance (sikhism) or is considered to cause mental impairment (hinduism, islam) ( table 2) . nonetheless, in theory, those religions with an alcohol prohibition in everyday life demonstrate a pragmatic vision that allows acceptance of the most valuable approach in the perspective of optimal patient care delivery. despite this generally tolerant approach, however, the religious background still may influence some health care workers who are unwilling to use alcohol-based formulations due to either reluctance to come in contact with alcohol or concerns about alcohol ingestion, inhalation, or skin absorption. 8, 26 even the designation of a product simply as an ''alcohol-based formulation'' could become an obstacle for the implementation of worldwide recommendations. islamic tradition poses the toughest challenge to alcohol use. alcohol is clearly defined as forbidden (haram) in islam, and some muslim health care workers may feel ambivalent about using alcohol-based hand rub formulations. but in fact the qu'ran permits the use of any substance that man can manufacture or develop to reduce illness or contribute to better health, including alcohol used as a medicinal agent. similarly, cocaine is allowed for use as a local anesthetic, but not as a recreational drug. to better understand muslim health care workers' attitudes toward alcohol-based hand cleansers in an islamic country, the study by ahmed et al 26 conducted in the kingdom of saudi arabia is very instructive. interestingly, although saudi arabia is considered the historic epicenter of islam, no state policy or permission or fatwa (islamic religious edict) was sought for the approval of alcohol-based hand rubs. indeed, hand rub dispensers have been installed in numerous health care settings since 2005. 26 this experience demonstrates that alcohol-containing hand rub solutions are indeed finally acceptable to many muslim health care workers, even within an islamic kingdom legislated by sharia (islamic law), and this may encourage other muslims to reconsider their attitude (fig 2) . one concern of health care workers regarding the use of hand rub formulations is the potential systemic diffusion of alcohol or its metabolites after skin absorption or airborne inhalation. only a few anecdotal and unproven cases of alcohol skin absorption leading to clinical symptoms have been reported in the literature. 27, 28 in contrast, reliable studies on human volunteers clearly demonstrate that the quantity of alcohol absorbed after application is minimal and well below toxic levels for humans. [29] [30] [31] [32] in a study mimicking high-quantity, high-frequency use, 31 the cutaneous absorption of 2 alcohol-based hand rubs 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 the participants, isopropanol was not detected. finally, alcohol smell on the skin may be an additional barrier to the use of hand rubs; further product development should be conducted to eliminate this smell from hand rub preparations. in addition to targeting areas for further research, some possible solutions to existing problems may be identified (table 3) . for example, starting in childhood, the inherent nature of hand hygiene, which is strongly influenced by religious habits and norms in some populations, could be shaped in favor of an optimal elective behavior toward hand hygiene. indeed, some studies have demonstrated that it is possible to successfully educate children of school age to practice optimal hand hygiene to help prevent common pediatric community-acquired infections. [33] [34] [35] when preparing such guidelines, international and local religious authorities should be consulted and their advice clearly reported. an example of this is the statement issued by the muslim scholars' board of the muslim world league at its 16th annual meeting 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.'' 36 in hand hygiene promotion campaigns in health care settings in which religions prohibiting the use of alcohol are represented, educational strategies should include focus groups on this topic to allow health care workers to openly raise their concerns regarding the use of alcohol-based hand rubs, help them understand the scientific evidence underlying this recommendation, and identify possible solutions to overcome obstacles ( table 3) . results of these discussions could be summarized in an information leaflet to be produced and distributed locally. it has been suggested that in settings in which the observance of related religious norms is very strict, the term ''alcohol'' be avoided in favor of the adjective ''antiseptic'' when describing hand rubs. but concealing the true nature of the product by using a nonspecific term may be construed by some as deceptive and considered unethical. further research is needed before any final recommendation along these lines can be made. finally, the opportunity to involve patients in a multimodal strategy to promote hand hygiene in health care should be carefully evaluated. despite its potential value, this intervention may be premature in settings in which religious proscriptions are taken literally; rather, it could be a later step, after the achievement of awareness and compliance among health care workers. religious faith has made many important contributions to the ethics of health care and has helped focus the attention of health care providers on both the physical and spiritual nature of humans. however, wellknown examples exist of health interventions in which a religious viewpoint had a critical impact on implementation or even interfered with it. 37, 38 an awareness of commonly held religious and cultural beliefs is vital when attempting to apply innovative concepts of modern medicine and implementing good clinical practice in today's increasingly mobile, multicultural health care community. in response to the challenge of incorporating an understanding of religious and cultural beliefs into programs to promote hand hygiene compliance, our study has identified some of the implications of those beliefs, has offered some potential solutions in response, and has suggested some areas for future research. the global patient safety challenge guideline for hand hygiene in health care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force. society for healthcare epidemiology of america/association for professionals in infection control/infectious diseases society of america hand hygiene and patient care: pursuing the semmelweis legacy perneger tv, and the members of the infection control program. compliance with handwashing in a teaching hospital hand hygiene among physicians: performance, beliefs, and perceptions patient safety: a global priority clean care is safer care: a worldwide priority world health organization. who guidelines on hand hygiene in health care (advanced draft) hand hygiene: simple and complex culturally sensitive care of the muslim patient religion-based tobacco control interventions: how should who proceed? religion and health: a review and critical analysis the 2005 annual megacensus of religions why healthcare workers don't wash their hands: a behavioral explanation behavioural considerations for hand hygiene practices: the basic building blocks muslim teaching gives rules for when hands must be washed maintaining cleanliness and protecting health as proclaimed by koran texts and hadiths of mohammed savs you need hands constructing shared understanding: the role of non-verbal input in learning contexts teachers' gestures facilitate students' learning: a lesson in symmetry effectiveness of a hospital-wide programme to improve compliance with hand hygiene culture, religion and patient care in a multi-ethnic society. london: age concern books culture, religion and patient care in a multi-ethnic society. london: age concern books use alcohol hand rubs between patients: they reduce the transmission of infection cost implications of successful hand hygiene promotion hand hygiene and the muslim healthcare worker topical absorption of isopropyl alcohol induced cardiac and neurologic deficits in an adult female with intact skin gait disturbance, confusion and coma in a 93-year-old blind woman dermal absorption of isopropyl alcohol from a commercial hand rub: implications for its use in hand decontamination alcohol-based hand sanitizer: can frequent use cause an elevated blood alcohol level? can alcohol-based hand-rub solutions cause you to lose your driver's license? comparative cutaneous absorption of various alcohols quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans effect of hand sanitizer use on elementary school absenteeism effect of handwashing on child health: a randomized controlled trial a systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children resolutions of the islamic fiqh council crusading for change key: cord-272912-2wv4mfzl authors: mukherjee, ramanuj; roy, pritha; parik, madhav title: achieving perfect hand washing: an audit cycle with surgical internees date: 2020-10-06 journal: indian j surg doi: 10.1007/s12262-020-02619-8 sha: doc_id: 272912 cord_uid: 2wv4mfzl the aim of this study is to achieve 100% compliance in surgical hand antisepsis along with identification of areas of worst compliance and efficacies of various interventions best suited to deal with them. this audit was performed over 6 days in a tertiary care hospital in calcutta, india, with 42 surgical internees. compliance to ideal hand washing technique was recorded after each attempt with the first attempt as baseline. video demonstration, personal demonstration by a consultant, and individual instruction were used as subsequent interventions to achieve 100% compliance. the baseline level of compliance was found to be 33.59%. a total of 6 attempts was required to achieve 100% compliance, with the increase in compliance being statistically significant (p = 0.0294). personal instruction was found to be the most effective intervention. hand washing technique was the criterion that needed the most number of attempts (n = 6) to rectify. this study found video-based instruction and individual guidance effective teaching tools for surgical hand disinfection and gave novel data regarding the reasons responsible for poor compliance to proper hand washing in a general surgical setting. this study demonstrated the efficiency of audit cycles in the improvement of surgical hand washing and can be the preferred mode of intervention in future studies aimed at achieving ideal hand antisepsis. in the twenty-first century, hand washing has become an essential practice in the field of healthcare, even though the relationship between hand washing and spread of infections was established about two centuries ago [1] . it is well established in current scientific literature that cross infection of patients from the hands of the care giver results in healthcare-associated infection (hcai) [2, 3] . hcai is a global problem as it leads to increased morbidity and mortality amongst patients and development of resistance amongst microorganisms due to the rampant use of antimicrobials and is a huge economic burden for patients as well as healthcare systems. hcai is specially challenging to deal with in developing countries due to limited resources and the lack of reliable investigations, monitoring and standardization of medical records. this along with factors like overcrowding, understaffed healthcare systems and the lack of nationwide surveillance leads to the several-fold higher incidence of hcais in developing countries compared with developed countries [4] . thus in india, education regarding proper hand hygiene in all tiers of healthcare delivery becomes all the more essential. this bears all the more significance with the emergence and global spread of covid-19, declared a pandemic by the who on march 11, 2020 . proper hand washing can help protect healthcare providers from contracting the virus themselves, in turn preventing them from transmitting it further to their patients [5] . to reduce the incidence of hcai, the who recommends five situations where hand washing is deemed necessary: (1) before patient contact; (2) before an aseptic task; (3) after body fluid exposure risk; (4) after patient contact; and (5) after contact with patient surroundings [6] . surgeons all over the world routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient microorganisms and inhibit the growth of resident microorganisms. the world health organization (who)-recommended guidelines for surgical scrubbing are thus a useful tool for achieving optimum hand hygiene and are followed in our institution. even though surgical hand scrubbing is practised worldwide, noncompliance has been noted in its various aspects by different researchers [7, 8] . thus, an audit cycle was conducted in the general surgery department of our institution with surgical interns to achieve a 100% compliance rate in surgical hand washing. this audit cycle was performed in a general surgical unit of a tertiary medical care centre in india, with 42 surgical internees over a period of 6 days from june 1, 2020, to july 1, 2020. on the first day, all participants were asked to wash their hands after entering the operation theatre. this attempt (attempt 1) was observed, and a video tutorial was then displayed to all candidates not following ideal hand washing protocol [10] . on the following day, the same procedure was repeated, and results were recorded (attempt 2). for subjects still unable to follow the ideal method, a demonstration of proper technique was done by a consultant surgeon followed by attempt 3 the next day. subjects still failing to follow proper procedure were then given personal demonstrations, and individual mistakes were addressed by the consultant. this intervention was done every day till the entire group showed 100% efficacy on the sixth day (attempt 6). during each attempt, the participants were observed by three consultants from a single surgical unit, who graded them based on their compliance to the checklist in table 1 . the same protocols were followed by all units of the hospital. flow chart of attempts 1-6, the interventions at each step and the success rates have been depicted in fig. 1 . a total of 42 undergraduate general surgical internees participated in the audit cycle conducted over 6 days with an end goal of 100% efficacy in hand washing according to the hand washing checklist shown in table 1 [9] . in attempt 1 on the first day, 14 and 6 participants were found to comply with only points 1 and 4 of the checklist, respectively, and all of the 42 participants were compliant with the remaining 12 points. every attempt by each of the participants in each individual checklist criterion was counted as a single unit, and the success rate of each attempt was determined based on the percentage of correct attempts with respect to the total number of attempts. success units were calculated by adding the total number of new criteria the participants fulfilled after each intervention, and the success rates of the attempts were determined. once a participant correctly performed one step of the 14 step checklist, he/she was considered to have mastered that aspect of hand washing and was not evaluated on that step in successive attempts. once all the participants eligible for a particular criterion on the checklist performed it correctly, that criterion was called a successful criterion and was not hands are rubbed to create a lather 10. a copy of the 10 steps to effective hand hygiene wall chart is prominently displayed at each wash basin 11. the lather is rubbed over all surfaces of the hands for 10-15 s, including the thumbs, between the fingers, fingertips and the wrist 12. hand are rinsed thoroughly under running water drying of hands 13.taps are turned off using wrist/elbow levers or using a clean paper towel 14. hands are dried using paper towels monitored for data collection in the successive attempts (bold marking in table 2 ). a total of 42 undergraduate general surgical internees were monitored for their hand washing skills, and necessary interventions were carried out for rectification of mistakes in different aspects of hand washing. as the participants improved their hand washing technique, the number of total units in each attempt decreased from 524 in attempt 1 to 4 in attempt 6, as shown in table 2 . in attempt 1 (baseline data), the success rate was 33.59%. after the video demonstration of hand washing, the success rate increased to 41.38%, and after a real life demonstration by the consultant, it increased to 65.69%. thereafter, three rounds of individual guidance by the consultant were required to increase the success rates from 71.43% in attempt 4 to 80% in attempt 5 and finally 100% in attempt 6. the increase in success rates or the improvement of hand washing across the six attempts was found to be statistically significant (p = 0.0294). maximum number of five successful criteria was found in attempt 4 after intervention 3 and thus attempt 4 was statistically the most significant attempt; in other words, intervention 3 which is personal guidance by the consultant was statistically the most significant intervention in improving hand washing practices. attempt 4 was followed by attempt 3 with 3 successful criteria, attempts 1 and 5 (2 successful criteria each) and finally by attempts 2 and 6 (1 successful criterion each). criteria with > 70% success rate in any attempt are mentioned in italics in table 2 . according to the individual criterion in the hand washing checklist (table 1) , best adherence was noted in criteria 7 (dispensed liquid soap used) and 10 (a copy of the 10 steps to effective hand hygiene wall chart is prominently displayed at each wash basin) with 100% success rates for each of the criteria in attempt 1. in attempt 2, criterion 8 (liquid soap applied to wet hands) had a success rate of 100%, while in attempt 3, criteria 1 (hands and wrists are free from watches and jewellery), 3 (sleeves are short or rolled up during hand washing) and 9 (hands are rubbed to create a lather) achieved 100% success rates. in attempt 3, maximum number of criteria were seen to achieve a success rate of > 70%-criteria 4 (cuts are covered with a waterproof dressing), 12(hands are rinsed thoroughly under running water), 13(taps are turned off using wrist/elbow levers or using a clean paper towel) and fig. 1 flowchart displaying the study methodology, with the attempts and interventions made at each step 14(hands are dried using paper towels). in attempt 4, as mentioned before, 5 successful criteria were seen-2 (nails are short and without nail extensions and varnish), 4, 12, 13 and 14, and > 70% success rate was seen in 2 criteria-5 (hands are wet under continuously running water) and 6 (warm water is used to wash hands). however, as hand washing is an extremely important practice in the surgical setting, a 100% efficiency rate was targeted in the project, thus making attempt 4 (4 successful criteria) more significant than attempt 3 (3 successful criteria). in attempt 5, 100% success rates were documented in criteria 5 and 6. worst adherence was noticed in criteria 12, that is, proper hand washing technique, and it was also the most resilient against change being the only aspect of hand washing requiring six attempts and 5 interventions for 100% success. hand washing is defined by the who guidelines on hand hygiene in health care as washing hands with plain or antimicrobial soap and water [1] . with the advent of hand washing in a healthcare setup in early nineteenth century, it has remained as one of the most valuable practices in prevention of nosocomial infections. the practice of hand cleansing with chloride compounds as documented by ignaz semmelweis in an obstetrics clinic in 1846-1847 has evolved over decades to give rise to the concept of 'hand hygiene' used widely in current clinical setting. 'hand hygiene' is a general term referring to any action of hand cleansing which includes various components of hand washing, hand rubbing and hand care [1] . in the history of hand hygiene, surgical hand antisepsis deserves special mention as invasive procedures quite understandably are associated with increased risk of transmission of infective organisms from surgeons to patients and results in surgical site infections and sepsis [11] . joseph lister had documented the effect of hand disinfection with carbolic acid on reduction of wound infections from 1827 to 1912 [12] . surgical hand washing with antiseptic hand wash was found to be broad spectrum but slow acting and less efficacious, whereas antiseptic hand rubs (alcohol based) were broad spectrum and fast acting but were with less persistent activity [1] . us guidelines summed that agents used for surgical hand scrubs should be a non-irritant antimicrobial agent that significantly reduces microorganisms on intact skin, have broadspectrum activity, and be fast-acting and persistent [13, 14] . the data collection template given in the study published on october 2018 named 'hand hygiene -quality improvement toolkit for infection prevention and control in general practice' formulated by primary care quality and information service under the national public health service for wales has been used as a reference standard for this study [9] . in the abovementioned study, an effective hand washing technique has been shown to involve three stages-hand preparation, washing and rinsing and drying. a total of 14 criteria for optimum hand washing were suggested, and these have been monitored in the current audit cycle. the current study evaluated 42 surgical internees for compliance to hand washing guidelines shown in table 1 . it was seen that none of the participants were able to perform ideal hand washing in the first attempt, and data collected in attempt 1 prior to any interventions showed a compliance rate of only 33.59% across the 14 criteria. this is well below the compliance rates in the study conducted by basurrah et al. (69.2% in internees) but higher than that found in the studies conducted by salemi [18] . in our study, the video demonstration done as the first intervention resulted in 100% compliance in the category of liquid soap on hand-an increase by 26.19% from the previous attempt. it also resulted in more than 70% compliance rate in four other categories. however, in our study, it was seen that demonstration of proper hand washing technique by a consultant (intervention 3) to the individual participants and addressing their individual drawbacks was the most effective intervention in achieving better compliance to ideal protocols. it led to 100% compliance rates in five categories of hand washing, with a maximum increase of 33.3% in the category involving clipping of nails prior to surgical hand washing. the importance of individual guidance in surgical hand washing noted in our study is in agreement to the findings of salemi et al., in which 70% of participants were able to recall the personal presentations [16] . in the stage of hand preparation, nail varnish or artificial nails are regarded as major risk factors for transmitting infections by altering the growth of normal skin flora and have been thoroughly discouraged in a clinical setting [19] [20] [21] . in addition, surgical teams should avoid any form of hand jewellery (except nonstoned wedding rings) or watches to maintain optimum hand hygiene [9, 20, 22, 23] . in the current study, it was noticed that it took four attempts for all the participants to achieve optimum nail hygiene during surgical hand washing. the 14 participants who initially were wearing some form of hand jewellery during hand washing took three attempts to comply with the guidelines. any cuts or portions of damaged skin are prone to harbour increased number of microorganisms leading to an increased risk of cross infection between the care giver and the patient. thus water-proof dressing of cuts before surgical hand washing is essential [24] . however, it took four attempts for the 6 participants of this study having cuts on their hands to achieve 100% compliance rate in this section. in the stage of hand washing, the hands should be first made wet with tepid running water and only then followed by the application of soap/hand wash, which should come in contact with all the surfaces of the hand and rubbed to form adequate lather [9] . in this study, it was found that following this correct sequence of activities during hand washing was difficult for the participants with uniform application of liquid soap on hand, formation of lather and wetting hands before application of soap took respectively two, three and five attempts to master. however, as the medical institution has a universal supply of warm water to all the operation theatres and wall charts showing proper hand washing technique are hung near the wash basin outside the elective general surgical operation theatres, a 100% compliance in these two fields have been noted in the first attempt. even though the use of warm water has been mentioned as a criterion under optimum hand washing in the template used in this study, water temperature has not been found to be a critical factor in removal of microorganisms from the hand during hand washing according to the who guidelines published in 2009 [1] . in contrast, in a study comparing water of various temperatures (4â°c, 20â°c and 40â°c) used in hand washing showed a significant level of skin irritation associated with higher temperatures of water as water of higher temperatures are found to remove protective fatty acids from the skin of the hand [25] . in our study, the ten steps of optimum hand washing required the most number of attempts (six) to be completely corrected. as audit cycles on hand washing including these criteria have not been discovered in the literature search, correlation of these findings with worldwide prevalence could not be performed. proper method of hand drying after hand washing is equally important as in this stage, there might be recontamination of hands with infective agents [26] . 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; no significant difference in the efficacy of the methods was reported [27] . however, articles contradicting this finding are available, and further research in this field needs to be performed before formulation of a universal guideline can be done [28, 29] . if any type of towel is used for hand drying, it must be discarded without touching the disposal bins to prevent recontamination [9] . sterile cloth towels are used in our institution, and both turning off the tap and hand drying with towels took four attempts in our audit to achieve 100% efficacy. recognizing this aspect of hand hygiene is predicted to improve practices related to hand hygiene in health sectors [26] . in light of the current global health crisis, proper hand hygiene in all healthcare providers assumes an even greater significance. with a case fatality rate of 2.3% reported by the chinese cdc, covid-19 represents one of the greatest public health emergencies in recent times [30] . it is known to spread via droplet transmission and by fomites, thereby leaving healthcare providers at great risk of contracting the virus themselves, as well as spreading it further amongst their patients and the community at large [6] . proper hand washing practices thus can be a powerful weapon to help control this pandemic not just in surgical specialities, but for other medical disciplines as well. hand washing is a well-documented method to prevent surgical site infections, with baseline data showing suboptimal compliance in our institution. the results of this audit are a representation of the efficacy of the use of instructional videos and personal supervision as tools for attaining 100% compliance in the field of surgical hand washing. this study model can be expanded to achieve complete departmental coverage and can also act as a template for similar studies in the future. however, an objective microbiological distribution analysis along with appropriate follow-up is needed for assessing the long-term benefit arising from the programme. the use of cctv cameras can also be made to limit any observation bias. who guidelines on hand hygiene in health care surgical hand antisepsis: the evidence hand washing and surgical hand antisepsis healthcare-associated infection in developing countries: simple solutions to meet complex challenges national patient safety agency (npsa) patient safety alert second edition compliance with hand hygiene guidelines and determinants of compliance are we following the who recommendations for surgical scrubbing hand hygiene quality improvement toolkit for infection prevention & control in general practice. national public health service for wales who (2015) who: how to handwash? with soap and water guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force lister revisited: surgical antisepsis and asepsis the prevalence of nosocomial infection in intensive care units in europe. results of the european prevalence of infection in intensive care (epic) study. epic international advisory committee faucet aerators: a source of patient colonization with stenotrophomonas maltophilia hand washing and gloving practice among health care workers in medical and surgical wards in a tertiary care centre in riyadh, saudi arabia hand washing and physicians: how to get them together compliance with hand washing in health care settings video-based instructions for surgical hand disinfection as a replacement for conventional tuition? a randomised, blind comparative study effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers guidelines on hand hygiene in health care (2006) current issues and forthcoming events pathogenic organisms associated with artificial fingernails worn by healthcare workers guideline for hand hygiene in healthcare settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/ shea/apic/idsa hand hygiene task force european norms in hand hygiene infection control prevention of healthcare associated infection in primary and com effects of water temperature on surfactant-induced skin irritation residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial efficiency of hand drying for removing bacteria from washed hands: comparison of paper towel drying with warm air drying dispersal of bacteria by an electric air hand dryer the novel coronavirus pneumonia emergency response epidemiology team (2020) the epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (covid-19) -china publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors declare that they have no conflicts of interest. key: cord-290441-r4tzodkj authors: iversen, anne-mette; stangerup, marie; from-hansen, michelle; hansen, rosa; sode, louise palasin; kostadinov, krassimir; hansen, marco bo; calum, henrik; ellermann-eriksen, svend; knudsen, jenny dahl title: light-guided nudging and data-driven performance feedback improve hand hygiene compliance among nurses and doctors date: 2020-11-10 journal: am j infect control doi: 10.1016/j.ajic.2020.11.007 sha: doc_id: 290441 cord_uid: r4tzodkj background: evidence-based practices to increase hand hygiene compliance (hhc) among healthcare workers are warranted. we aimed to investigate the effect of a multimodal strategy on hhc. methods: during this 14-months prospective, observational study, an automated monitoring system was implemented in a 29-beds surgical ward. hand hygiene opportunities and alcohol-based hand rubbing events were measured in patient and working rooms (medication, utility, storerooms, toilets). we compared baseline hhc of healthcare workers across periods with light-guided nudging from sensors on dispensers and data-driven performance feedback (multimodal strategy) using the student's t-test. results: the doctors (n=10) significantly increased their hhc in patient rooms (16% vs. 42%, p<0.0001) and working rooms (24% vs. 78%, p=0.0006) when using the multimodal strategy. the nurses (n=26) also increased their hhc significantly from baseline in both patient rooms (27% vs. 43%, p=0.0005) and working rooms (39% vs. 64%, p<0.0001). the nurses (n=9), who subsequently received individual performance feedback, further increased hhc, compared with the period when they received group performance feedback (patient rooms: 43% vs. 55%, p<0.0001 and working rooms: 64% vs. 80%, p<0.0001). conclusions: hhc of doctors and nurses can be significantly improved with light-guided nudging and data-driven performance feedback using an automated hand hygiene system.  doctors (surgeons) have lower baseline hand hygiene compliance than nurses  light-guided nudging and data-driven performance feedback improve compliance  individual performance feedback might be more effective than group feedback  the sani nudge system detects more opportunities than using manual observations  nurses and doctors disinfect hands more often after rather than before patient contact background evidence-based practices to increase hand hygiene compliance (hhc) among healthcare workers are warranted. we aimed to investigate the effect of a multimodal strategy on hhc. during this 14-months prospective, observational study, an automated monitoring system was implemented in a 29-beds surgical ward. hand hygiene opportunities and alcohol-based hand rubbing events were measured in patient and working rooms (medication, utility, storerooms, toilets). we compared baseline hhc of healthcare workers across periods with light-guided nudging from sensors on dispensers and data-driven performance feedback (multimodal strategy) using the student's t-test. the doctors (n=10) significantly increased their hhc in patient rooms (16% vs. 42%, p<0.0001) and working rooms (24% vs. 78%, p=0.0006) when using the multimodal strategy. the nurses (n=26) also increased their hhc significantly from baseline in both patient rooms (27% vs. 43%, p=0.0005) and working rooms (39% vs. 64%, p<0.0001). the nurses (n=9), who subsequently received individual performance feedback, further increased hhc, compared with the period when they received group performance feedback (patient rooms: 43% vs. 55%, p<0.0001 and working rooms: 64% vs. 80%, p<0.0001). hhc of doctors and nurses can be significantly improved with light-guided nudging and data-driven performance feedback using an automated hand hygiene system. light-guided nudging and data-driven performance feedback improve hand hygiene compliance among nurses and doctors background hospital-acquired infections (hais) continue to burden patients, healthcare workers (hcws) and society by increasing morbidity, mortality, absenteeism and treatment costs (1-3). the covid-19 pandemic has underlined the importance of effective infection prevention measures in hospitals, including proper hand hygiene. hcws are at the front-line, and their constant exposure to infected patients and contaminated surfaces puts them at risk of acquiring and transmitting pathogens (4) . their adherence to hand hygiene guidelines is vital in combatting infectious diseases in hospitals, especially hais and now also sars-cov-2 (5). adequate hand hygiene among hcws can prevent an estimated 15-30% of the hais (6-8) but compliance remains suboptimal (9) . many strategies have tried to improve the hand hygiene compliance (hhc) of hcws but most effects are small to moderate and often short term (6, 10, 11) . a recent cochrane review identified 26 studies which assessed the combinations of the following strategies: availability, education, reminders (verbal and written), performance feedback, administrating support and staff involvement. the authors conclude that the strategies may improve the hhc, but the certainty of evidence varies from low to moderate and the most effectful method remains unclear (12) . two systematic reviews found that multimodal strategies were more successful in improving hhc rates of hcws than single interventions (13, 14) . moreover, the improvement strategies directed towards education, motivation and continuous feedback proved to be effective. the authors also conclude that we should be more creative in the application of alternative improvement activities. now automated hand hygiene monitoring systems create an opportunity to provide real-time data and feedback using light-guided nudging (sani nudge; copenhagen, denmark, https://saninudge.com. accessed sep 20, 2020) . the author group has previously described their experiences with the automated hand hygiene monitoring system from a development and implementation perspective (15) . nudging is a friendly reminder to encourage desired behavior. it can be anything from posters to sounds or dynamic lights that change over time to mitigate "banner blindness". however, the impact of nudges on clinicians' behavior has only recently started to be formally evaluated and it is mostly investigated using static interventions, such as posters, signs, stickers, brochures, letters and emails (16, 17) . given the potential of 'nudge' strategies to impact on clinicians' behaviors, efforts to describe the application and potential effect of such strategies on hhc are warranted. we aimed to determine if a multimodal strategy, consisting of light-guided nudging and data-driven performance feedback on group and individual levels, can be used in a clinical context as a supporting tool to improve hhc among hcws. we conducted a single-site, prospective, observational, quality improvement study between february 2018 and april 2019 in a surgical department with 29 beds (3 single, 1 twin and 8 multi bedrooms) as a substudy of a multiregional project (15) . some data from the present cohort have been published elsewhere (15) . however, the hand hygiene improvement data have not previously been reported. this ward was chosen because it had a history of infectious disease outbreaks and, although normally contained within few weeks, we had the assumption that hand hygiene could be improved. in denmark, who's "my 5 moments for hand hygiene" is the standard practice (18, 19) . we focused on alcohol-based hand rubbing based on the danish national hygiene guidelines for hcws stating that hand washing must always be followed by alcohol-based hand rubbing (19) . we included both doctors and nurses from the surgical ward of which 17 of the nurses were also included in our previous study (15) . participation in the study was voluntary and data were anonymized to both study participants and investigators, except from a group of 9 nurses who volunteered to receive their own hand hygiene results via a weekly email to test how individualized performance data affect the performance. no information about the study subjects besides healthcare profession was obtained to ensure anonymity. all participants were briefed about the study purposes and placement of the hand hygiene system prior to study initiation. data were collected using an automated hand hygiene monitoring system (sani nudge, copenhagen, denmark, https://saninudge.com. accessed sep 20, 2020). sensors were placed on the existing alcohol-based hand rub dispenser solutions from where every hand hygiene event was registered, as previously described (15) . in brief, the sensors had a built-in nudging feature with discrete light symbols which was activated during selected periods of the study ( fig. 1.a) . other sensors were placed above the patient beds, creating a patient zone around each bed ( fig. 1.b) . this allows the system to be used for monitoring who moments 1 (before touching a patient), 4 (after touching a patient), and 5 (after touching patient near surroundings). moments 2 (before clean/aseptic procedures) and 3 (after body fluid exposure/risk) were included in the data because many of these procedures also take place in the patient zone. however, it was not possible to distinguish them from the other moments. finally, anonymous bluetooth sensors were placed on the existing name badge of the hcws and was coded to be either a doctor or a nurse ( fig. 1.c) . the sensors made it possible to measure when an hcw had a hand hygiene opportunity and whether alcohol-based hand rubbing was performed in that moment. a hand hygiene data report was sent on a weekly basis to the infection control nurses and the head nurse who would then show it to the hcws in the ward during bi-weekly meetings ( fig. 1.d) . after the meeting a copy of the data were put on a bulletin board for display. the system did not measure physical contact but used clinically validated algorithms based on time and distance measurements in the patient zone to calculate whether contact was most likely to have taken place. the study was divided into three phases ( table 1 ): in phase one (baseline), the system was implemented, and a compliance baseline was measured. the baseline functioned as a control period with data representing the current hhc status of the ward before the improvement initiatives began. all study participants were blinded to data during this period to minimize the risk of bias. period (months) description control period: a period without any interventions, reflecting the current hand hygiene compliance of the ward. data-driven performance feedback: the head nurse and hygiene coordinator presented the department's hand hygiene compliance for each room type (patient room, mediation room, staff toilet, dirty and clean utility rooms) followed by an open discussion on how to overcome hand hygiene barriers. a copy of the results would be put on a bulletin board for display. light-guided nudging: the sani nudge sensors, located on existing alcohol-based hand rub dispensers, used visual nudges (lights and symbols) to bring staff's attention towards hand hygiene. the visual nudges appeared when staff was in a situation that required hand sanitization. once a sanitization was performed, a smiley appeared to complete the positive feedback loop. the nudging was switched on and off with different intervals and in a random manner to avoid banner blindness. data-driven performance feedback: 8 months into phase 2, nine nurses started receiving individual performance feedback which consisted of weekly reports send by email directly to each of them. the nurses were able to see their own compliance data in each room as well as before and after patient contact. they were also able to compare their own results with the rest of their colleagues' group compliance. during phase two (group intervention: data-driven performance feedback and light-guided nudging), the head nurse and the hygiene coordinator in the ward presented the hhc to their colleagues in the ward at short (5-10 minutes) bi-weekly meetings. all hcws at work participated in the meetings. the data were shown as a general compliance number of the ward and stratified according to the following six room types: patient room, medication room, dirty utility room (sluice room for soiled goods), clean utility room (sluice room for storage of clean goods), storeroom and staff toilet. the agenda of the meetings were: the head nurse and hygiene coordinator provided an overview on the previous week's hhc to make sure that everyone was updated on the most recent data. they also followed up on the previous week's goal as an evaluation of the performance. contact'-moments. the guidelines state that we must perform hand hygiene before touching a patient (moment 1). as a goal the following week, we must all remember to sanitize hands every time we are walking into a patient room, before touching a patient". in addition, the nudging feature of the system was switched on periodically during phase 2. the nudges consisted of lights in 10 different colors (yellow, orange, red, pink, magenta, purple, blue, turquoise, dark green, lime) which were displayed by the sensors on the dispensers (fig. 1.a) . a nudge was provided when staff approached a dispenser and once alcohol-based hand rubbing was performed. in order to avoid banner blindness (i.e. unconsciously desensitization of a stimuli over time due to repeated exposure), the nudging mode (light) and length of time were switched on and off at random. the nudging colors were also displayed in a random manner. the symbols switched between random lights (cue) to increase awareness and green smileys after sanitizations (reward) to reinforce the desired behavior and create a persistent routine. during phase 3 (individual intervention: performance data on an individual level), 9 nurses volunteered to receive weekly individual compliance data by email in order to personalize the feedback. this was done automatically by the system and was blinded to the head nurse, hygiene coordinator or the rest of the staff. those not receiving individualized data continued as described in phase 2 for the rest of the study period. our primary analysis focused on the effect of light-guided nudging and data-driven performance feedback as a combined intervention (multimodal strategy). we compared the mean hhc between the baseline period and the intervention period. the secondary analysis evaluated the effect of individual performance feedback. hand hygiene performance rates were calculated by dividing hand hygiene events (number of hand we enrolled 26 nurses and 10 doctors. the system registered an average of 5000 hand hygiene opportunities in the ward per week for these 36 hcws during the study period. in general, the hhc was lowest in the patient rooms compared with the other rooms for both the doctors and the nurses ( fig. 2 and 3) . the doctors had a baseline hhc of 16% in the patient rooms and 24% in the other rooms in the ward. hhc increased significantly to 42% (p < 0.0001) in the patient rooms and to 78% (p = 0.0006) in all other situations once the nudging feature was activated and the group performance feedback used (fig. 3) . the doctors were more likely to sanitize hands after rather than before patient contact during the baseline period (21% vs. 11%, respectively). the same behavioral pattern was observed during the period with nudging and performance feedback (53% vs. 21%). the nurses had a baseline hhc of 27% in the patient rooms and 39% in the rest of the rooms in the ward. hhc increased significantly to 43% (p = 0.0002) in the patient rooms and to 64% (p < 0.0001) in all other situations once the nudging feature was activated and the group performance feedback provided (fig. 4) . the hhc of the nurses receiving individual performance feedback further increased to 55% (p < 0.0001) in the patient rooms and to 80% (p < 0.0001) in all other situations compared with the period when group level data and nudging were provided (fig. 4) . as with the doctors, the nurses were more likely to sanitize hands after rather than before patient contact during the baseline period (35% vs. 19%, respectively). the same pattern was observed during nudging and group performance feedback (50% vs. 36%) as well as during individual performance feedback (61% vs. 49%). to our knowledge, this is the first study to examine the combinatory effect of data-driven performance feedback and light-guided nudging on hhc. the multimodal intervention significantly increased hhc of both doctors and nurses. the doctors had the lowest baseline compliance but seemed to be very responsive to the intervention and reached the same compliance levels as the nurses in the patient rooms and even higher levels in the working rooms. however, the nurses receiving individual performance feedback demonstrated the best performance in all the different room types. a reason for the improvements observed could be the reduction in cognitive biases. when hais manifest several days after exposure, hcws do not encounter the consequences of poor hand hygiene and they could consider their risk of causing infections negligible (16) . when being reminded about the importance of good hand hygiene through performance feedback and via nudges in the moment, some of these cognitive barriers are removed (20) . the baseline hhc was low but comparable to other studies using automated hand hygiene monitoring systems while the improvements seen in this study are some of the highest reported (21) . the hhc was lowest in the patient rooms both before and after the intervention period. one possible factor could be that the highest number of opportunities were measured in these rooms, making higher performance more difficult. this is an important factor because most other monitoring systems only measure compliance upon room entry and exit despite that several hand hygiene opportunities occur near the patient during a single visit (21) . the sani nudge system measures compliance around the patient bed, providing a more detailed picture of the hand hygiene behavior when performing patient-centered clinical tasks. this is of particular relevance in multiple bedrooms where hcws risk moving from patient to patient without performing hand hygiene. the hhc is comparable to studies using video-monitored direct observation systems which is often considered the highest technical standard but has limited implementation possibilities due to privacy (22, 23) . the findings of this study suggest that the sani nudge system can be used when you want to measure hhc in hospital settings according to who's "my 5 moments" or hospitals who needs a more nuanced picture of the hand hygiene situation in the patient rooms than room entry and exit measurements can provide. some limitations should be considered when interpreting the results. first, a small number of hcws (n=36) were included and their behavior might not be representative for other hcws. however, the system collected a high number of opportunities compared with studies performing direct observations which provides robustness to the analyses and increases the validity. in addition, data collection was done 24/7 for 14-months whereas direct observation studies normally do it sporadically during daytime and on weekdays only, presenting a limited picture of the true hygiene performance. second, there might have been some degree of selection bias towards the nurses choosing to receive individual data. as this was based on volunteering, it is possible that those whom felt confident about their own performance were more likely to volunteer. it was not possible to investigate if they were also the top performers during the baseline period because their data was anonymized up until they consented to have individual data collected. despite this consideration, the nurses significantly improved once they started receiving individualized data compared to when they received data on group level. an explanation could be that the increased insights into their own performance reduced the dunning-kruger effect even further (24) . third, the hand hygiene system did not measure the quality of the alcohol-based hand rubbing which also has a significant impact on the effectiveness to prevent the spread of pathogens. instead we learned that the hand hygiene system should be used as a prioritization tool for the hygiene organization to identify wards, professions and hygiene moments (e.g. before and after patient contact) where hand hygiene performance is good and where there is room for improvement. it allows the management or infection prevention team to direct their limited resources to where it is mostly needed and have the highest impact in terms of infection prevention risk. creating a transparent hand hygiene performance system also enhances an ongoing knowledge sharing of best practices which is highly needed in infection prevention during routine and outbreak situations (25) . finally, we did not note down the hcws who attended the bi-weekly data presentation meetings and we can therefore not assure that all hcws got exposed to the data performance intervention. we did put a copy of the performance results on a bulletin board for display after each meeting to mitigate the risk of not being exposed to the information. future studies should consider sending out emails or using other relevant approaches to ensure that all team members get exposed to the performance feedback interventions. we found that hhc with sanitizer of both doctors and nurses can be significantly improved with light-guided nudging and data-driven performance feedback on group and individual level using an automated hand hygiene system. this study provides justification for continued investigation on how improvement strategies can be designed to achieve an optimal hhc with limited efforts and resources. this study was partly funded by the danish ministry of health (j. no. 1608966). effectiveness of a hospital-wide programme to improve compliance with hand hygiene infection control -a problem for patient safety research priority setting working group of the who world alliance for patient safety. global priorities for patient safety research respiratory viruses in the patient environment coronavirus disease (covid-19) outbreak: rights, roles and responsibilities of healthcare workers, including key considerations for occupational safety from best evidence to best practice: effective implementation of change in patients' care the preventable proportion of nosocomial infections: an overview of published reports reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices systematic review of studies on compliance with hand hygiene guidelines in hospital care improving compliance with hand hygiene in hospitals enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial interventions to improve hand hygiene compliance in patient care the effectiveness of interventions aimed at increasing handwashing in healthcare workers -a systematic review a systematic review of hand hygiene improvement strategies: a behavioural approach blinded during the review process to avoid bias nudging to improve hand hygiene nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within cochrane systematic reviews world health organization. my 5 moments for hand hygiene the danish national hand hygiene guidelines (nationale infektionshygiejniske retningslinjer monitoring hand hygiene: meaningless, harmful, or helpful? automated and electronically assisted hand hygiene monitoring systems: a systematic review infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant staphylococcus aureus from surgical wards using hightechnology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments knowledge sharing in infection prevention in routine and outbreak situations: a survey of the society for healthcare epidemiology of america research network we thank all the hcws who took part in the study. key: cord-258712-q8b072m8 authors: lotfinejad, nasim; assadi, reza; aelami, mohammad hassan; pittet, didier title: emojis in public health and how they might be used for hand hygiene and infection prevention and control date: 2020-02-10 journal: antimicrob resist infect control doi: 10.1186/s13756-020-0692-2 sha: doc_id: 258712 cord_uid: q8b072m8 emojis are frequently used picture characters known as possible surrogates for non-verbal aspects of behavior. considering the ability of emojis to enhance and facilitate communication, there has been a growing interest in studying their effects in scientific and health-related topics over the past few years. infection prevention and control (ipc) is a field of medicine that is directly associated with specific behaviors. these include hand hygiene, which is the cornerstone of the prevention of healthcare-associated infections, and essential in stemming the spread of antimicrobial resistance. this paper aims to provide an overview of how emojis have been used in the medical and public health literature and proposes their possible use in ipc and hand hygiene to put forth a vision for the future research. emojis are new generation of emoticons. these ideograms have evolved beyond facial expressions, and are increasingly used on digital platforms to demonstrate concepts and ideas. as a japanese word meaning "picture character", emojis were initially created at the end of the twentieth century in order to improve and simplify digital messages [1, 2] . they are increasingly used as a new language worldwide, conveying nonverbal communication cues and, in the case of the latter, substituting for the face-to-face conditions, and proving to exert a direct effect on readers' moods [3, 4] . emojis have enabled users from different countries to communicate in a standardized way with single compact characters that circumvent language barriers [5, 6] . the number of existing emojis is increasing each year in a number of categories including smileys and people, animals and nature, food and drinks, activity, travel and places, objects, symbols, and flags [1] . these pictographs became so popular that the oxford dictionary announced the "face with tears of joy" ( ) emoji as the 2015 word of the year [7] . more than 90% of the online users employ emojis to communicate complex concepts more effectively while using less words [2] . as technology improves and emojis continue to grow in popularity in the digital world, various studies have been conducted in the past few years regarding the impact of these symbols in scientific fields. however, the use of emojis has not yet been highlighted in the medical literature. these surrogates of nonverbal communication have a direct impact on different social interactions that could facilitate communication among healthcare providers and receivers, thus enhancing public health [8] . this paper primarily focuses on the possible effects of emojis on healthcare systems and outlines important issues for further consideration. the potential roles of these symbols in infection prevention and control (ipc), as a globally recognized essential part of health systems [9] , are further described through the example of using emojis to promote hand hygiene. the ever-evolving medical language, which is globally accepted as medical english, has faced significant changes over time [10] . but despite all the developments that have taken place, language barriers still hinder disseminating knowledge worldwide [11] by preventing sufficient quality of care among patients and healthcare providers who speak different languages and come from different cultures [12, 13] . numerous pictographs have been developed to enrich verbal communication and facilitate digital communication by substituting for nonverbal cues [8] . they received so much attention that in 2005, a number of medical emoticons were recommended instead of abbreviations and acronyms used in medicine [14] . emojis are a step further than emoticons. for example, ":-o" is an emoticon for surprise while " " is the emoji with the same meaning. more natural in design, emojis have attracted scientific attention as they are able to transmit emotion, attitude and attention when added to text [1, 15] . as emojis are easily distributed by users around the world, they enable researchers to conduct studies and surveys across geographical boundaries using this language [6] . shah et al. [5] suggested benefiting from emojis by adding them in editorial communications and writing manuscripts using emojis as substitutes for words to augment medical literature. however, some disadvantages of using emojis in scientific studies were reported such as lack of standardization in different platforms, variability of meaning over time and according to different cultures, and conveyance of unintended messages. concerning the infiltration of emojis into scientific literature, it is imperative to evaluate the impact of these symbols in health-related fields in order to harness their potential advantages for appropriate research applications and stave off scientific miscommunication. the impact of narrative health messages and emojis on message processing and attention has been studied by willoughby and liu [16] . their findings demonstrated that using emojis in health messages is reliant on the objectives and content of the message. according to the authors, participants' attention was better when emojis were added to weaker and less interesting health messages. another study conducted by siegel et al. [17] on 297 elementary school children revealed that placing "green smiley face" emoticons near plain milk and vegetables increased their desire to purchase healthy products. lee et al. [18] used emojis as simple, languageindependent, and less time consuming tools for detecting depression after stroke. based on their results, the sad emoticon showed a high agreement rate with the diagnostic and statistical manual for major depression, fourth edition, and the use of emojis was found effective in screening for depression among patients. marengo et al. [19] developed a 91-item questionnaire with emojis related to personality characteristics in order to assess a language-free instrument for personality. the authors involved a sample of 234 young adults online, and a brief big-five personality questionnaire was administered along with the emoji questionnaire to each participant. it was concluded that 36 out of 91 emojis were significantly associated with extraversion, emotional stability and agreeableness. other studies have been conducted regarding the use of emojis, especially in psychology [20] [21] [22] [23] ; yet there is only limited data on the effects of these pictographs in other fields of medicine. the latter is mainly due to the availability of many emojis describing emotion and behavior, while only a few emojis are precisely related to health and medical terms. with the dramatic increase in public awareness about the significant role of the internet and social media in disseminating health-related data [24] , internet access to medical information has gone far beyond reading sources as we are witnessing more interactive communicational methods being introduced each day [25] . medical emojis have a great potential to gain popularity on digital platforms as the internet is an integral part of both healthcare workers' and patients' lives. currently, attempts are being made to create new emojis related to health issues, such as the medical sign and symptoms [26] . in a recent study, assadi et al. have designed and evaluated the possibility of using emojis to depict about 80 clinical signs and symptoms according to the 10th revision of the international statistical classification of diseases [27] . implementing ipc programs is recognized as a global health priority, and it is known that failure to achieve an adequate level of ipc harms patients around the world. that points to the necessity of using a full arsenal of tools and technologies to improve ipc interventions globally [28] . in recent times, trends in infectious diseases have become detectable in populations via the internet and social media; they function as new and available sources of health-related data [29, 30] . this ability of the internet and social media was further illustrated in a study of distribution of emojis used on twitter around the world [31] . the aforementioned study indicated that south-eastern asia and south america had the highest, while the usa and japan had the lowest rates of using emojis on twitter. it has also been possible to detect the emojis used most often by various countries; based on the results of this study, developed countries used less face emojis than developing countries. it was further concluded that emojis could reflect the living conditions of different counties around the world using correlation analyses between emoji distribution and world development indicators including life expectancy, tax rate, trade, and gross domestic product per capita. according to another study by kim et al. [32] , policy makers should benefit from online information including emoticons along with proven scientific data, since these symbols can represent public feelings like frustration about an infectious disease such as h1n1. emoticons and internet slang were also targeted in the process of extracting emotional contents from social media regarding public reaction to the outbreak of middle east respiratory syndrome in korea in 2015 [33] . pointing out the impact of an infectious disease outbreak on public emotions, it was suggested that understanding interactions between a disease, mass media and public emotions might be effective to avoid from excessive fear and overreactions to infectious diseases. conceivably, by using digital surveillance with the internet, disease outbreaks could be detected earlier in every part of the world, providing an opportunity to react more quickly [34, 35] . a number of emojis have been created that could be related to infectious diseases. in 2017, the "mosquito" ( ) emoji was proposed with the objective to improve communication and research regarding mosquito-borne diseases and to monitor mosquito-borne disease outbreaks [36] . "face with thermometer" ( ) and "sneezing face" ( ) are among the smileys that may be used to represent a hospital patient, person with a cold or flu or other physical diseases. new health-related emojis in other categories including "lab coat" ( ), "microbe" ( ), "test tube" ( ), "petri dish" ( ) and "dna" ( ) have also been added as part of unicode 11.0 in 2018 to facilitate scientific communication in the digital world. considering the significant role of person-to-person transmission of infectious diseases and the necessity of behavioral adherence to ipc interventions, behavioral science is directly associated with infectious disease models [37] . therefore, the existing set of emojis may be useful for showing behaviors associated with ipc such as hand hygiene. bearing in mind the limited number of health-related emojis, positive effects of the currently available symbols in the field of ipc are questionable. healthcare-associated infections are considered a threat to patient safety [38] . hand hygiene with alcohol-based hand rub, which is the global standard of care, is recognized as the cornerstone of ipc for preventing healthcare-associated infections [39] . although hand hygiene is a very simple procedure, adherence levels are still worrisome and improving this behavior has been challenging despite using numerous interventions [40, 41] . the core components of the who multimodal hand hygiene improvement strategy include system change, education, evaluation and feedback, reminders in the workplace, and institutional safety climate [42] . in order to overcome behavioral barriers multiple interventions have been performed. emojis may be beneficial in bridging the large gap that exists between the verbal text-based and nonverbal face-to-face interactions related to hand hygiene and the multimodal promotion approach. thereby, employing them to improve hand hygiene behavior in accordance with the multimodal strategy deserves much more attention. education entertainment provided by social media is a promising method to promote individual behavior change such as hand hygiene [43] , and emojis are helpful tools to add topics and ideas by facilitating a more natural communication [6] . according to the literature, visual stimuli have been found effective to use in lectures and written texts in order to improve hand hygiene behavior and it has also been suggested that animated visual elements may have a better and more direct effect compared with static pictures [44] [45] [46] . likewise, emotional events are memorized more precisely and for a longer duration compared with neutral events, making them beneficial aspects to consider in education and memory [47] . in line with the possible advantages mentioned for these symbols, the first pilot intervention to assess the impact of emoticons on hand hygiene was performed by gaube et al. in a german hospital [48] . monitoring and feedback devices were installed above handrub dispensers that displayed a frowny face to remind people to perform hand hygiene and, once used, a smiley face was shown to reinforce the positive behavior. based on their findings, emoticons can enhance hand hygiene in hospitals by providing visual cues and preventing forgetfulness concerning when it needs to be performed. furthermore, emoticons could reinforce the hand hygiene behavior by providing instant feedback in patients' rooms. other studies have pointed to the importance of improving the use of social media platforms by ipc professionals in order to leverage the latest technologies in conveying hand hygiene messages [43, 49, 50] . this was further illustrated in a study conducted in china, which suggested that hand hygiene promotion strategies could be assessed using information obtained from social media, augmenting the data provided by traditional sources such as radio, print, and television [51] . according to the study performed by pan et al. [50] , a hand hygiene campaign video was more effectively connected through facebook than through a group email and hospital website in taiwan. it was also recommended that utilization of social media improves hand hygiene programs by providing a safe environment that enables public awareness and includes patient participation. the aforementioned results are consistent with previously performed studies describing the emotional content that is available on facebook, twitter, and other social media sites as "contagious" [52, 53] . therefore, health-related interventions could also be influenced by the emotional cascade effect from one person to others, leading to improved efficacy and increased costeffectiveness of medical interventions [53] . a preponderance of evidence suggests that it seems beneficial to study the impact of emojis as an inseparable language of the digital platform on the emotional contagion and subsequent behavioral changes regarding hand hygiene. a wide variety of other new strategies for the use of emojis could be suggested to improve hand hygiene. a qualitative study was performed in australia to evaluate hand hygiene compliance among hospital cleaners [54] . despite being aware of the necessity of hand hygiene, adherence levels were still very low in this group. their results indicated that hand hygiene information overload and confusing training material and programs were barriers to hand hygiene promotion. using simplified reminders such as posters with comprehensive language may be more beneficial and less time consuming compared with the detailed materials used for training hospital cleaning staff. another advantage of using emojis in hand hygiene could be the possibility of introducing universal emoji translation of the who "my five moments for hand hygiene" [55, 56] with precisely selected emojis in order to prevent misinterpretations by different individuals. hand hygiene-related terms have been transformed over the past years from handwashing and hand disinfection to hand hygiene, underlining the increased performance and use of alcohol-based handrub compared to soap and water, and the prominence of this topic in patient safety [56, 57] . there are currently 30 different hand gesture emojis available, however there is no emoji directly showing hand washing, handrubbing or handrub (fig. 1) . the act of cleaning hands could be only demonstrated using a sequence of any of the existing hand emojis with the "bar of soap" ( ) emoji, which makes communication more complicated than using a single emoji. for example, some people may interpret the combination of the "clapping hands" and "bar of soap" ( ) emojis as applauding the use of soap and it may not directly demonstrate hand washing with soap. the development of hand hygiene-related emojis will enable health professionals to communicate more specifically regarding their discoveries and concerns in this field. in addition, the hand hygiene compliance of different places in the world could be better notified by detecting relevant emojis in the social media to predict compliance or even identify problems caused by low adherence. hand hygienerelated emojis on social media could regularly remind us to protect ourselves against healthcare-associated infections, and the spread of influenza or antimicrobial resistance. more importantly, the general public, including patients suffering from healthcare-associated infections, might be able to easily share and communicate the problems they have faced, as they could be better heard emojis may empower ipc in different aspects such as raising awareness with no language barrier, educating people to adopt healthy behaviors, and enhancing surveillance systems to monitor infectious diseases. it is recommended to evaluate the relevance and appropriateness of the current set of emojis to use for hand hygiene promotion in order to harness the potential beneficial impact of these symbols. medical emojis that are standardized as a new category of emojis offer much hope for the future, especially in the field of ipc. sentiment of emojis emojis: insights, affordances, and possibilities for psychological science the impacts of emoticons on message interpretation in computer-mediated communication brain activity when reading sentences and emoticons: an fmri study of verbal and nonverbal communication is it time to start using the emoji in biomedical literature? learning from the ubiquitous language: an empirical analysis of emoji usage of smartphone users emoji: what does the scientific literature say about them?-a new way to communicate in the 21th century observations of infection prevention and control practices in primary health care the language of medicine languages are still a major barrier to global science hurdles to health: immigrant and refugee health care in australia. australian health review: a publication of the australian hospital association language barriers and their impact on provision of care to patients with limited english proficiency: nurses' perspectives medical emoticons the nonverbal communication functions of emoticons in computermediated communication do pictures help tell the story? an experimental test of narrative and emojis in a health text message intervention emoticon use increases plain milk and vegetable purchase in a school cafeteria without adversely affecting total milk purchase the smiley as a simple screening tool for depression after stroke: a preliminary study assessing personality using emoji: an exploratory study do emojis influence social interactions? neural and behavioral responses to affective emojis in bargaining situations mood detection in ambiguous messages: the interaction between text and emoticons sender gender influences emoji interpretation in text messages sarcasm and emoticons: comprehension and emotional impact health and social media: perfect storm of information a population-based survey face with tears of joy is word of the year: are emoji a sign of things to come in health care? medical emoji a new paradigm for virtual medical counseling global infection prevention and control priorities 2018-22: a call for action social media in public health the use of social media in public health surveillance a global analysis of emoji usage: proceedings of the 10th web as corpus workshop assessment of h1n1 questions and answers posted on the web large-scale machine learning of media outlets for understanding public reactions to nation-wide viral infection outbreaks methods using social media and search queries to predict infectious disease outbreaks using social media for actionable disease surveillance and outbreak management: a systematic literature review infection prevention behaviour and infectious disease modelling: a review of the literature and recommendations for the future clean care is safer care: a worldwide priority hand hygiene in hospitals: anatomy of a revolution interventions to improve hand hygiene compliance in patient care hand hygiene: from research to action guide to implementation: a guide to the implementation of the who multimodal hand hygiene improvement strategy exploring the use of entertainmenteducation youtube videos focused on infection prevention and control the use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting the effect of eye images and a social norms message on healthcare provider hand hygiene adherence creating visual explanations improves learning the influences of emotion on learning and memory how a smiley protects health: a pilot intervention to improve hand hygiene in hospitals by activating injunctive norms through emoticons hand hygiene posters: motivators or mixed messages? promoting a hand hygiene program using social media: an observational study global handwashing day 2012: a qualitative content analysis of chinese social media reaction to a health promotion event is happiness contagious online? a case of twitter and the 2010 winter olympics detecting emotional contagion in massive social networks cleaning staff's attitudes about hand hygiene in a metropolitan hospital in australia: a qualitative study my five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene world health organization. guidelines on hand hygiene in health care. first global patient safety challenge clean care is safer care why language matters: a tour through hand hygiene literature publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations didier pittet works with who in the context of the who initiative 'private organizations for patient safety -hand hygiene'. the aim of this who initiative is to harness industry strengths to align and improve implementation of who recommendations for hand hygiene in health care indifferent parts of the world, including in least developed countries. in this instance, companies/industry with a focus on hand hygiene and infection control related advancement have the specific aim of improving access to affordable hand hygiene products as well as through education and research. all listed authors declare no financial support, grants, financial interests or consultancy that could lead to conflicts of interest. the authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. who takes no responsibility for the information provided or the views expressed in this paper. authors' contributions nl drafted the manuscript with the help of ra and ma. dp critically revised and supervised the study. all authors read and approved the final manuscript. this work is supported by the infection control programme and world health organization (who) collaborating centre on patient safety (spci/ wcc), university of geneva hospitals and faculty of medicine, geneva, switzerland; hand hygiene research activities at the spci/wcc are also supported by the swiss national science foundation (grant no. 32003b_163262). data sharing not applicable to this article as no datasets were generated or analyzed during the current study.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord-000252-iejfgkst authors: chen, yanyi; xue, shenghui; zhou, yubin; yang, jenny jie title: calciomics: prediction and analysis of ef-hand calcium binding proteins by protein engineering date: 2010-02-07 journal: sci china chem doi: 10.1007/s11426-010-0011-5 sha: doc_id: 252 cord_uid: iejfgkst ca(2+) plays a pivotal role in the physiology and biochemistry of prokaryotic and mammalian organisms. viruses also utilize the universal ca(2+) signal to create a specific cellular environment to achieve coexistence with the host, and to propagate. in this paper we first describe our development of a grafting approach to understand site-specific ca(2+) binding properties of ef-hand proteins with a helix-loop-helix ca(2+) binding motif, then summarize our prediction and identification of ef-hand ca(2+) binding sites on a genome-wide scale in bacteria and virus, and next report the application of the grafting approach to probe the metal binding capability of predicted ef-hand motifs within the streptococcal hemoprotein receptor (shr) of streptococcus pyrogenes and the nonstructural protein 1 (nsp1) of sindbis virus. when methods such as the grafting approach are developed in conjunction with prediction algorithms we are better able to probe continuous ca(2+)-binding sites that have been previously underrepresented due to the limitation of conventional methodology. ca 2+ , a signal for "life and death", is involved in almost every aspect of cellular processes. due to its abundant bioavailability, ca 2+ was selected through evolution to perform multiple biochemical roles, acting as a second messenger inside mammalian cells to regulate a myriad of important cellular processes from triggering life during fertilization to facilitating apoptosis [1, 2] . as best exemplified by fast responses controlled by highly localized ca 2+ spikes and slow responses regulated by repetitive global ca 2+ transient oscillation or intracellular ca 2+ waves, ca 2+ signals exhibit diversified spatio-temporal patterns to meet varying demand of cellular processes [3] (figure 1 ). errors in any step of the calcium signal pathway can be critical, resulting in uncontrolled cell death or abnormal gene expression [4, 5] . ca 2+ is able to bind to hundreds of cellular proteins over a 10 6 -fold range of affinities (nm to mm) (figure 2 (a)), depending on the nature of the ca 2+ -modulated events. ca 2+ binding has been shown to be essential for stabilizing proteins as well as maintaining proper cellular free ca 2+ concentrations as seen in buffer proteins such as calbindin d 9k and parvalbumin ( figure 2 ). generally the ca 2+ modulated activity is achieved through ca 2+ -dependent conformational changes in ca 2+ -binding proteins. for example, one of the ubiquitous intracellular trigger (modulating) proteins, calmodulin (cam), has been shown to interact with over 300 proteins [6] ( figure 2 ). interestingly, this protein has been recently shown to regulate a large class of membrane proteins that are essential for cell signaling and cell-cell communication such as gap junctions [6] and voltage-dependent ca 2+ channels. although bacterial cells do not have complex subcompartments or organelles, there is strong evidence that ca 2+ plays an essential role in bacterial signaling, communication and stability similar to that observed in eukaryotic cells (figure 1 (a)) [7] [8] [9] [10] [11] . bacterial cells also have a well-regulated cytosolic free ca 2+ concentration (apviruses avidly perturb the intracellular ca 2+ signaling network to achieve their own demand. a number of viral proteins (oval shape) from different families of viruses disrupt ca 2+ signaling by targeting various ca 2+ signaling components. adapted with permission from ref. [3, 6] . proximately 0.1-2 μm) that is significantly lower than that observed in the extracellular medium (mm) due to ca 2+ transporters and channels [8] [9] [10] [11] . similar to the eukaryotic systems, p-type atpase ca 2+ efflux pumps have been characterized from synechococcus and flavobacterium. a ca 2+ transporter of s. pneumoniae is involved in ca 2+ -dna uptake, lysis, and competence [12, 13] . uptake of ca 2+ and other divalent cations can also accompany uptake of phosphate by the phosphate transport system of e. coli. furthermore, it has been reported that bacteria contain ca 2+ binding proteins that are essential for cell adhesion and communication [14] [15] [16] [17] . viruses, on the other hand, utilize the universal ca 2+ signal to create a specific cellular environment to achieve their own purposes (figure 1(b) ). ca 2+ plays important roles in viral gene expression, post-translational processing of viral proteins, virion structure formation, virus entry, and virion maturation and release. as shown in figure 1 (b), the interplay between viruses and ca 2+ in the infected cell falls generally into three major categories: (1) viral proteins directly or indirectly disturb ca 2+ homeostasis by altering membrane permeability and/or manipulating key components of the ca 2+ -signaling apparatus; (2) viral proteins directly bind to ca 2+ for structural integrity or functionality; and (3) critical virus-host interactions depend on cellular ca 2+ -regulated proteins or pathways. according to their structural features, ca 2+ -binding sites in proteins are classified as either non-continuous or continuous. in non-continuous sites the ca 2+ ligand residues are located remotely from one another in the protein sequence. most of the ca 2+ binding proteins, such as cadherins, c 2 domains, site i of thermitase, phospholipase a 2 , and dgalactose binding protein (gbp) belong to this family. continuous ca 2+ -binding sites have binding pockets formed by a stretch of contiguous amino acids in the primary sequence (e.g. ef-hand proteins) ( figure 2 ). ef-hand proteins have a conserved ca 2+ binding loop flanked by two helices [18, 19] . based on the conserved features of the ca 2+ -binding loop, ef-hand proteins have been divided into two major groups: the canonical ef-hands as seen in cam and the pseudo ef-hands exclusively found in the n-termini of s100 and s100-like proteins [18] . their major difference lies in the ca 2+ binding loop: the 12-residue canonical ef-hand loop binds ca 2+ mainly via sidechains (loop positions 1, 3, 5, 12), whereas the 14-residue pseudo ef-hand loop chelates ca 2+ mostly via backbone carbonyls (positions 1, 4, 6, 9) ( figure 2 ). each type of ef-hand loop has a bidentate ca 2+ ligand (glu or asp) that functions as an anchor at the c-terminal of the binding loop. among all the structures reported to date, the majority of ef-hand sites have been found to be paired either within multiple canonical ef-hand motifs or through the interaction of one pseudo ef-hand motif with one canonical motif [18] (figure 2 ). for proteins with odd numbers of ef-hands, such as the penta-ef-hand calpain, ef-hand motifs are coupled through homodimerization or heterodimerization [20] [21] [22] . due to the spectroscopically-silent nature of calcium and its physiological abundance, determination of the calcium binding capability of proteins is challenging. first, most experimental methods such as dialysis are only sensitive to the total calcium content. in addition, overcoming the persistent background contamination of calcium during the preparation of calcium-free sample for proteins with strong calcium binding affinities is a non-trivial task. further, since most calcium binding proteins contain multiple calcium binding sites that cooperatively bind calcium resulting in induced conformational change (e.g., cam) ( figure 2 ), obtaining site-specific calcium binding affinity is limited by complication from contributions from cooperativity and conformational entropy [23] . hence, understanding the molecular mechanism of biological function related to calcium is largely hampered by the lack of site specific information about the calcium-binding properties, especially for the ubiquitous ef-hand calcium-binding motif. progress in understanding the molecular mechanism of calcium modulated biological process requires us to answer several important questions. first, what are the site-specific calcium binding affinities of calcium binding proteins, particularly those that utilize multiple coupled calcium binding sites to respond to sharp changes in cellular calcium concentration? next, how can we predict or identify calcium binding sites in proteins using genomic and structural information? finally, how can we verify calcium binding capabilities in the bacteria and virus genomes? in this paper we first describe our effort in developing a grafting approach to understand site-specific calcium binding affinities using calmodulin as an example. next we discuss our progress in predicting ef-hand calcium binding sites in various biological systems such as bacteria and virus systems. we then report our results following application of the grafting approach to probe calcium binding capabilities in streptococcal hemoprotein receptor (shr) of streptococcus pyrogenes and the nonstructural protein of sindbis virus. to overcome the above-mentioned barriers and limitations associated with naturally-occurring ca 2+ binding proteins, we have developed a grafting approach for engineering a single ca 2+ -binding site in order to dissect the key structural factors that control ca 2+ -binding affinity, conformational change and cooperativity. in principle, the key determinants for ca 2+ affinity can be systematically introduced into a stable host protein frame and evaluated by eliminating or minimizing the contribution of conformational change. the key factors that are essential for ca 2+ -dependent conformational change can be further revealed by analyzing the folding, stability, dynamics, and conformations of the host protein upon binding of a designed ca 2+ -binding site without the complication of cooperativity. the cooperativity of two-coupled ca 2+ -binding sites can then be estimated once the intrinsic ca 2+ -binding affinities of both sites are obtained based on the energetics relationship. figure 3 shows our grafting approach in obtaining site-specific calcium binding affinity using domain1 cd2 as a scaffold protein. we have shown that cd2 is an excellent scaffold protein [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] . it retains its native structure following insertion of the ef-hand motif both in the absence and presence of ca 2+ ions. this provides the foundation for measuring the intrinsic ca 2+ binding affinity with minimized contribution of protein conformational change. in addition, the aromatic grafting approach to probe site-specific metal binding properties of ca 2+ -binding proteins. (a) schematic representation of the grafting approach. any predicted linear ca 2+ -binding sequence can be inserted into the host protein cd2 domain 1 (cd2.d1) between residues s52 and g53 without disrupting the integrity of the host protein. metal binding to the engineered protein can be monitored by taking advantage of a potential lret pair, the buried trp (w32) within the two layers of beta-sheets and the terbium ion bound to the inserted sequence. (b) flow chart showing the application of grafting approach to confirm metal binding of predicted ca 2+ binding sites. adapted with permission from ref. [23, 29] . residues in cd2 enable us to obtain tb 3+ affinity of the grafted ca 2+ binding loop using fret. ca 2+ and its analog la 3+ are able to compete with tb 3+ for the grafted metal binding site. we have also optimized the length of two glycine linkers that connect the ca 2+ binding loop and cd2 to provide sufficient freedom for the loop. the grafted efloop iii of cam in different protein environments and scaffolds (such as cd2) has similar metal binding affinities for la 3+ and tb 3+ , which implies that the grafted ef-hand loop is largely solvated and functions independently from the host protein or the protein environment. more importantly, using high resolution nmr and 15 n labeled protein, we have shown that both ca 2+ and la 3+ specifically interact with the residues in the grafted ef-loop [25] , suggesting that the grafted loop retains its native ca 2+ binding property. in addition, to dissect the contribution of the ef-loop and its flanking segments on ca 2+ affinity, we have inserted the ef-loop, the loop with the exiting f-helix, and the loop with both ef-helices of site iii of cam into cd2. in contrast to the largely unfolded structure of the isolated peptide fragment, the inserted flanking helices are partially formed, as revealed by both cd and nmr. ca 2+ affinity is enhanced about 3-10 fold when the flanking helices are attached. further, we have first estimated the intrinsic ca 2+ affinities of the four ef-hand loops of cam (i-iv) by individually grafting them into cd2. ef-loop i exhibits the strongest while ef-loop iv has the weakest binding affinity for ca 2+ , la 3+ , and tb 3+ . ef-loops i-iv of cam have dissociation constants for ca 2+ of 34, 245, 185, and 814 μm, respectively. based on the results, we proposed a charge-ligandbalanced model in which both the number of negatively charged ligand residues and the balanced electrostatic dentate-dentate repulsion by the adjacent charged residues are major determinants for the ca 2+ binding affinities of efloops in cam. our grafting method provides a new strategy to obtain site-specific ca 2+ binding properties and to estimate the cooperativity and conformational change contributions of coupled ef-hand motifs. we have shown that the contribution of the cooperativity and conformational change to the ca 2+ affinity for the c-terminal is 40% greater than that for the n-terminal. the same approach will be used to probe the site-specific ca 2+ affinity of bacterial proteins. furthermore, we have applied high resolution pulsed-fieldgradient diffusion nmr (pfg nmr) and analytical ultracentrifugation to investigate the oligomeric state of the isolated ef-loop iii of cam in cd2 with and without the flanking helices. the loop without the helices (cam-cd2-iii-5g) remains unpaired in solution in the absence and presence of ca 2+ . however, the loop with the flanking helices (cam-cd2-iii-5g-ef) is a dimer in the presence of ca 2+ [34] . our findings suggest that hydrophobic residues on flanking helices play an essential role in dimerization and coupling of two ef-hand motifs for stronger ca 2+ affinity. by taking advantage of the sequence homology of currently available ef-hand loops and the flanking structural contents, we generated a series of patterns for the prediction of efhand proteins. we have modified the pattern ps00018 by allowing more choices (glu, gln, and ser) at position 1 and adding constraints at the flanking helical regions for canonical ef-hand motifs. in addition, several patterns have been developed to identify ef-hand like sites with different structural elements flanking the loop. further, to circumvent the problem of identifying the pseudo ef-hand loop, a pattern has been developed by moderately loosening the constraints at the paired c-terminal canonical ef-hand and incorporating reserved residues in the n-terminal pseudo ef-hand. compared with the original pattern ps00303, the new pattern reflects conserved genomic information in both ef-motifs and significantly improved the predictive accuracy and sensitivity [41] . to understand the role of ca 2+ in bacteria, we have predicted and analyzed potential bacterial ef-hand and efhand like ca 2+ -binding motifs on a genome-wide scale using our developed bioinformatic tool (http://www.chemistry.gsu. edu/faculty/yang/calciomics.htm). a total of 390 putative ca 2+ -binding proteins have been predicted. of these, 40 proteins were identified with multiple ef-hands ranging from 2 to 6, and 16 of these 40 proteins have been reported previously [32] . the other 350 proteins contain mononuclear ef-hands. several examples in three classes of these predictions with diversity in the ca 2+ -binding loop and flanking structural regions together with one class of prediction from other methods are shown in table 1 . these proteins are implicated in a variety of cellular activities, including ca 2+ homeostasis [42] [43] [44] , chemotaxis [8, 45, 46] , binding to scaffold proteins [47] , resistance to acid stress [48, 49] etc. according to their sequence homology and based on the assumption that they evolved from a common ancestor, these proteins could be further classified into several major phylogenetic groups [41] . a notable example is the streptococcal hemoprotein receptor (shr), a surface protein with a role in iron uptake that has no significant homologues in other bacteria but shares partial homology with eukaryotic receptors such as toll and g-protein dependent receptors (gi 15675635, genbank). additional sequence analysis identified a leucine-rich repeat domain, an ef-hand ca 2+ domain, and two neat domains [50] . as shown in figure 4 , the single ef-hand motif identified in shr has a significant homology to that of cam with all the conserved ca 2+ binding ligand residues and two flanking helices (figure 4 ). though ef-hands have been found abundantly in eukaryotes and bacteria, literature reporting ef-hand or ef-hand like ca 2+ -binding motifs in virus proteins is scarce, possibly due to lack of accurate prediction methods and robust validating methodologies. a thorough search in pubmed with the key words "ef-hand and virus" only results in 4 examples (1, 3, 5, 7, 9, 12) and the hydrophobic residues (n, blue). the predicted ef-hand from shr (streptococcal hemoprotein receptor, s. pyrogenes) and plcr (phospholipase accessory protein, p. aeruginosa) are aligned with some ef-hands known to form oligomers: cam ef3, the third ef-hand from calmodulin; tnc ef3, the third ef-hand from troponin c; pv ef3, the third ef-hand from parvalbumin; d9k ef2, the canonical ef-hand from calbindin d9k, the search patterns used for the identification of the ef-hand loop and flanking helices (helix e and helix f) are also shown in the bottom. ). in addition, the functions of almost 20% of these matched proteins remain uncharacterized. we hope that our prediction will serve as a prelude to more extensive searching for additional viral ca 2+ -binding proteins that are closely associated with virus-host interacting events ( figure 1(b) ). rubella virus (rub), the only member of the genus rubivirus, in the togaviridae family, is the causative agent of a disease called rubella or german measles. nonstructural protein (ns) open reading frame (orf) of rub encodes a polypeptide precursor which is able to cleave itself into two replicase components involved in viral rna replication. a putative ef-hand ca 2+ binding motif of the nonstructural protease that cleaves the precursor was successfully predicted across different genotypes of rub and determined by established grafting approach [51] . the grafted ef-loop bound to ca 2+ and its trivalent analogs tb 3+ and la 3+ with dissociation constants of 214, 47, and 14 μm, respectively. the ns protease containing mutations of cal-cium binding sites elimination (d1210a and d1217a) was less efficient at precursor cleavage than the wt ns protease at 35°c, and the mutant ns protease was temperature sensitive at 39°c, confirming that the ca 2+ binding loop played a structural role in the ns protease and was specifically required for optimal stability under physiological conditions. interestingly, the same bioinformatics algorithm that successfully predicted the ca 2+ -binding loop in the rub ns protease also predicted an ef-hand ca 2+ -binding motif in nsp1 of alphaviruses (figure 4(b) ). nsp1 is one of the four nonstructural proteins produced by alphaviruses and is involved in membrane binding and has methyl/guanylyl transferase activity. next, we grafted two predicted 29-residue ef-hand motifs, one from the shr of s. pyrogenes (cd2.shr.ef) and the viral nsp1 of sindbis virus (cd2.sin.ef), into cd2.d1 to examine their ca 2+ binding capability by using aromatic residue-sensitized tb 3+ luminescence resonance energy transfer (tb 3+ -lret) ( figure 5 ). circular dichroism studies of both engineered proteins showed a notable trough at ~216 nm which is characteristic of β-sheet structure. more negative signals were observed below 240 nm due to the contribution from the insertion of the helix-loop-helix sequences. both proteins were able to bind the ca 2+ analog, tb 3+ , with affinities of 25.1 μm for cd2.shr.ef and 16.4 μm for cd2.sin.ef ( figure 5(c)-(d) ). the biological relevance of these ef-hand ca 2+ -binding motifs will be further investigated. overall, based on sequence homology, we have developed a straightforward and fast method to detect linear ca 2+ -binding motifs from genomic information. genome-wide analysis of ef-hand ca 2+ -binding motifs in bacteria and virus have been analyzed with this methodology. experimentally, we have also developed a robust and reliable grafting approach to study ca 2+ -binding properties of continuous ca 2+ binding sites. this novel approach has been successfully used to dissect site-specific ca 2+ binding affinity and cooperativity among the four canonical ef-hands in the prototypical ca 2+ -binding protein, calmodulin. the combination of these two approaches is expected to enable us to explore more ca 2+ binding sites that are underrepresented due to the limitation of available methodology. ef) and from the nsp1 of sindbis virus (cd2.sin.ef). (a) modeled structure of the engineered protein with the insertion of a 29-residue helix-loop-helix ef-hand motif. (b) far ultra-violet circular dichroism spectra of cd2 wild type and the engineered proteins. (c) and (d) tb 3+ -binding curves of the engineered proteins cd2.shr.ef and cd2.sin.ef. the titration curve is fitted for a 1:1 binding stoichiometry calcium: a life and death signal calcium and cell death calcium signalling: dynamics, homeostasis and remodelling calcium and cell death calcium transport proteins in the nonfailing and failing heart: gene expression and function viral calciomics: interplays between ca 2+ and virus a novel calcium-dependent bacterial phosphatidylinositol-specific phospholipase c displaying unprecedented magnitudes of thio effect, inverse thio effect, and stereoselectivity maintenance of intracellular calcium in escherichia coli energetics of calcium efflux from cells of escherichia coli free calcium transients in chemotactic and non-chemotactic strains of escherichia coli determined by using recombinant aequorin poly-3-hydroxybutyrate/polyphosphate complexes form voltage-activated ca 2+ channels in the plasma membranes of escherichia coli characterization of a calcium porter of streptococcus pneumoniae involved in calcium regulation of growth and competence mutations which alter the kinetics of calcium transport alter the regulation of competence in streptococcus pneumoniae cell adhesion receptors: signaling capacity and exploitation by bacterial pathogens calcium in bacteria: a solution to which problem? calcium signalling in bacteria an extracellular calcium-binding domain in bacteria with a distant relationship to efhands classification and evolution of ef-hand proteins chimeric hth motifs based on ef-hands dissociation and aggregation of calpain in the presence of calcium binding and aggregation of human mu-calpain by terbium ion homodimerization of calpain 3 penta-ef-hand domain probing site-specific calmodulin calcium and lanthanide affinity by grafting predicting calcium binding sites in proteins-a graph theory and geometry approach calcium and lanthanide affinity of the ef-loops from the c-terminal domain of calmodulin design of a calcium-binding protein with desired structure in a cell adhesion molecule the effects of ca 2+ binding on the dynamic properties of a designed ca 2+ -binding protein(,) the encyclopedia of inorganic chemistry, second edition a grafting approach to obtain site-specific metal-binding properties of ef-hand proteins rational design of a calcium-binding protein obtaining site-specific calcium-binding affinities of calmodulin structural analysis, identification, and design of calcium-binding sites in proteins metalbinding studies for a de novo designed calcium-binding protein isolated ef-loop iii of calmodulin in a scaffold protein remains unpaired in solution using pulsed-field-gradient nmr spectroscopy design, synthesis, and characterization of a calcium-sensitive near infrared dye calcium binding properties of ef-loops in a beta-sheet protein metal binding affinity and structural properties of an isolated ef-loop in a scaffold protein criteria for designing a calcium binding protein peptide analogs from e-cadherin with different calcium-binding affinities identifying and designing of calcium binding sites in proteins by computational algorithm. in: computational studies, nanotechnology, and solution thermodynamics of polymer systems prediction of ef-hand calcium-binding proteins and analysis of bacterial ef-hand proteins calcium signalling in bacillus subtilis maintenance of intracellular calcium in escherichia coli nmr assignments, secondary structure, and global fold of calerythrin, an ef-hand calcium-binding protein from saccharopolyspora erythraea nmr assignments, secondary structure, and global fold of calerythrin, an ef-hand calcium-binding protein from saccharopolyspora erythraea a novel calcium binding site in the galactose-binding protein of bacterial transport and chemotaxis cellulosome assembly revealed by the crystal structure of the cohesin-dockerin complex protein synthesis in brucella abortus induced during macrophage infection characterization of heat, oxidative, and acid stress responses in brucella melitensis neat: a domain duplicated in genes near the components of a putative fe 3+ siderophore transporter from gram-positive pathogenic bacteria identification of a ca 2+ -binding domain in the rubella virus nonstructural protease key: cord-354832-lps2qbxy authors: wong, j. s. w.; lee, j. k. f. title: the common missed handwashing instances and areas after 15 years of hand-hygiene education date: 2019-08-08 journal: j environ public health doi: 10.1155/2019/5928924 sha: doc_id: 354832 cord_uid: lps2qbxy the outbreak of severe acute respiratory syndrome (sars) claimed the lives of 286 hong kong people in 2003. since then, the hong kong government has been promoting the benefits of proper hand hygiene. there are few studies that explore the general quality of handwashing and the hand-hygiene practices of the public of hong kong; given this, the aim of this study is to explore this neglected topic. this study is a quantitative study that was conducted in january 2018. the results show that the majority of participants only wash their hands after using the toilet (87%) or handling vomitus or faecal matter (91%). the mean duration of handwashing was 36.54 seconds (sd = 18.57). the areas of the hand most neglected during handwashing were the fingertips (48.1%), medial area (30.5%), and back of the hand (28%). a multiple logistic regression shows that participants who have reached third-level education or higher often tend to be more hand hygienic than those who have not reached third-level education (p ≤ 0.001, b = 1.003). thus, participants aged 30 and above tend to neglect 5 more areas of the hand than those aged below 30 (p=0.001, b = 4.933). in 2003, hong kong was profoundly affected by an unknown communicable disease entitled "severe acute respiratory syndrome" (sars). e outbreak originated in a hospital and then spread to the wider community. e disease took the lives of 286 hong kong citizens and 774 people worldwide. in total, there were 8,096 known cases [1] . given the seriousness of this outbreak, the promotion of the world health organization (who) guidelines and implementation of the "save lives: clean your hands" campaign became imperative. furthermore, in 2004, the hong kong government established the centre for health protection (chp), a similar entity as the us's centers for disease control and prevention (cdc). e chp aims to effectively prevent and control diseases in hong kong, in collaboration with both national and international stakeholders. since the beginning of chp, the agency has devised numerous guidelines and publications for health workers and the general public in order to prevent the spread of communicable diseases and promote healthy living. following the sars outbreak in hong kong, proper hand hygiene has been widely promoted in multiple contexts, focusing on the instances when hands should be washed as well as the duration and technique of handwashing. e worldwide public health agencies have asserted that proper hand hygiene can control the spread of communicable diseases from the common cold to the life-threatening severe acute respiratory syndrome, as well as fight against the rise in antibiotic resistance. systematic reviews also show that insufficient washing of hands increases food-borne illness outbreaks and diarrheal diseases [2, 3] . however, there are few studies that evaluate the compliance of hong kong people in this area or the effectiveness of their handwashing after 15 years of health education on this topic. us, these are the main topics of interest for this study. the effectiveness of handwashing and alcohol-based hand sanitizers. e majority of handwashing and hygiene studies typically focused on healthcare providers and students, while few studies targeted the general public. e common areas of focus for these studies included the length of time spent handwashing, missed areas, common situations where handwashing was warranted, compliance with guidelines, and the relationship between demographic data and hand cleanliness. for instance, in the us, monk-tuner et al. reported that only 10% of their 313 participants washed their hands for 15 seconds or longer. drankiewicz and dundes observed in their study that only 2% of participating university students washed their hands for 10 seconds or more [4] . shanks and peteroy-kelly found that the average time university students spent washing their hands was a mere 4.87 seconds [5] . a observational study conducted by michigan state university researchers also revealed that, among 3,749 people, the average washing times for men and women are 6.27 and 7.07 seconds, respectively, even though the cdc has been advocating the proper method for handwashing since 2012 [6] . in turkey, ergin et al. reported that 27% of 303 university students washed their hands just 4 times per day. ey found that the main reason for students not washing their hands on a more regular basis was due to the belief that there was no need to do so. ey also found that female participants scored significantly higher in knowledge, skills, and practices of hand hygiene [7] . in greece, mentziou et al. found that handrails and desks were the most frequently touched objects in universities, and the majority of university students performed handwashing after using the toilet and on returning home from university [8] . in kenya, curtis et al. also found that handwashing after using the toilet was the most common instance of hand hygiene [9, 10] . also, previous studies have identified that gender, age, employment status, and educational level are the factors that affect an individual's hand-hygiene practices. in the us, anderson et al., berry et al., edwards et al., and vanyolos et al. found that female participants washed their hands significantly more than male participants; in korea, park et al. also found this to be true [11] [12] [13] [14] . in the us, duggan et al. found that there was a reciprocal relationship between professional education and handwashing compliance [15] . burnett found that an increase in age was linked to improved perceptions of hand-hygiene practices [16] . lau et al. found that factors such as age, employment status, and perceived local outbreaks of sars were related to adopting good handhygiene practices for the protection of oneself and others [17] . in contrast, pan et al. found that the number of areas of the hands that were neglected during handwashing had no correlation with the demographic data (gender, age, or profession) of participants; they also found no significant relationship between the duration of handwashing and the number of missed areas [18] . some studies have revealed that exposure to proper hand-hygiene practices through mass media and the availability of handwashing facilities affect general handwashing practice [9, 10, 13] . regarding the effectiveness of handwashing, szilágyi et al. and vanyolos et al. used fluorescent hand gel with ultraviolet (uv) light to assess the nursing and medical students' quality of handwashing [12, 19] . e results showed that women wash their hands better than men, with nurses displaying the best handwashing practices. when comparing different age groups, participants aged 40-49 performed the best overall. e most common missed areas were the fingernails and wrists [19] . a similar procedure using visual assessment was carried out by kampf et al., and the results showed that the palms and fingertips were usually quite thoroughly cleaned [20] . in another study, kampf et al. used gel containing uv-sensitive dye [21] . participants were asked to apply this gel to their hands and then wash them under running water. a graphical assessment technique was then used to assess the missed areas by evaluating the absence of the uv dye. e tools used in this study make reference to the above-mentioned literature. in hong kong, the chp advocates proper handwashing practice to the public aligned with the cdc in the united states, the national health service (nhs) in the united kingdom, the public health agency of canada, and the global handwashing partnership which includes washing one's hands with water and soap before and after at least eight specific situations; the process comprises six steps over seven areas of both hands for no less than 20 seconds [22] . in 2014, the chp conducted a handhygiene survey. e results revealed that although hong kong people had a good understanding of hand hygiene, 6% of them reported that they did not wash their hands after using the toilet, and less than a third washed their hands after touching public equipment or installations. recently, lee et al. developed an observational checklist in order to assess foreign domestic workers' handwashing practices in hong kong [23] . on average, they correctly performed 5 out of the necessary 13 handwashing steps. none of the participants rubbed their hands for 20 seconds or more, and none of the participants rubbed all areas of their hands. moreover, a study was also conducted in a local hospital in relation to the compliance of healthcare professionals with the who's "my 5 moments for hand hygiene" guidelines. e frequency of hand-hygiene practices was measured, but the quality of the practices was not evaluated. of the 13,694 situations in which hand hygiene should have been practiced in a unit with 21 healthcare professionals, including nurses, physiotherapists, and healthcare assistants, the compliance rate was 35.1%. lower rates of compliance were noted from 12:00 p.m. to 14:00 p.m. (21.3%, 95% ci: 17.2-25.3), as well as among nurses who shared their badges with others (23.7%, 95% ci: 17.8-29.6) [24] . among the above-mentioned local studies, none of them was able to unveil the overall effectiveness of handwashing, and a comprehensive and in-depth exploration of hand-hygiene practices among hong kong people is neglected [25] . erefore, this study was designed to fill this gap, and the following research questions were developed: (1) what are the most common instances of handwashing among hong kong adults? (2) how long do hong kong adults spend washing their hands? (3) what areas are most commonly missed in handwashing? (4) how many of the participants have received proper hand-hygiene information, and what are the common information resources? (5) what are the differences between independent variables, common missed areas, and handwashing instances? (6) what is the relationship between independent variables, common missed areas, and handwashing instances? is study used a cross-sectional survey with convenience sampling, and behavioural observations were conducted from january to march in 2018. before conducting this study, ethical approval was obtained from the research ethics committee of a local higher-education institute in hong kong. e ethical committee reference number is nur/src/20171220/016. given that the target population was hong kong adults and that public handwashing facilities were required, this study was conducted in several public barbecue sites in three different territories of hong kong (i.e., hong kong island, kowloon, and the new territories) in order to broaden the scope of this study. barbeque sites were chosen as areas to recruit participants because spacious handwashing facilities with touchless faucets and sinks were provided in an outdoor washing area. e participants were the visitors to the barbecue sites whose age ≥18, mentally sound hong kong residents, and those who were able to communicate with cantonese as cantonese is the mother tongue of hong kong people. participants who had experience working in healthcare settings and those with artificial nails, irremovable hand accessories, or a disability in both hands were excluded from this study. a survey was carried out by face-to-face interviews at the barbecue sites. e participants were required to report their demographic information, instances of handwashing, and their sources of handwashing information. 3.4. procedure. first, information sheets were given to the participants. after obtaining informed consent from them, the participants were asked to rub glo germ gel in their hands. after the rater confirmed that both hands were fully covered by the gel, the participants were asked to wash their hands under running water in a way that was typical for them. when the participants were washing their hands, the rater stood far behind them and recorded the time it took them to complete the process. after the participants had washed their hands, a portable, rechargeable black box with 10 watts of uv light was used to assess the residual fluorescent stains on the hands of the participants. e rater then recorded the results. machine (ibm) statistical product and service solutions (spss) for windows version 24.0 (ibm corp, 2016) was used for data analysis. e situations in which participants would commonly wash their hands, demographic data, and the duration of handwashing were analyzed by using descriptive statistics of frequency count, mean, and standard deviation. to compare the continuous data between the missed areas and variables in demographic data, independent t-test and one-way anova were used. linear and multiple logistic regressions were used to examine the relationship between variables in demographic data, duration of handwashing, and coverage of missed areas during handwashing. variables were presented as regression coefficients. e odds ratio was adjusted with corresponding 95% confidence intervals and p values. e statistical significance of p < 0.05 was taken into account. all statistical tests were two-tailed. eventually, 190 (94 males and 96 females) valid data were collected from the barbeque sites in three main regions of hong kong, comprising 47 (25%) participants from hong kong island, 59 (31%) from kowloon, and 84 (44%) from the new territories. e ratio of the number of participants in these three geographical areas was similar to the total population distribution of hong kong. e characteristics of the samples are shown in table 1 . e leaflet devised by the chp advises hong kong people to wash their hands in at least 8 different instances. ey are as follows: (1) after handling vomitus or faecal matter, (2) after using the toilet, (3) before and after visiting hospitals or residential care homes or caring for the sick, (4) after contact with animals or pets, (5) before eating or handling food, (6) after coughing or sneezing, (7) after touching public installations or equipment, and (8) before touching eyes, nose, and mouth. among the 190 participants of this study, half (52.6%) washed their hands in 5 of the 8 instances and only 3 participants (1.6%) washed their hands in all 8 instances. e results showed that more than half of the participants washed their hands after handling vomitus or faecal matter (91.1%), after using the toilet (87.4%), before and after visiting a hospital or a residential care home or caring for the sick (72.6%), after having contact with animals or pets (61.6%), and before eating or handling food (58.4%). in contrast, less than half of the participants washed their hands after coughing or sneezing (48.4%), after touching public installations or equipment (16.8%), and before touching their eyes, nose, and mouth (12.1%) (figure 1 ). using an independent t-test and an analysis of variance (anova) to compare the demographic data with handwashing instances, the results showed that the mean handwashing instances of participants with third-level education or above were significantly higher than those of participants who had primary-and secondary-level education only (p ≤ 0.001). among the 190 participants, 84 (44.2%) received proper hand-hygiene information. given that this was an open-ended question, participants could list more than one resource. us, 106 resources were reported. after grouping and categorising the resources, the result was revealed that the participants obtained information from the media (45%) and from schools (34%); relatively less information was obtained from hospitals (15%) and the workplace (12%). in addition, nearly two-thirds of the youngest age group obtained information from both schools and the media. however, only 31% of the oldest age group received that same information. moreover, the instances of handwashing of those participants who received informed hand-hygiene information were significantly higher than those of participants who did not (p ≤ 0.001). us, the mean of the total missed areas was significantly higher in participants who did not receive information about proper hand hygiene than those who received it (p � 0.004). on average, the participants took 36.54 seconds (range � 10-120, sd � 18.57) to wash their hands. e majority of participants (86.8%) washed their hands for longer than 20 seconds, as advocated. for each participant, a total of 86 anatomical areas were evaluated. e results showed that the fingertips (48.1%), medial area (30.5%), and back of the hand (28%) were the most commonly missed areas in terms of washing. using an independent t-test and anova to compare the differences between the demographic data and missed areas, we found that unemployed participants had significantly more missed areas than the other participants; the unemployed missed certain areas, including the back of the fingers (p � 0.014), palms (p � 0.007), back of the hand (p � 0.010), and medial areas (p � 0.003) ( table 2 ). fulltime university students also neglected the back of the fingers (p � 0.037). blue-collar workers had significantly more missed areas, with the medial areas (p � 0.003) and the lateral areas (p � 0.005) of the hands being neglected. moreover, the results showed that participants with thirdlevel education or above (m � 10.88, sd � 9.54) had significantly (p � 0.004) fewer total missed areas than those with primary-and secondary-level education only (m � 11.91, sd � 7.94). among the different age groups, the youngest age group performed significantly better than the older age groups over the front of the fingers (p � 0.038), the back of the fingers (p � 0.015), and the lateral side of the hand (p � 0.012 and 0.019). in terms of the total missed areas, the youngest age group missed significantly fewer areas than the oldest (p � 0.046). multiple logistic regression was used to examine the relationship between the demographic variables, total missed areas, and instances of handwashing. e results showed that age is the only significant predictor of the total missed areas. ose aged 30 and above tended to have 5 more missed areas than those aged 30 or below (p � 0.001, b � 4.933, 95% ci � 2.119-7.747). considering the variables affecting the total number of instances of hand hygiene, the only significant predictor among the variables was the educational level of the participants. ose with only primary-and secondary-level education tended to have 1 more missed hand-hygiene instance than those whose educational levels were above the third level (p � 0.001, b � 1.003, 95% ci � 0.511-1.495). although there is scant empirical evidence on the duration of handwashing for the general public, the key public health agencies around the world, such as cdc, nhs, public health agency of canada, and global handwashing partnership, adopt the who's guideline for the healthcare providers as well as for the community use. in our study, almost 90% of the participants completed their handwashing routine in 20 seconds or more. is contrasts with the studies conducted in the united states by drankiewicz and dundes, shanks and peteroy-kelly, and borchgrevink et al. [4] [5] [6] . in 2008, the who designed a handwashing leaflet, making reference to taylor, who indicated that the fingertips, interdigital areas, thumbs, and wrists are the most commonly missed areas in handwashing [26] . pan et al. also found that the tips of the nails and the fingertips had the largest amount of residual florescent stains left after handwashing among healthcare workers in taiwan [18] . e commonly missed areas among medical students in the study conducted by vanyolos et al. was the first metacarpal, the proximal part of the palm (lateral), the distal phalanges, and the nail beds [12] . in healthcare workers inškodová et al.'s study, the thumbs and fingertips were the most commonly missed areas [27, 28] . in this study, the most frequently missed area was also the fingertips. however, the medial aspect and back of the hand were the second and third most missed areas, respectively. moreover, the interdigital area and the front and back of the fingers were the [2, 3, 6, [11] [12] [13] [14] 30] . in this study, we found that participants with higher educational levels had fewer missed areas, and they performed handwashing on a more regular basis; this is in contrast to the findings of duggan et al. [15] . however, curtis et al. in kenya found that participants who had higher levels of education and literacy had a greater frequency of handwashing [9] . eir study also revealed that media exposure is an important determinant of the frequency of handwashing. in korea, park et al. reported that participants who received information about handwashing did wash their hands on a more frequent basis; this finding is in concordance with the finding presented in this study [6] . furthermore, curtis et al. also reported that "after defecation," "before feeding a child," and "before handling food" were the most common situations in which participants washed their hands [9] . similar results were also found by blanton et al. amongst caregivers in kenyan schools [10] . is was also the case with ergin et al. in relation to turkish university students [7] . is study elicited the same results: "after handling vomitus or faecal matter," "before and after caring for the sick," and "before eating or handling food" are common situations in which hong kong people wash their hands. in relation to the association between age and handhygiene practices, we found that as age increases, handwashing becomes more neglected. however, burnett highlighted that participants aged 55 years and older had good perceptions of hand hygiene, while the age group with the poorest perceptions was those under 26 years of age. [16] e results of this study may be explained by the intense focus on hand-hygiene education in primary and/or secondary schools after the sars attack in 2003 but relatively less in the community. is study did have its limitations. one of these limitations is the potential unease felt by the participants that evolved by asking for ad hoc handwashing at the venue. erefore, the researcher did stand far behind the participants, and the participants were not informed that the time spent washing their hands was being recorded. given the researcher stayed far behind the participants, their compliance with the steps of handwashing could not be evaluated. besides, although the self-report survey is the fastest way to gather abundant data, this method cannot avoid social-desirability bias in which the participants wanted to "be good," even though the survey is anonymous. hence, these two unpreventable conditions may produce potential influences on the results. furthermore, since most people had barbeque at sunny weekends only, suitable weather and period were quite short which limited the sample size. e results provide insights that will be useful for public health and primary-care professionals when reviewing health-promotion strategies for proper hand hygiene. although the sample size of this study was not large, this study and pan et al.'s taiwanese study found that the fingertips are the most commonly neglected areas [18] . given that taiwan and hong kong are located in the same region, it is worth investigating if similar results are found in other asian countries. us, the reinforcement of fingertip washing is necessary for future handwashing practices. in addition, hand-hygiene education in schools seems to be quite effective; however, hand-hygiene education within the community seems inadequate, particularly for older adults and less well-educated groups. according to the world bank in 2018, the population density of hong kong increased from 6,587 people per square kilometre in 2007 to 7,040 in 2017, and it ranks as the fourth highest one in the world. people live more closely together than before, and population will increase in the future. since the outbreak of seasonal influenza and handfoot-mouth disease has been attacking hong kong frequently in recent years, the high population density of hong kong may exacerbate the risk of contracting communicable diseases through common contact surfaces such as door knobs, elevator buttons, handrails of escalators, and public transport. in addition to the effects of globalisation, other developed countries or cities with high population density may also be facing similar challenges. erefore, the public health and primary-care professionals may consider reviewing the protocol for proper hand hygiene and strategy of education and promotion and examine its effectiveness. all the quantitative data used to support the findings of this study are available from the corresponding author upon request. e authors declare that there are no conflicts of interest with respect to the research, authorship, and publication of this article. summary of probable sars cases with onset of illness from 1 systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects effect of washing hands with soap on diarrhoea risk in the community: a systematic review handwashing among female college students research article: analysis of antimicrobial resistance in bacteria found at various sites on surfaces in an urban university hand washing practices in a college town environment evaluation of students' social hand washing knowledge, practices, and skills in a university setting evaluation of hand hygiene in groups of students in greece planned, motivated and habitual hygiene behaviour: an eleven country review evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households-nyanza province, western kenya predictors of hand-washing behavior usage of ultraviolet test method for monitoring the efficacy of surgical hand rub technique among medical students examining hand-washing rates and durations in public restrooms gender and ethnic differences in hand hygiene practices among college students inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital perceptions, attitudes, and behavior towards patient hand hygiene anticipated and current preventive behaviors in response to an anticipated human-to-human h5n1 epidemic in the hong kong chinese general population assessing the thoroughness of hand hygiene: "seeing is believing a large-scale assessment of hand hygiene quality and the effectiveness of the "who 6-steps influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection centre for health protection, perform hand hygiene properly, centre for health protection what is the hand washing performance in foreign domestic helpers in hong kong? introduction of an electronic monitoring system for monitoring compliance with moments 1 and 4 of the who "my 5 moments for hand hygiene" methodology centre for health protection, chp survey shows personal hygiene not fully practised by public, centre for health protection an evaluation of handwashing techniques-2 hand hygiene technique quality evaluation in nursing and medicine students of two academic courses hand hygiene assessment in the workplace using a uv lamp graphical assessment technique (gat)-an objective, comprehensive and comparative hand hygiene quantification tool key: cord-318980-8cclwzob authors: dindarloo, kavoos; aghamolaei, teamur; ghanbarnejad, amin; turki, habibollah; hoseinvandtabar, sommayeh; pasalari, hasan; ghaffari, hamid reza title: pattern of disinfectants use and their adverse effects on the consumers after covid-19 outbreak date: 2020-09-30 journal: j environ health sci eng doi: 10.1007/s40201-020-00548-y sha: doc_id: 318980 cord_uid: 8cclwzob background and objective: the aim of this study was to investigate the pattern of disinfectants use within outbreak of covid-19 and estimate their adverse effects on the consumer’s health. methods: in this descriptive-analytical study, 1090 participants were entered into the study without age and gender limitations. a researcher-made electronic checklist containing 43 questions was applied to collect data. the checklist included three sections: demographic characteristics (8 questions), disinfection of body and non-living surfaces (21 questions), and adverse effects of disinfectants on health (15 questions). results: 87% of participants used the incorrect proportions of water and alcohol to make this disinfectant available at home. the percentage of people with wrong proportion of sodium hypochlorite was 74.2%. approximately 42% of participants experienced at least one disorder on their hands, feet, eyes, respiratory or gastrointestinal systems after sequential uses of disinfectants. the most common disorders among the participants were found to be skin dryness (76.3%), obsession (42.2%), skin itching (41.2%), coughing (41.1%), and eyes irritation (39.5%). the mean frequency of hand washing and hand disinfecting were 15.28 and 10.74 times per a day, respectively, and the clean-up in case of surfaces was 2.99 times a day. the frequency of hand washing and disinfecting in women group (16.4 and 11.2 times a day) were higher than in men (14.0 and 10.3 times a day) group. in addition, these self-care actions in married people (15.6 and 11.0 times a day) were higher compared to those in single people (14.0 and 10.6 times a day). conclusion: being unaware of participants with instruction for preparation and use disinfectants may harm their health. therefore, it is suggested that the authorities provide the necessary training program for public through official media. coronaviruses are viruses that can infect the respiratory tract, gastrointestinal tract, liver, and central nervous system of humans, cows, birds, bats, rodents, and other wildlife [1] [2] [3] . coronaviruses, like influenza viruses, are being transmitted by various animal species in the wild. alpha-coronavirus and beta-coronavirus can infect mammals, and gamma-corona viruses and delta-coronaviruses tend to infect birds, however some types of coronaviruses can also be transmitted to mammals [3] . the serious and applicable measurements were not considered until the outbreak of viruses of severe acute respiratory syndrome (sars-cov) in 2002 and 2003 in guangdong province, china. the middle east respiratory syndrome (mers-cov) coronavirus outbreak posed the greatest threat to the public [4, 5] . however, in early december 2019, the first cases of a syndrome with unknown origin were first identified in wuhan, hubei province, china [6, 7] . the new and emerging coronavirus, which is considered as the seventh member of the coronavirus family [8, 9] , has been responsible for this respiratory syndrome. currently, the prevalence of this acute respiratory syndrome, known as covid-19, has been confirmed, worldwide. the total number of confirmed cases and deaths in the world as of june 9, 2020 was 7,261,476 and 410,972, respectively. in iran, the total number of cases and death at the same date was reported to be 175,927 and 8425, respectively [10] . in iran, the first death contributed to covid-19 was officially announced by the ministry of health and medical education on february 19, 2020 [11, 12] . common symptoms of covid-19 include fever, cough, shortness of breath and respiratory problems. in more severe cases, the infection can cause pneumonia, severe acute respiratory syndrome, kidney failure, and even death [13] . the two main routes of covid-19 transmission are respiratory and contact routes. contact with infected person's respiratory droplets via coughing or sneezing, contact with a person with respiratory symptoms (sneezing, coughing, etc.), and contact with surfaces on which respiratory droplets are located are currently known as the primary pathways of coronavirus transmission [14] . the literature show that the survival of human coronaviruses on surfaces varies from 2 h to 9 days [15] . survival time depends on a variety of factors, including surface type, temperature, relative humidity, and pressure. the previous studies showed that effective inactivation (within 1 min) using common disinfectants such as ethanol 70% and sodium hypochlorite is acceptable [14] . health tips to prevent the spread of covid-19 include regular hand washing, covering the mouth and nose when coughing and sneezing, full cooking, avoiding close contact with a person who has symptoms of a respiratory illness such as cough and sneezing, and disinfecting surfaces [2] . there are many disinfectants that are effective against covert viruses such as the covid-19 virus. the most commonly recommended disinfectants are ethanol 70% and chlorinated disinfectants such as sodium hypochlorite and calcium hypochlorite. after the outbreak of covid-19 and due to the lack of familiarity of consumers with disinfectants and their preparing methods, the lack of proper training in this field by trustees, and finally profiteering of some people and companies, some poisonings and health problems in disinfectants users have been reported. the aim of this study was to investigate the pattern of consumption for disinfectants by public after the outbreak of coronavirus and compare it with standard protocol. the additional aim of present research was to identify the adverse effects of disinfectants misuse. this cross-sectional study was performed within march 2020 and april 2020. the research was approved by the ethics committee of hormozgan university of medical sciences (code: ir.hums.rec.1398.480). since there is no previous study in this field, 384 cases were estimated to be studied based on cohen's table with 5% error and 80% power. the participants in the present study were the citizens of hormozgan province. hormozgan is a province in the south of iran. this province includes 13 counties. the population of this province, according to the census in 2017 was estimated to be 177,641,500. until 5 june 2020, the number of people afflicted with covid-19 in this province was estimated to be 4480 and the mortalities were 56 [16] . no age or gender limitation were considered for participants. data were collected by completing questionnaires. due to the risk of transmitting the coronavirus through paper questionnaire, electronic self-made questionnaire were applied to collect data. the questionnaire consisted of three sections, including demographic characteristics (8 questions), pattern of disinfectants use (30 questions), and health effects of these substances on consumers (8 questions). the total number of questions in the questionnaire was 46. questions were presented individually on the screen of mobile, tablet and computer and respondents were able to enter their answers by touching the corresponding buttons on the screen. respondents were not able to move on to the next question without completing the previous one, however they were able to go back and change their previous responses. the collected data were analyzed by spss22. descriptive analysis were employed to describe the frequency, percentage, mean score and standard deviation of obtained data. t-test, one-way anova or their nonparametric equivalences were applied to analyze the data and the differences between groups. the results of the demographic characteristics of the participants in the study are shown in table 1 . of 1090 participants entered into the present study, 513 were male and 577 were female. the mean age of the participants in the study was 35.22 years with a range of 15 to 70 years and the highest frequency was observed in the age group of 31 to 45 years. 21.2% of the participants were married and 78.8% were single. most of the participants (47.2%) were employed by the government or the private sectors. in terms of education level, most of the participants (50.7) were found to have bachelor degree. 21.7% of the participants lived in the rural and 78.3% in the urban areas. the average frequency of hand washing between participants was found to be 15.28 times per day with minimum and maximum of 1 and 100, respectively. the average handwashing frequency in women was higher than in the men group, and the difference between two groups was statistically significant according to the t-test statistics (p < 0.05). the main explanation for this result may be attributed to this assumption that women pay more attention to their personal hygiene than men [17] . in addition, due to the fact that women in iran are responsible for doing household chores, including cooking and cleaning, and therefore this can increase their responsibility in relation to the health of other family members. the results obtained showed that married people washed their hands more compared to single people. however, the difference between two groups was not statistically significant based on the t-test statistics (p < 0.05). among married people, those who had children washed their hands more than those who did not have children. the t-test statistical test showed that the average hand washing frequency of two groups was significantly different. this result can be due to the responsibility of parents for the health of their and children. in addition, in the majority of iranian families, fathers are responsible for financing the living expenses. father's illness or death leads to temporary or permanent disruption of the family economy. in terms of the average frequency of hand washing, there was no significant difference between urban and rural areas (p > 0.05). the anova statistics showed that there was a significant difference between different jobs in terms of the frequency of hand washing (p < 0.05). however, this difference was not statistically significant between participants with different education level. the most effective cleaning agent for hand washing is liquid soap followed by, and solid soap is the next. 38.5% of the participants claimed that they use other ingredients, such as washing powder and dishwashing liquid, to wash their hands. the contribution of different detergent applied for hand washing are shown in the fig. 1 . due to the presence of skin incompatible substances in these detergents, skin damage is possible for the consumers of these detergents. 1% of participants do not use any detergent to wash their hands. as water alone is not able to eliminate microorganisms, especially coronavirus, these people are at higher risk for coronavirus. according to the world health organization (who), the proper time to wash hands is 20 s [18] [19] [20] . according to water supply officials in iran, the water consumption has increased by about 20-40% since initial stage of the outbreak of covid-19 in iran. it is worth noting that part of this water consumption is contributed to washing and cleaning the house in special days of the new year, which coincides with the outbreak of covid-19. approximately 77.9% of participants sanitize their hands when the outbreak of covid-19 spread. in addition to the hands, disinfection of the feet, face and whole body was performed by 22.4, 30.2 and 13% of the participants, respectively. the average frequency of hand sanitization by participants was 10.74 times with a minimum and a maximum of 1 and 100, respectively. according to the t-test or anova statistics, there was no significant difference in the number of hand disinfections between different people categorized by age, gender, level of education, marital status, having children, place of residence and occupation (p > 0.05). the situations in which participants disinfect their hands are shown in the fig. 2 . as can be seen from the figure, most participants disinfect their hands after coming back to home, nothing fig. 1 the type of detergents applied for hand washing fig. 2 the situations in which participants sanitize their hands after shopping, after going to the toilet, and after touching the hands of other. it is recommended that people disinfect their hands when doing certain activities, such as before and after eating, after going to the toilet, after shopping, and after touching contaminated or suspected surfaces of contamination. on the one hand, not disinfecting hands in the mentioned situations can increase the risk of spreading covid-19, on the other hand, increases in the frequency of disinfections and overuse of these matters can cause adverse effects on consumer health. to overcome these problems, it is necessary to educate the people about the correct methods of hand disinfection. disinfection of the face, and feet was performed by 30.2, 22.4% of the participants, respectively. 13% of participants disinfect their entire body. apart from the hand, the recommendation to disinfect other parts of the body has not been reported so far [21, 22] . over frequent disinfection of other organs, especially the face, can cause skin, eye, lung, and gastrointestinal disorders [23] . 241 participants (22.1%) reported that they did not disinfect their hands after the coronavirus virus outbreak. of this group, 31.1% wash their hands less than 10 times a day. since washing hands with soapy water as well as disinfecting hands with alcoholic solutions is recommended as the most important ways to prevent covid-19 [24] [25] [26] , the risk of getting covid-19 further threatens the health of these persons. 91% of participants disinfect surfaces. the average frequency of surface disinfection by participants was 2.99 times with a maximum of 30 and a minimum of 1. the frequency of disinfections recommended for surfaces is 2 [27, 28] . in addition to health problems, frequent disinfection of surfaces can also damage the family economy. according to the t-test or anova statistics, there was no significant difference in the number of surface disinfections between different participants categorized by age, gender, level of education, marital status, having children, place of residence and occupation. the most important surfaces disinfected by participants were toilet (80.7%), keys (86.1%), credit card (87%), and mobile phone (86.6%). the frequency of disinfection of other surfaces by the participants is shown in the fig. 3 . the correlations between hand washing frequency, hand sanitizing frequency and surface disinfection frequency are shown in fig. 4 . the correlation between hand washing and hand sanitizing frequency was 0.61, while the correlation between hand washing and surface disinfection frequency, and between hand sanitizing and surface disinfection frequency were 0.16 and 0.28 and all of them were significant at level of 0.05. the most commonly used substance by participants to disinfect their hands was found to be alcoholic solutions (51.4%). 4.8% of people use sodium hypochlorite bleach and 43.8% use other substances. alcohol is not available for everyone due to its high cost and scarcity. some people, mostly lowincome people, use sodium hypochlorite bleach to disinfect their hands due to its low cost and availability. although lowconcentration of sodium hypochlorite bleach (0.05%) can be used for hand disinfection [29] [30] [31] , uses of sodium hypochlorite bleach with high concentration are limited unless in emergency conditions. repeated use of sodium hypochlorite bleach with inappropriate concentrations can cause damage fig. 3 the surfaces disinfected by participants to the skin of the hands and respiratory problems for these people. some people have also resorted to the use of natural and herbal disinfectants such as vinegar. given that the effectiveness of these disinfectants has not been proven by scientific sources [32] [33] [34] , their use causes a false sense of the safety, and the risk of afflicting these people to covid-19 is increased. sodium hypochlorite bleach is the most widely used disinfectant for surfaces disinfection by individuals (57.3%). the next ranks belong to the alcohol solution (22.6%). 20.2% of participants use other materials than these for surface disinfection. lack of proper training to people to prepare and use sodium hypochlorite bleach can cause irreparable damage to their health. the best way to use sodium hypochlorite bleach for surface disinfection is to soak the fabric in sodium hypochlorite bleach and draw it on the surfaces. spraying sodium hypochlorite bleach on surfaces, in addition to spreading sodium hypochlorite bleach itself in the air, removes contaminants from the surfaces and suspend them in the air [35] . correct time for disinfection is another point that, if not followed properly, the disinfection efficiency will be reduced. the appropriate time for disinfection by sodium hypochlorite bleach (0.5%) is at least 10 min [36] . only 5.5% of participants consider this contact time. 21.6% of people claimed that they start drying surfaces immediately after using sodium hypochlorite bleach. due to the lack of contact time, the efficiency of the disinfection process will be reduced. 38.6% of participants buy ready-to-use disinfectant solutions, and 61.4% buy the raw materials and mix them at home with fig. 4 correlation between hand washing frequency, hand disinfection frequency, and surface disinfection frequency according to spearmen rank correlation coefficient other substances such as water to make them ready for use. alcohol-based solutions and sodium hypochlorite bleach are the most widely used disinfectants by participants after the outbreak of coronavirus. 2.1% of participants mix alcohol with substances other than water. the reaction of these substances with alcohol can lead to the production of harmful secondary compounds that are harmful to health. due to the facts that the appropriate concentration of ethanol for disinfection is 60 to 70% [37] [38] [39] [40] and the alcohol available in the market mainly has a concentration higher than 95-99%. the best way to prepare an alcohol solution to disinfect the hands and surfaces is mixing three cup of 99% alcohol with one cup of water [41, 42] . this method has been followed only by 10% of participants. other patterns used by people neither have the necessary effectiveness for disinfection, nor have adverse health effects on consumers. 40% of participants do not follow the correct pattern of mixing alcohol with water. the correct pattern for mixing sodium hypochlorite bleach)5% active chlorine(with water to prepare a concentration of 0.1% chlorine suitable for disinfection of surfaces is one cup of sodium hypochlorite bleach with 49 cup of water [43] . about 82% of the participants used a different method other than the aforementioned pattern to prepare the sodium hypochlorite bleach solution. approximately 0.7% of people have used the sodium hypochlorite bleach in a concentrated form without mixing it with water, which can have very adverse effects on their health. approximately 1.3% of participants mix sodium hypochlorite bleach with other substances than water. secondary substances produced by the reaction of these substances may have an adverse effect on consumer health [44] . the use of personal protective equipment (ppe) such as masks and gloves is one of the requirements when uses of surface disinfectants [13, 45] . 47.5% of people didn't use any personal protective equipment when using disinfectants for surfaces, which endangers their health. the ppe used by consumers were shown in fig. 5 . in iran, the national radio and television are known as the most important and reputable source of news related to covid-19, and the people have been advised to follow the news and recommendations for the preventive measurements against covid-19 through these media. selected references by participants to obtain instructions on the use of disinfectants are shown in fig. 6 . as can be seen from this figure, the highest contribution belongs to social networks (55.3%), followed by radio and television (43.8%). although social media has played an undeniable role in informing about covid-19, a large number of unscientific recommendations have been spread through social networks. the implementation of this recommendation by some people has caused irreparable damage to their health. advices to use methanol instead of ethanol for disinfecting hands and surfaces and drink alcohol to remove the virus from the body were those that have led to poisoning, blindness and even death in some people. 5.4% of participants have used methanol (red or industrial alcohol) instead of ethanol (white or medical alcohol) for disinfection. due to the proven adverse effects of methanol such as blindness, skin damage and even death [46] [47] [48] , its use for disinfecting body organs and surfaces is strictly prohibited. 15.4% of the participants provide disinfectants from centers other than pharmacies and health centers. the huge profits from the sale of disinfectants after the outbreak of the coronavirus have led some profiteers to produce counterfeit disinfectants using hazardous chemicals; many of disinfectants produces have been seized by legal authorities [49, 50] . therefore, it is recommended that people obtain disinfectants from reputable centers and stores and ensure the safety of these substances. 65.2% of people keep disinfectants in inappropriate places such as kitchens, bedrooms, toilets and bathrooms. storage of disinfectants and disposal of empty containers is one of the points that must be done correctly in terms of safety. keeping disinfectants available to children and near food items can cause poisonous effects on family members. the best place to store these materials is in a warehouse, away from family members and flammable materials [51] [52] [53] [54] [55] . in addition, the appropriate temperature and storage time for these materials must be considered according to the manufacturer's instructions. regarding the majority of chemicals, including disinfectants, it is recommended that their empty containers must be delivered separately from other waste to organizations that are responsible for managing such waste. 70.3% of participants dispose empty containers, along with other waste, which can be detrimental to the health of waste collection personnel and cause possible fires at waste storage and disposal sites. adverse effect of disinfectants 41.4% of participants had health problems in at least one organ of their body due to the use of disinfectants. the results of the adverse effects of disinfectants observed between the participants re shown in fig. 7 . the most important skin effects on the hands and feet, were found to be itching, redness, dryness, and sores. eye effects included eye irritation and itching, tearing, and decreased vision. lung irritation, shortness of breath, cough and sneezing are some of the frequent effects observed in the respiratory system. abdominal pain, diarrhea and vomiting have been common gastrointestinal symptoms. throat irritation, obsessive-compulsive disorder, lack of concentration, headaches and dizziness and fatigue have been other adverse effects of disinfectants on people. in addition, 1.7% of participants claimed that they or their relatives had eaten disinfectants, including alcohol, to treat coronavirus and had to see a doctor because of its side effects. in this study, the pattern of preparation and consumption of disinfectants after corona outbreak and adverse effects of these substances on consumer health were examined. the results indicated that a significant number of participants are unfamiliar with the principles of preparation and use of disinfectants. improper preparation, uses of disinfectants in unconventional concentrations, storage in unsafe places, excessive use of these materials, receiving instructions for the use of these materials from unreliable sources and improper disposal of empty containers are the most important mistakes made by participants. because the misuse of these substances can have irreversible effects on people's health, it is necessary for health authorities to provide the necessary training for consumers from official and reputable authorities. fig. 7 the impacts of disinfectants observed in participants emerging coronaviruses: genome structure, replication, and pathogenesis the severe acute respiratory syndrome: impact on travel and tourism discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin protecting health-care workers from subclinical coronavirus infection trypsin treatment unlocks barrier for zoonotic bat coronavirus infection coronavirus disease 2019 (covid-19): a literature review clinical features of patients infected with 2019 novel coronavirus in wuhan chest ct findings in coronavirus disease-19 (covid-19): relationship to duration of infection a novel coronavirus from patients with pneumonia in china a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran covid-19 battle during the toughest sanctions against iran critical supply shortages-the need for ventilators and personal protective equipment during the covid-19 pandemic water, sanitation, hygiene and waste management for covid-19: technical brief persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents situation report -covid 19 on 18 saudi arabians' health beliefs pertaining to middle east respiratory syndrome-coronavirus (mers-cov): knowledge, attitudes, and practices (kap) assessment practical-10 disinfection and house keeping. ignou improving infection prevention and control at the health facility: interim practical manual supporting implementation of the who guidelines on core components of infection prevention and control programmes: world health organization personal hygiene. principles of food sanitation handwashing and hand sanitizer use at home, at play, and out and about safety evaluation of topical applications of ethanol on the skin and inside the oral cavity evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant infection prevention and control guidelines for patients with middle east respiratory syndrome coronavirus (mers-cov) infection potential hazards of concern in the walk-through screening system for the corona virus disease 2019 from the perspective of infection preventionists persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents the antibacterial efficacy and in vivo toxicity of sodium hypochlorite and electrolyzed oxidizing (eo) water-based endodontic irrigating solutions enteric virus survival during household laundering and impact of disinfection with sodium hypochlorite efficacy of sodium hypochlorite bleach and" alternative" products improvement of solar based rainwater disinfection by using lemon and vinegar as catalysts vinegar as a disinfectant of extracted human teeth for dental educational use antimicrobial activity of home disinfectants and natural products against potential human pathogens significant impact of terminal room cleaning with bleach on reducing nosocomial clostridium difficile activity of selected oxidizing microbicides against the spores of clostridium difficile: relevance to environmental control ethanol disinfection of plasticadherent micro-organisms chemical disinfection of non-porous inanimate surfaces experimentally contaminated with four human pathogenic viruses activity of bleach, ethanol and two commercial disinfectants against spores of encephalitozoon cuniculi comparative efficacy of ethanol and isopropanol against feline calicivirus, a norovirus surrogate microheterogeneity of ethanol-water binary mixtures observed at the cluster level outbreaks where food workers have been implicated in the spread of foodborne disease. part 10. alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps cleaning and disinfection of environmental surfaces in the context of covid-19: interim guidance uses of inorganic hypochlorite (bleach) in health-care facilities rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance investigation into a cluster of infant deaths following immunization: evidence for methanol intoxication ethylene glycol or methanol intoxication: which antidote should be used, fomepizole or ethanol impulsive differential equation model in methanol poisoning detoxification climate impact on corona virus in the world a critical analysis to comprehend panic buying behaviour of mumbaikar's in covid-19 era acute hazards to young children from residential pesticide exposures women's strategies for handling household detergents hazardous waste, impact on health and environment for development of better waste management strategies in future in india household hazardous materials and their labels: a reference for teachers store hazardous products safely: your home may be an accident waiting to happen publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments we are sincerely thankful to social determinants in health promotion research center, hormozgan health institute, hormozgan university of medical sciences for funding this research. conflict of interests the authors declare that there is no conflict of interests. key: cord-263245-2qub96mz authors: singh, d.; joshi, k.; samuel, a.; patra, j.; mahindroo, n. title: alcohol-based hand sanitisers as first line of defence against sars-cov-2: a review of biology, chemistry and formulations date: 2020-09-29 journal: epidemiol infect doi: 10.1017/s0950268820002319 sha: doc_id: 263245 cord_uid: 2qub96mz the pandemic due to severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has emerged as a serious global public health issue. since the start of the outbreak, the importance of hand-hygiene and respiratory protection to prevent the spread of the virus has been the prime focus for infection control. health regulatory organisations have produced guidelines for the formulation of hand sanitisers to the manufacturing industries. this review summarises the studies on alcohol-based hand sanitisers and their disinfectant activity against sars-cov-2 and related viruses. the literature shows that the type and concentration of alcohol, formulation and nature of product, presence of excipients, applied volume, contact time and viral contamination load are critical factors that determine the effectiveness of hand sanitisers. the outbreak of respiratory infection with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus has emerged as a serious global public health threat [1] . it is the third time in the last two decades that an animal coronavirus has emerged to cause epidemic infection in humans. the disease was first reported in wuhan province of china at the end of 2019 but rapidly spread to infect more than 23 million people as of 25 august 2020, and has been associated with > 800 000 deaths [2] . the world health organization (who) declared a pandemic on 11 march 2020 and the infection has spread across almost all countries and regions of the world. most infections appear to be asymptomatic or with mild flu-like symptoms but severe and life-threatening presentations including pneumonia, fever, nausea and gastrointestinal upset have been associated with individuals with predisposing factors, particularly age, respiratory insufficiency, diabetes and obesity, among others [3] . the who, and national disease control agencies, have continuously emphasised the importance of hand hygiene to reduce spread of the virus. who guidelines recommend maintaining hand hygiene, by frequent washing using soap and water for at least 20 s especially after going to the bathroom, before eating and after coughing, sneezing or blowing one's nose. when soap and water are not available, the food and drug administration (fda) recommends sanitising of non-visibly soiled hands with an alcoholbased agent containing 80% v/v ethanol or 75% v/v isopropanol [4] . enveloped viruses such as coronavirus and influenza a h1n1 are able to survive on inanimate surfaces for long periods [5] . it has been reported that some covid-19 patients discharged the virus in their stool for up to 73 days after symptom onset [6] , and as diarrhoea is a common symptom, faecal to oral cross-transmission is likely [7] , and hence maintaining effective hand hygiene is paramount. alcohol-based hand sanitisation is widely considered to be effective to reduce or eliminate bacterial/viral load, but with variable compliance rates [8] . the alcohols, ethanol, isopropanol and n-propanol as used for disinfection are commonly applied in the form of hand rub rinses, gels and foams. owing to the increasing demand for hand sanitisation to control the spread of sars-cov-2, some manufacturers have resorted to their own formulations, which are not validated and licensed for use. to combat this, the fda, who, the united states pharmacopeia (usp) and the central drugs standard control organization (cdsco), india, have produced guidelines for the formulation and manufacture of such preparations [4, 9, 10] . this review assesses available information on the composition, formulation and effectiveness of alcohol-based hand disinfection products with specific reference to their activity against sars-cov-2. sars-cov-2 is a new member of the family coronaviridae, order nidovirales, and comprise of two sub-families, coronavirinae and torovirinae [11] ; it is the seventh coronavirus known to infect humans [12] . sars-cov-2 is relatively large in size (0.12 μm) and characterised by the presence of highly glycosylated spikes on the protein membrane in a crown-like arrangement, hence the name, corona (fig. 1 ). it has a single-stranded positive-sense rna genome of 29 891 nucleotides. the glycosylated spike protein binds to the host angiotensin converting enzyme-2 (ace-2) protein which serves as a functional receptor for entry into host respiratory cells. this receptor also binds the earlier sars-cov but with 10-20 times less affinity than for sars-cov-2 spike protein [13, 14] . several antimicrobial compounds have been utilised for hand disinfection and include, among others, alcohols, chlorhexidine, chloroxylenol, hexachlorophene, benzalkonium chloride, cetrimide, triclosan and povidone-iodine [15] . the alcohols, namely ethanol and isopropanol, are most commonly used for skin disinfection due to their broad activity against bacteria, viruses and fungi [16] ; their mode of action against enveloped viruses is shown in figure 2 . lipid membrane dissolution and protein denaturation are key mechanisms of the antimicrobial action of ethanol, leading to the disruption of membrane and inhibition of metabolism [17, 18] . alcohols are amphiphilic compounds, as they possess both hydrophilic and lipophilic (hydrophobic) properties that facilitate their entry through the viral envelope. the outermost membrane of sars-cov-2 comprises lipids bound together by an alkane chain of hydrophobic fatty acids. contact of the virus with an alcohol leads to alteration in its membrane fluidity [19] . the presence of polar oxygen atoms weaken the lipophilic interactions between the non-polar residues, and increase the internal affinity of the membrane for water, thus destabilising and denaturing the protein structure [17] . the antimicrobial mechanism of alcohol against enveloped viruses is similar to that for bacteria as both have a lipid-rich outer membrane. non-enveloped viruses are relatively more resistant to this mechanism due to the lack of a lipid membrane. the family coronaviridae is comprised of four groups (table 1) . sars-cov-2 is considered to be taxonomically related to group 2 coronaviruses [20, 21] . virus and bovine viral diarrhoea virus (bvdv) are used for testing the effectiveness of chemical disinfectants and antiseptics against enveloped viruses according to dvv/robert koch institute (rki) guidelines [22] . the modified vaccinia ankara (mva) virus can also be used as a surrogate model for this purpose as it exhibits high stability against alcohol-based inactivation. the latter virus does not replicate in humans, thus eliminating the risk of disease through unintentional inoculation [23, 24] . bovine coronavirus (bcv) has been used as a surrogate virus for sars-cov [25] , and owing to its high (80%) relatedness to sars-cov-2, consequently may have potential value as a surrogate test agent for the latter. the two most widely used guidelines for testing and regulation of hand disinfectants are the european committee for standardization (cen) and the food and drug administration (fda), according to standards set by the american society for testing and materials (astm). en 1499 and en 1500 are the standard methods related to hygienic hand wash and hygienic hand disinfection respectively [26, 27] . in en 1499, agents are tested against a reference nonmedicated soap and in en 1500 against 60% v/v isopropanol, both applied for 1 min. in the latter standard, the test hand rub formulation should not be significantly inferior, in terms of log reduction of the challenge microbe, compared with the reference alcohol-based product. en 14476 is the standard method for evaluating the virucidal activity of disinfectants [28] and is based on an in-vitro quantitative suspension test in which agents should exhibit a minimum of 4-log reduction in viability of the microbe. poliovirus, adenovirus and murine norovirus serve as the basis for efficacy evaluation of surface disinfectants. pren 16777 is also a quantitative virucidal test method and is recommended for nonporous surfaces (in-vivo carrier test); a 4-log reduction is specified and ready-to-use surface disinfectants should be tested undiluted using adenovirus and murine norovirus as test pathogens. this test method simulates practical conditions and together with en 14476 forms the basis for biocidal product registration in europe [29] . a finger pad test method designed to compare the virus-eliminating effectiveness of hand washing and hand rubbing sanitisers using at least three healthy participants. exposure time should be 10-20 s for hand washing and 20-30 s for a hand sanitation. the recommended test viruses include adenovirus 5, feline calicivirus, rotavirus, rhinovirus and murine norovirus at a minimum of 10 4 infectious units with or without a soil load. a 4-log reduction in virus load must be demonstrated by the test product in the presence and absence of 5% foetal bovine serum [30] . this method evaluates the virucidal activity of hand wash and hand rub agents against viruses and is claimed to better reflect actual working conditions as it incorporates mechanical friction during whole-hand decontamination. at least three healthy participants are required and following application of virus suspension, the specified product exposure times are 10-20 s for hand washing and 20-30 s for a sanitiser. test viruses include adenovirus type 2 or 5, feline calicivirus, rotavirus, rhinovirus and murine norovirus in the presence and absence of 5% foetal bovine serum as an interfering substance to simulate dirty conditions [31, 32] . this method determines the efficacy of test disinfectants to inactivate viruses on disk carriers of brushed stainless steel, which act as a surrogate material for hard, non-porous environmental surfaces and medical devices [ alcohol type and concentration most alcohols exhibit a broad spectrum of germicidal activity against vegetative bacteria, viruses and fungi. in general, isopropanol is considered to have better activity against bacteria, while ethanol is more potent against viruses. however, the degree of effect depends on the percentage concentrations of the alcohol and the physical properties of the target microorganism. isopropanol is more lipophilic than ethanol and is consequently less active against hydrophilic viruses such as polioviruses. being a lipophilic enveloped virus, sars-cov-2 exhibits greater susceptibility to isopropanol than ethanol [20, 37, 38] . the optimum bactericidal concentrations of alcohols range from 60% to 90% v/v solutions in water but are generally ineffective against most microorganisms below 50% v/v [39] . the effect of different concentrations of alcohol against enveloped viruses is shown in table 2 [25, 37, [40] [41] [42] [43] [44] [45] [46] . a recent study has shown that >30% concentrations of ethanol or isopropanol were effective in inactivating sars-cov-2 within 30 s [47] . propanol has a marginally higher boiling point than ethanol, hence, the drying time of isopropanol is slightly longer compared to ethanol [48] . the who has recommended two alcohol-based hand sanitiser formulations which differ only in their alcohol constituent, and is widely followed throughout the world. formulation isopropyl alcohol 75% v/v, glycerol 1.45% v/v, hydrogen peroxide 0.125% v/v [49] . due to the inherent variability of raw materials and the volatility of alcohol, and in response to the covid-19 pandemic, the united states pharmacopeia has issued a revision of who formulation 2 by increasing the concentration of isopropanol to 91% v/v [10] . an n-propanol-based formulation has not been proposed owing to the lack of safety data on human use [49] . in march 2020, the fda recommended the industry to use either of the two who formulas but emphasised that ethanol should not be used at a concentration of <94.9% by volume. in a separate fda guideline addressing the preparation and distribution of alcohol for incorporation in hand disinfectants, mention was made of the search for other active constituents including the use of denaturants such as acetone [50] . there was also comment that the recommended amount of glycerol in the who formulation might negatively impact the effectiveness of isopropanol [50] . nevertheless, both who formulations have been shown to be effective against sars-cov-2 [47] . indeed, with regards to the latter, cdc recommends the use of alcohol-based sanitisers containing >60% ethanol or 70% isopropanol for personnel working in healthcare settings [51] . this is supported by the finding that the who formulation containing isopropanol had higher activity against enveloped viruses [52] . the virucidal efficacy of hand sanitisers depends on several factors. as illustrated by the ishikawa diagram (fig. 3) showing the key factors which determine the efficacy of alcohol against sars-cov-2. the most commonly used formulations for hand sanitisers are rinse, foam, gel, wipes and spray. the 70% ethanol-based liquid products have proved highly effective against the non-enveloped viruses, poliovirus and adenovirus following exposure for 30 s [53] . alcohol-based hand rubs in the form of foam, rinse and gel did not differ significantly in trials of antimicrobial activity but the application volume and drying time had a profound effect on their efficacy [54] . another study, however, found that alcoholbased hand wipes were comparable in activity to foam and gel products against enveloped influenza (h1n1) virus. this was ascribed to better mechanical friction achieved with wipes, resulting in additional physical removal of virus that might survive the antimicrobial treatment [40] . indeed, another comparative study concluded that hand gels are less effective for hand hygiene because of a shorter application time (<30 s) and therefore should not replace alcohol-based liquid hand disinfectants, or used as first choice agents [55] despite the benefit of reducing skin irritation and dryness associated with liquid alcohol agents preparations. however, gel preparations containing 62% ethanol have been reported to be superior to 70% ethanol for the inactivation of surrogate coronaviruses mhv and tgev on hard surfaces [41] . foams have an advantage of better compliance by users due to ease of handling, non-spilling and non-stickiness. bis-peg12-dimethicone is commonly used as the foaming agent. it is recommended that an amount equivalent in size to a golf ball should be applied to hands [56] ; they also have the added benefit of the shortest drying times compared with rinses and gels [57] . the approximate drying times of different alcoholbased formulations are given in table 3 . an increase in the volume of alcohol and contact time results in increased efficacy of alcohol-based hand sanitisers. one pump dispenser push releases approximately 1.5 ml of gel containing 70% alcohol has been found to be insufficient for complete coverage of both hands and hence, do not comply with astm efficacy standards [57] . the use of 3 ml volume for foam, rinse and gel sanitisers containing 70%, 80% and 90% alcohol, respectively, is necessary to meet en 1500 efficacy requirements, but the drying times of all preparations exceeded 30 s [54] . the amount of sanitiser used also depends on the size of the subject's hands; females are relatively smaller (mean of eight volunteers 148.39 cm 2 , rsd = 5.17), and a lower volume of the agent could be sufficient when compared with men's hands (mean of eight volunteers 183.63 cm 2 , rsd = 7.5) [58] . it is generally acknowledged that the ideal application volume is unknown, but us national guidelines suggest that a drying time of <15 s is insufficient [59] , while the who recommends use of a 'palmful' of product and that the hand-hygiene process should take at least 20 s [60] . rotter et al. found that 3 ml of the en 1500 reference product (isopropanol) takes more than 49 s to dry, despite a specified rub-time of 30 s [61] . similarly, a trial on disinfection of volunteer hands artificially contaminated with escherichia coli k12 showed that who formulations containing either ethanol or isopropanol did not comply with the en 1500 requirement as 60 s were taken to achieve the required log reduction. this led to the proposal that the ethanol concentration should be changed from 80% v/v to 80% w/w (equivalent to 85% v/v), and for isopropanol from 75% v/v to 75% w/w (equivalent to 80% v/v) [62] . the contact time of the agent is also relevant as a survey showed that the majority of nursing staff took only 6-24 s for hand cleansing [63] . it has also been suggested that better compliance might be achievable in the hospital setting through listening to background music during the process [64] . glycerin is added in hand sanitisers as a humectant to reduce loss of skin moisture. who-recommended formulations contain glycerin but other nontoxic or allergenic emollients miscible in water and alcohol are not permitted for skin care [49] . studies have shown that glycerol can reduce the efficacy of isopropanol-based sanitiser through agglomerates of flaking skin cells forming in the sticky glycerol [65] . a mixture of ethylhexylglycerin, dexpanthenol and a fatty alcohol serves as a suitable alternative with no effect on hand rub efficacy [66] . indeed, the removal of glycerol from a formulation markedly increased the bactericidal activity of an isopropanol-based sanitiser [67] . this negative impact of glycerol has been noted in fda guidelines regarding temporary compounding of alcoholbased hand sanitisers by industry during the covid-19 pandemic [4] . similarly, reducing the glycerol content from 1.45%, as per the who formulation, to 0.5% provided a better balance between antimicrobial efficacy and skin tolerance [68] . an extract of the aloe vera plant has also been used as an emollient [69] . ph human and canine corona viruses are reported to be more stable at a slightly acidic than alkaline ph [70, 71] but mild alkaline (ph 8) conditions are sufficient to induce conformational changes in the spike protein of coronavirus mouse hepatitis virus [72] . both high and low ph cause inactivation of sars-cov [73] . the virucidal activity of ethanol against poliovirus and ms2 phage is significantly increased on the addition of sodium hydroxide [74] due to protein denaturation [75] . sodium hydroxide has also been shown to have cidal activity against surface dried lipid enveloped human immunodeficiency virus (hiv), bovine diarrhoeal virus and pseudorabies virus [76] . other anti-viral agents include acetic acid and calcium hydroxide against influenza virus on hard and non-porous surfaces [75] . moreover, citric acid and urea (2%) have been reported to increase the effectiveness of alcohol-based sanitisers [37] ; citric and malic acid, in combination with 70% alcohol have also been suggested to enhance killing of rhinovirus on hands [77] . it is quite likely that the effect of hand sanitisers is reduced in the presence of dirt or soil on hands. a number of interfering substances have been used to simulate dirty conditions including foetal calf serum, bovine serum albumin and sheep erythrocytes according to dvv, rki, astm and cen standard guidelines [37, 78] . soap hand wash coupled with an alcohol gel sanitiser was shown to be more effective than either agent used alone, and activity persisted for longer [79] . these findings are corroborated by other studies showing increased reduction of murine norovirus with a wash-sanitiser regimen compared to washing with 70% ethanol alone in the presence of a high level of organic loads [80] . however, it is worth noting that hand washing with soap and water alone was found to be more effective than alcoholbased rubs for hands soiled with meat [81] . hand hygiene by washing hands with soap and water or with alcohol-based hand sanitisers are primary preventive measures against the spread of sars-cov-2. this review of the literature shows that several factors are pertinent to the antiviral activity of sanitising agents. alcohol-based agents cause dissolution of the lipid membrane and denature proteins, thereby disrupting the virus membrane and inhibiting metabolism. the concentration of alcohol in hand-cleansing products, the volume used, contact time, degree of soiling, product formulation and use of excipients are some of the critical factors that affect the efficacy of alcohol against viruses. due to its relatively greater lipophilicity, isopropanol is considered more effective than ethanol against sars-cov-2. to ensure a greater than 3-log reduction of sars-cov-2, a hand sanitiser should ideally contain >80% v/v ethanol or >75% v/v isopropanol. however, recent study which suggests that ethanol and isopropanol used above 30% v/v is effective against sars-cov-2 [47] requires confirmation by other investigators. gel-based hand sanitisers are reported to have more efficacy against enveloped viruses while foam-based preparations have the most rapid drying time. it is recommended that at least 3 ml of product should be used with a total contact time of around 45-50 s. soiled hands can limit the efficacy of alcohol-based products as well as the presence of excipients; for isopropanol-based formulations, the replacement of glycerol with other emollients is recommended. similarly, the addition of sodium hydroxide potentiates the antiviral activity of alcohols. further studies are clearly needed on the optimum design and delivery form of agents for efficient hand decontamination of sars-cov-2. such knowledge will prove of benefit for preparedness against other highly infectious viruses. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 clinical features of patients infected with 2019 novel coronavirus in wuhan policy for temporary compounding of certain alcohol-based hand sanitizer products during the public health emergency immediately in effect guidance for industry. u.s. department of health and human services. food and drug administration survival of enveloped and non-enveloped viruses on inanimate surfaces enteric involvement of severe acute respiratory syndrome-associated coronavirus infection public health might be endangered by possible prolonged discharge of sars-cov-2 in stool hand sanitizers: a review on formulation aspects, adverse effects, and regulations monitoring of quality standards of hand sanitizers as per drugs and cosmetics act 1940, and rules made thereunder and expediting the licensing of manufacturers of such products (2020) government of india, directorate general of health services, central drugs standard control organization compounding alcohol-based hand sanitizer during covid-19 coronaviruses: an overview of their replication and pathogenesis the proximal origin of sars-cov-2 cryo-em structure of the 2019-ncov spike in the prefusion conformation genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding who guidelines on hand hygiene in health care (advanced draft) global patient safety challenge spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent sterillium gel interaction of alcohol with phospholipid membrane: nmr and xrd investigations on dppc-hexanol system hand sanitizers: a review of ingredients, mechanisms of action, modes of delivery, and efficacy against coronaviruses adaptation of membrane lipids to alcohols coronavirus envelope protein: current knowledge a review of the 2019 novel coronavirus (covid-19) based on current evidence povidone-iodine hand wash and hand rub products demonstrated excellent in vitro virucidal efficacy against ebola virus and modified vaccinia virus ankara, the new european test virus for enveloped viruses can vaccinia virus be replaced by mva virus for testing virucidal activity of chemical disinfectants? virucidal activity of a new hand disinfectant with reduced ethanol content: comparison with other alcohol-based formulations chemical disinfectants and antiseptics. hygienic hand wash. test method and requirements chemical disinfectants and antiseptics. hygienic handrub. test method and requirements chemical disinfectants and antiseptics -quantitative suspension test for the evaluation of virucidal activity in the medical area -test method and requirements (phase 2/ step 1) chemical disinfectants and antiseptics. quantitative non-porous surface test without mechanical action for the evaluation of virucidal activity of chemical disinfectants used in the medical area. test method and requirements (phase 2/step 2) astm e1838 determining the virus-eliminating effectiveness of hygienic handwash and handrub agents using the fingerpads of adults astm e2011 -virucidal activity for hygienic hand washing. valencian institute of microbiology standard test method for evaluation of hygienic handwash and handrub formulations for virus-eliminating activity using the entire hand mycobactericidal, sporicidal activities of chemical agents astm e2197-17e1 -standard quantitative disk carrier test method for determining bactericidal, virucidal, fungicidal, mycobactericidal, and sporicidal activities of chemicals guideline of deutsche vereinigung zur bekampfungder viruskrankheiten e.v. (dvv; german association for the control of virus diseases) and robert koch institute (rki; german federal health authority) for testing the virucidal efficacy of chemical disinfectants in the human medical area leitline der deutschen vereinigung zur bekämpfung der viruskrankheiten (dvv) e.v. zur quantitativen prüfung der viruziden wirksamkeit chemischer desinfektionsmittel auf nicht-porösen oberflächen development and virucidal activity of a novel alcohol-based hand disinfectant supplemented with urea and citric acid the e protein is a multifunctional membrane protein of sars-cov the relationship of concentration and germicidal efficiency of ethyl alcohol analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza a (h1n1) virus on hands inactivation of surrogate coronaviruses on hard surfaces by health care germicides chemical disinfection of non-porous inanimate surfaces experimentally contaminated with four human pathogenic viruses inactivation of respiratory syncytial virus by detergents and disinfectants inactivation of sars coronavirus by means of povidone-iodine, physical conditions and chemical reagents stability and inactivation of sars coronavirus efficacy of various disinfectants against sars coronavirus inactivation of severe acute respiratory syndrome coronavirus 2 by who-recommended hand rub formulations and alcohols comparison of the efficacy and drying times of liquid, gel and foam formats of alcohol-based hand rubs who recommended hand-rub formulations temporary policy for manufacture of alcohol for incorporation into alcohol based hand sanitizer products during the public health emergency (covid-19); guidance for industry u.s. department of health and human services, food and drug administration, center for drug evaluation and research (cder) cdc statement for healthcare personnel on hand hygiene during the response to the international emergence of covid-19 virucidal activity of world health organization-recommended formulations against enveloped viruses, including zika, ebola, and emerging coronaviruses efficacy of hand rubs with a low alcohol concentration listed as effective by a national hospital hygiene society in europe the relative influences of product volume, delivery format and alcohol concentration on dry-time and efficacy of alcohol-based hand rubs limited efficacy of alcohol-based hand gels efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection impact of the amount of hand rub applied in hygienic hand disinfection on the reduction of microbial counts on hands healthcare infection control practices advisory committee guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hipac/shea/apic/idsa hygiene task force who guidelines on hand hygiene in health care impact of shortening the duration of application and the standardized rubbing sequence as well as the reduction of the disinfectant volume used for the hygienic hand rub with 2-propanol (60% v/ v) testing of the world health organization recommended formulations in their application as hygienic hand rubs and proposals for increased efficacy comparison of waterless hand antisepsis agents at short application times: raising the flag of concern effect of music on surgical hand disinfection: a video-based intervention study influence of glycerol and an alternative humectant on the immediate and 3-hours bactericidal efficacies of two isopropanol-based antiseptics in laboratory experiments in vivo according to en 12791 glycerol significantly decreases the 3-hours efficacy of alcohol-based surgical hand rubs modified world health organization hand rub formulations comply with european efficacy requirements for preoperative surgical hand preparations glycerol content within the who ethanolbased handrub formulation: balancing tolerability with antimicrobial efficacy hand sanitisers amid covid-19: a critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand effect of ph and temperature on the infectivity of human coronavirus 229e canine coronavirus inactivation with physical and chemical agents monoclonal antibodies to the peplomer glycoprotein of coronavirus mouse hepatitis virus identify two subunits and detect a conformational change in the subunit released under mild alkaline conditions inactivation of the coronavirus that induces severe acute respiratory syndrome, sars-cov the use of bacteriophage ms2 as a model system to evaluate virucidal hand disinfectants inactivation of avian influenza virus using four common chemicals and one detergent resistance of surface-dried virus to common disinfection procedures effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands the effects of test variables on the efficacy of hand hygiene agents a close look at alcohol gel as an antimicrobial sanitizing agent hand hygiene regimens for the reduction of risk in food service environments a method of assessing the efficacy of hand sanitizers: use of real soil encountered in the food service industry acknowledgements. the doctoral research fellowship from the university of petroleum and energy studies to jeevan patra is gratefully acknowledged.conflict of interest. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.data availability statement. the datasets supporting the conclusions of this review article are included within the article and in references listed in the paper. key: cord-312738-p5macofk authors: biezen, ruby; grando, danilla; mazza, danielle; brijnath, bianca title: visibility and transmission: complexities around promoting hand hygiene in young children – a qualitative study date: 2019-04-11 journal: bmc public health doi: 10.1186/s12889-019-6729-x sha: doc_id: 312738 cord_uid: p5macofk background: effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (rtis) and gastrointestinal infections, especially in young children. while hand hygiene has been widely promoted within australia, primary care providers’ (pcps) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. therefore, the aim of this study was to explore the views of pcps and parents of young children on their knowledge and practice of hand hygiene in disease transmission. methods: using a cross-sectional qualitative research design, we conducted 30 in-depth interviews with pcps and five focus groups with parents (n = 50) between june 2014 and july 2015 in melbourne, australia. data were thematically analysed. results: participants agreed that hand hygiene practice was important in reducing disease transmissions. however, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children. conclusion: despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. to overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, pcps prompting parents and young children to practice hand hygiene when coming for an rti consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns. hand hygiene, including hand washing with soap and water, or the use of hand sanitizers, has been shown to reduce transmission of infectious diseases [1] [2] [3] , especially gastrointestinal and respiratory tract infections [4] . young children < 5 years of age are most at risk, in particular those attending childcare or preschool [5] [6] [7] . effective hand hygiene practice in community settings, has demonstrated a reduction of infections occurring in childcare [7] [8] [9] [10] , schools [2, [11] [12] [13] , and in the home [14] [15] [16] . according to aiello et. al's meta-analysis [4] improvements in hand hygiene resulted in a 21% reduction in respiratory illnesses and a 31% reduction in gastrointestinal illnesses in community-based settings. the importance of hand hygiene practice in the prevention of infectious diseases was emphasized in all 30 studies included in this meta-analysis. studies from europe, us, and the uk have also shown that hand hygiene interventions in the community can increase hand hygiene compliance among children [17] [18] [19] . for example, interventions involving teacher modelling hand hygiene to school children [20] , improving educator's knowledge and attitude towards hand hygiene [21] , and the use of alcohol-based sanitizers [15, 22, 23] have significantly reduced illness absenteeism in schools. however, factors such as lack of time to practice hand hygiene, poor adult modelling of regular hand washing, limited facilities including available sinks, soap and water, and the lack of knowledge regarding the importance of hand hygiene have hindered the compliance and sustainability of good hand hygiene practice [24, 25] . despite wide promotion of hand hygiene in australia [26] and good evidence that effective hand hygiene practice reduces infectious disease transmission, to date no studies have measured the efficacy and sustainability of hand hygiene practice in the australian primary care setting. thus, it is unclear whether primary care providers (pcps) and their patients follow recommended protocols to reduce infectious diseases, especially in young children. accordingly, the aim of this study was to explore the views of pcps and parents of young children regarding the practice of hand hygiene in the transmission of diseases in young children. data for this research were derived from a larger mixed methods qualitative study exploring pcps and parents' views, knowledge and attitudes towards their hand hygiene practice and reducing rti transmission in children < 5 years of age. the methods applied have been previously described [27] ; in summary, interviews were conducted with 30 pcps and five focus groups with 50 parents of young children (see table 1 for schedules). pcps were defined as general practitioners (gps), practice nurses (pns), maternal child health nurses (mchns), and pharmacists (phs), and a diversified sampling strategy was applied to recruit them. the contact details of gps and pns were generated from an existing general practice database at monash university, victoria, australia. contact details for mchns and phs were generated from the maternal child health services directory [28] and the local business directory respectively. recruitment was limited to one pcp per practice site across metropolitan melbourne, australia. purposive sampling via advertisements circulated to playgroups and mothers' groups was used to target parents and carers from the south east and east of melbourne, australia. five mothers' groups and play groups were initially approached to recruit the required number of 50 parents and carers. if one site refused due to time or not enough willing participants then another would be approached until the total number of 50 participants were reached. a total of five play groups (two accepted) and three mothers' group (all three accepted) were approached. interested participants were asked to contact the researcher (rb). all participants consented to up to an hour interview or focus group to explore their views, knowledge and attitudes towards management of respiratory tract infections, including prevention strategies such as influenza vaccination and hand hygiene in children < 5 years of age. interviews and focus groups (each approximately 1 h long) were conducted between june 2014 and july 2015 by rb. pcps' were interviewed at their work place or at a place convenient to them during practice hours; focus groups were conducted at play group centres or at scheduled mothers' group meetings. all participants gave written consent prior to data collection; pcps were provided with a aud$120 and parents with a aud$40 gift voucher upon completion. interviews and focus group discussions were digitally recorded and transcribed verbatim. data were analysed using a thematic approach [29] to provide a flexible approach to identify, analyse and report themes or patterns within the data. initially, two researchers (rb and bb) read three transcripts independently to generate initial codes and themes, which were then compared and refined until consensus was reached. a further three transcripts were coded using the schemata and this process was repeated, three transcripts at a time, to incorporate emerging themes, until all transcripts were coded. data were managed using nvivo10. study approval was obtained from monash university human research ethics committee (cf14/1384-2,014,000,648). a total of 30 pcps (13 females) and 50 parents and carers (47 females) participated in the study. the average years of experience for gps, pns, mchns and phs were 18.0, 3.0, 17.7, and 7.2 years respectively. in the parents and carers cohort, 62% (n = 31) were in the 31-40 years age group, with over 70% (n = 36) having a graduate degree or higher. all participants revealed high levels of knowledge regarding hand hygiene and its importance. when asked, they gave their definition of hand hygiene, and discussed the importance of hand hygiene in reducing transmission of infection, including day to day practice. "washing hands frequently especially after sneezing, touching the nose, touching the mouth, coughing in the hands… the droplets in the transmission and what it means and even touching the handles of the doors, all of these can be a source of infection sometimes, and washing hands, i mean, they are important." gp11 "yeah i think it's [hand hygiene] quite important, because your hands touch anything. like your hands will touch the table and someone will come to the table your hands touched -without even realising, you're touching things. like you're touching your face all day. scratching your hair, everything, and then you go and touch things…" fg1 despite participants having good knowledge of hand hygiene, and recognising the importance in reducing disease transmission, many barriers such as variation in the practice of hand hygiene among pcps and parents, linking visibility to disease transmission, and doubts that hand hygiene practice was attainable in young children hindered good hand hygiene practice. we elaborate on these themes below. although pcps unanimously agreed that hand hygiene was important in reducing the transmission of diseases, there were large variations in practice. three types of hand hygiene practice were identified among gps and phs: some would wash hands between seeing patients irrespective of whether contact has been made, some would only wash hands if skin contact was made, while others would practice hand hygiene only if patients were visibly infectious. however, most gps commented that they would use alcohol sanitizers between patients if hand washing with soap and water was not possible. "… every time i examine the patient…" gp11 "not everyone, not if there's no skin contact…"gp12 "…if i'm handling something or i thought they are likely infectious..." gp17 "would be very rare. we don't try and touch… [we don't wash hands] not unless they are obviously sick…"ph1 pns on the other hand would often wash hands between patients as they were more likely to 'touch' patients during procedures, and rarely would mchns see babies/ children without skin contact. to the latter group, hand hygiene was habitual and 'routine'. alongside variations in hand hygiene practices among pcps, there were also divided views about whether to educate parents and patients on hand hygiene during a sick child consultation. some commented they would if time permitted; some would not as they assumed parents already had good knowledge of hand hygiene and transmission of infection. "i do talk to them and tell them it prevents a lot of cross infections…" gp16 "…it just doesn't come up, often there are other things to talk about, and we just don't have time." ph4 "look, parents… i don't know… but i can see most of the parents are quite… they know the hygiene.... they have the knowledge…" gp4 however, pcps commented they would not hesitate to discuss hand hygiene during a gastrointestinal tract infection consultation, but they did not always for an rti consultation. similar to pcps, parents also prioritised hand hygiene practice with gastrointestinal infections, which were seen as more infectious as they were more 'visible'. "just because i think of a cold as being non-severe… like, just a natural part of life. but gastro just would prefer to avoid." fg3 "gastro i would [discuss hand hygiene], but not respiratory tract infections." gp2 "but gastro, you're also vomiting and stuff, and go through places, institutions, like hospitals…" gp5 "… so when we triage… we do have a chat… like gastro… we have a chat to them about the transmission, and decreasing the spread of virus or whatever is causing the gastro, and what is going around..." pn1 "they [pharmacy staff] don't do it [wash hands] always, but if someone comes in with gastro, they would come straight up and (do the alcohol sanitising motion)…" ph4 pcps also commented that the interview process for this study gave them pause for thought making some gps realise that they need to talk to parents. while parents considered good hand hygiene as washing hands before meals, after meals and after going to the toilet, similar to pcps, parents also conflated 'dirt' with 'infectious' and dirt was a visual cue to prompt them to wash their hands. "just teaching her that if your hands are dirty you wash them, so even though i don't wash my hands every time i eat, i don't wash my hands if i've been out to the washing line, when she comes in [from outside] -"oh okay, we've got to wash our hands now"" fg2 "… if somebody has a cold or somebody has gastro or something like that then i'm really freaky about it and i clean everything within an inch of its life. but then other times, we're, kind of, more relaxed and pretty lazy about it." fg3 visual cues therefore determined behaviour such as when hands should be washed. gastrointestinal infections were seen as being 'visible' , therefore considered as more 'severe' than rtis, leading to the perception that disease transmission and infection control were visually based. although pcps demonstrated good knowledge of transmission of rtis -respiratory route and fomite transmissionthey still insisted that hand hygiene practice would not be effective in preventing or reducing rti transmission. "there is no prevention. i would have to stop sending children to crèche, and kinders, and schools because they get an infection … this is a part of life and growing up … it's not possible [to prevent]" gp10 pcps also believed that hand hygiene could not be achieved in young children as they presumed young children would not have hand hygiene awareness and good practice. in addition, prevention would not be achievable as parents and children have constant contact, especially as young children needed comforting when unwell. "yeah, well, probably not so much in the context of colds, kids are little anyway and they are not going to do it. i talk probably more in terms of gastro, we talk a bit about heightened domestic awareness and practice…" gp7 "they are going to kiss you, they are going to touch you… and they are going to kiss each other…" gp2 similarly, though parents acknowledged the importance of hand hygiene in reducing transmission of diseases, they also expressed reservations about 'over-surveying' their children and becoming 'germophobic'. over emphasising hand hygiene was perceived as leading to obsessive behaviours and psychological distress: "… i've actually had to pull it back because she was in there every five minutes… she got really quite ocd (obsessive compulsive disorder) about the whole thing…" fg1 "we sound like we're a bit paranoid… my daughter did say to me that i was turning her into a germ-a-phobe…" fg1 "i have seen a lot of quite obsessive hand washers at my new workplace." fg3 "i kind of figured i don't want to be too paranoid because you can't wipe your hand every two seconds…" fg4 while parents did not want to be 'paranoid' about being too clean and obsessive about hand hygiene, ultimately, they wanted to find that balance between good hand hygiene practice and not being paranoid about diseases. they did describe struggling to determine what was 'right' , the 'correct' hand hygiene practice, and what was considered as being 'too clean'. children being too clean was perceived as weakening immunity whereas being 'dirty' built immunity: "i also wonder about that whole cause [and] effect. because the people i know who wash their hands obsessively are always sick. and i just can't decide if they're always sick because they're obsessive hand washers or if they're obsessive hand washers because they're always sick…" fg3 "i worry about using the hand sanitiser too much… i don't know, i always think there's … almost too clean…" fg4 "i know some people that are clean, i don't know about too clean, but their kids get sick quite easily. i don't know whether it's because they're not getting immune to some dirt or something…" fg5 "we sound like we're a bit paranoid, but that's just us i think." fg1 even though barriers exist for both pcps and parents of young children when it came to good hand hygiene practice, they all agreed that hand hygiene training still needed to be taught early in life. "it really stems from the parents…"teaching hand hygiene when asked whose responsibility it was to teach hand hygiene practice to young children, pcps and parents commented that parents should be responsible. "… parents seem to talk to their kids about washing their hands…" gp5 "no, i haven't been telling them, no… i thought the mums would do it…" gp8 "so basically, it comes from the parents, if they set good examples…" fg4 the most effective approach to teaching young children good hand hygiene practice was identified by pcps and parents as role modelling. role modelling, the concept of washing hands in front of an audience so the behaviour can be imitated, was expressed as a good way to 'show' children how and when hands should be washed, allowing the behaviour to be 'copied'. hence developing their hand hygiene practice early in life, and eventually leading to sustained hand hygiene behaviour later in life. "i'm role modelling, so they can see me washing my hands… the most important thing i do (in the mother's group sessions)… that's hand hygiene." mchn1 "…having things down at the children's level, rolemodelling" fg2 this theme highlighted the general consensus that pcps and parents thought parents should be responsible for their children's hand hygiene practice, with prompting and role modeling as the most effective way to teach young children to start the good hand hygiene habit early in life. results from this study demonstrated the complex reasoning behind why a simple but important task such as hand hygiene is so difficult to consistently implement in everyday life. far from a benign, dispassionate process, there are inherent emotions invested in undertaking this task. while the world health organization 'my 5 moments for health hygiene' recommends health-care workers to clean their hands before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings [30] , factors such as the pcp's own habitual hand hygiene behaviour; the expectation that parents themselves have good hand hygiene practice; scepticism that hand hygiene is effective in reducing rtis or achievable in young children contributed to the large variation seen in pcps' recommendations to promote hand hygiene. for pcps and parents of young children, hand hygiene practices were centered on visual cues such as gastrointestinal infections and 'dirt' as being 'visible' , rather than the transmission of diseases. while coughing and sneezing can be quite 'visible' , it is often not associated with being 'dirty' , hence it is less likely to result in a reflexive action resulting in hand washing. the risk that promoting hand hygiene practice could result in paranoia and the effect of being 'too clean' were overriding concerns for parents more so than the message itself. variations in practice stemmed from personal attitudes, perceived behaviour, control and subjective norms [31] , leading to the intent to wash hands. some pcps thought parents were knowledgeable in hand hygiene practice and therefore did not feel the need to mention hand hygiene during an rti consultation. a recent study by barroso et al. [25] found a counterintuitive inverse relationship between knowledge and hand hygiene behaviour: where medical students reported high hand hygiene behaviour yet had lower knowledge as compared with medical residents, suggesting that factors other than knowledge were important in determining hand hygiene behaviour in this cohort. furthermore, many pcps said they would not wash their hands if there was no patient contact and if the patient was not visibly 'infectious'. whitby et al. [32] , describe how inherent hand hygiene practice drives the community where visibly soiled, sticky, or gritty hands would prompt hand hygiene behaviour. this 'perceived susceptibility' or 'personal risk' was also described in a study from eight mediterranean countries [33] , where they found health care workers' hand hygiene compliance was significantly higher after patient contact compared to before patient contact, implying that self-protection was a major driver of hand hygiene performance in this cohort. our results indicated that while the importance of hand hygiene was undeniable, hand hygiene practice and passing hand hygiene knowledge to parents of young children varied considerably within and across pcp groups. the diverse situations each pcp face in different scenarios such as whether patients were seen as 'infectious' , or whether they believed parents have the knowledge as to whether they needed to talk to them about hand hygiene were contributing factors to the variations seen in these groups. parents also relied heavily on visual cues such as 'dirty' and 'infectious' , to determine the need to hand wash, as they did not always remind their children to wash their hands. however, the 'awareness' of hand hygiene practice might also explain that hand hygiene was often taken for granted, and not 'thought about'. therefore, behaviour change interventions might need to be regular and applied in small incremental steps. raising awareness of possible personal risk could improve practice and sustainability when it comes to hand hygiene behaviour [34] . additionally, parents were reluctant to encourage hand hygiene practices in their child for fear their children would be 'too clean' , and that they needed to be visibly 'dirty' or 'infectious' to build their own immunity. this belief needs to be directly challenged by pcps during discussion in an rti consultation, and further educating parents on good hand hygiene practice should therefore be considered. a more concerning theme that emerged from our study resulting from the discussions emanating from the parents focus groups was parents' fear of their child developing abnormal behavior such as ocd. although studies have shown strong links between people with ocd and feelings driving them to engage repeatedly and excessively in behavior such as hand washing [35, 36] , there is no evidence suggesting that hand washing 'triggers' ocd. these studies found that ocd was characterized by the reduced ability to terminate an action, such as hand washing, rather than a response to a perceive threat i.e. perceived susceptibility or personal risk. therefore, parents' fear of excessing hand washing leading to ocd was not valid. however, the fear was enough for parents to be vigilant with children's hand washing practice, therefore an important area for further research. perhaps one of the biggest barriers to good hand hygiene practice in young children was the skepticism displayed by parents and pcps that good hand hygiene practice was achievable in young children, and almost not worth pursuing. thus, while the 'intent' was there regarding hand hygiene, compliance did not always follow. even though successful interventions incorporating hand washing in young children have shown to reduce absenteeism due to infection [9] , a recent study of childcare centres in the netherlands [37] found that while hand hygiene opportunities were readily available for children, overall adherence to hand hygiene guidelines was only 31% in participating day care centres, which supports the publicly held view that hand hygiene practice is not achievable in young children. however, participants in the study also believed that hand hygiene behaviour should start early in life. a study in seoul, korea [38] , conducted in an elementary school setting with year 6 students, showed parents' handwashing practice, parent and child bonding, and shared time have a significant correlation with children's hand hygiene practice. our study also suggested that both pcps and parents thought hand hygiene practice should start with good role modelling in the home, with frequent reminders. our study was not without limitations. first, the research was conducted in metropolitan melbourne, and therefore our results may be not generalisable to other areas such as rural or remote sites, or developing countries where there might be reduced access to hand hygiene products and handwashing facilities. second, pcps and parents of young children who participated in the study were very interested in this area, potentially introducing selection bias. third, providing incentives to participants may have led to a possible source of bias, although these incentives are aligned with similar work with estimated earnings and average australian wage [39, 40] . currently little is known regarding young children's hand hygiene practice in the australian community. our study has taken the first step in exploring pcps' and parents' attitude, views and practice of hand hygiene practice, thereby identifying barriers to hand hygiene practice for pcps and parents of young children, which potentially impact hand hygiene habit and behaviour of young children. to overcome some of these barriers to good hand hygiene practice, the following interventions targeting pcps and parents may help increase awareness of the importance of hand hygiene and encourage effective hand hygiene behaviour: 1) introduce health promotion that will educate and remind the public that diseases are not always 'visible' and that whether or not one appears dirty, transmission is still possible; 2) good hand hygiene habits should be taught early in a child's life to sustain effective hand hygiene behaviour; and 3) the importance of role modelling as a way to develop good hand hygiene habit in young children. in addition, pcps should at least encourage parents and young children to practice hand hygiene when coming for an rti consultation, which may reduce the transmission of rtis, reinforce the message of the importance of hand hygiene compliance and result in healthy hand hygiene practice in young children. finally, parents should be reassured that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children and that hand washing will not reduce a child's immunity. this study demonstrated that on the surface, both pcps and parents of young children thought hand hygiene practice was important. however, dissonance emerged in practice because hand hygiene is implicitly tied to beliefs such as washing hands only when 'dirty'; concerns that children need to build their immunity and are already too clean; and skepticism that hand hygiene can be achieved in young children. pcps should be made aware that hand hygiene can be part of the habit of washing hands between patients, due to fomite transmission of diseases in practice. parental education around the importance of hand hygiene, focused on the tangible goals of making hand hygiene a regular habit is paramount in teaching young children to develop good hand hygiene practice early in life. the decision to perform hand hygiene should not be based on 'dirt' or relating visibility of infection to transmission of infection. rather role modelling hand hygiene by parents as well as enforcing hand hygiene early in the child's life will help with better hand hygiene compliance leading to reduced transmission of infectious diseases. effect of handwashing on child health: a randomised controlled trial the impact of common infections on school absenteeism during an academic year effectiveness of alcohol-based hand disinfectants in a public adminstration: impact on health and work performance related to acute respiratory symptoms and diarrhoea effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis incidence of acute respiratory infections in australia risk factors for acute respiratory infection in the australian community transmission of acute gastroenteritis and respiratory illness from children to parents hand hygiene to reduce community transmission of influenza and acute respiratory tract infection: a systematic review. influenza other respir viruses the effect of enhanced hygiene practices on absences due to infectious diseases among children in day care centers in helsinki enterococcus spp on fomites and hands indicate increased risk of respiratory illness in child care centers hand hygiene instruction decreases illness-related absenteeism in elementary schools: a prospective cohort study reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention hand sanitiser provision for reducing illness absences in primary school children: a cluster randomised trial a randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home impact of the use of an alcoholbased hand sanitizer in the home on reduction in probability of infection by respiratory and enteric viruses an investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in indian urban communities impact of an educational intervention upon the hand hygiene compliance of children enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial utilizing improvement science methods to improve physician compliance with proper hand hygiene inexpensive and time-efficient hand hygiene interventions increase elementary school children's hand hygiene rates the effect of a handwashing intervention on preschool educator beliefs, attitudes, knowledge and self-efficacy cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care healthy hands: use of alcohol gel as an adjunct to handwashing in elementary school children factors influencing hand washing behaviour in primary schools: process evaluation within a randomized controlled trial hand hygiene of medical students and resident physicians: predictors of attitudes and behaviour welcome to hand hygiene australia (hha): hand hygiene australia why do we not want to recommend influenza vaccination to young children? a qualitative study of australian parents and primary care providers. vaccine maternal child health services: victoria state government using thematic analysis in psychology world health organization. my 5 moments for hand hygiene. world health organization in the era of corona virus: health care professionals' knowledge, attitudes, and practice of hand hygiene in saudi primary care centers: a cross-sectional study behavioural considerations for hand hygiene practices: the basic building blocks self-protection as a driver for hand hygiene among healthcare workers using an analysis of behavior change to inform effective digital intervention design: how did the primit website change hand hygiene behavior across 8993 users? in the wake of a possible mistake: security motivation, checking behavior, and ocd when too much is not enough: obsessive-compulsive disorder as a pathology of stopping, rather than starting children's hand hygiene behaviour and available facilities: an observational study in dutch day care centres family factors associated with children's handwashing hygiene behavior general practice research. problems and solutions in participant recruitment and retention australian bureau of statistics. 6306.0 -employee earnings and hours the authors would like to thank all the participants in this research. this study was part of a phd study, funded by the national health and medical research council (nhmrc), and the royal australian college of general practitioners (racgp). not applicable authors' contributions rb completed the background literature search and rb, bb, dg and dm contributed to the study design. rb conducted and transcribed all interviews. rb and bb performed the analysis of the data. rb drafted the manuscript. all authors revised all drafts and approved the final version of the manuscript.ethics approval and consent to participate all participants were provided with a plain language statement explaining the study and gave written consent prior to interview/focus group. the study was approved by monash university human research ethics committee (cf14/1384-2,014,000,648). the authors declare that they have no competing interest. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-325546-bgdr25z1 authors: pham, t. m.; mo, y.; cooper, b. title: the potential impact of intensified community hand hygiene interventions on respiratory tract infections: a modelling study date: 2020-05-27 journal: nan doi: 10.1101/2020.05.26.20113464 sha: doc_id: 325546 cord_uid: bgdr25z1 increased hand hygiene amongst the general public has been widely promoted as one of the most important non-pharmaceutical interventions for reducing transmission during the ongoing covid-19 pandemic and is likely to continue to play a key role in long-term efforts to suppress transmission before a vaccine can be deployed. for other respiratory tract infections community hand hygiene interventions are supported by evidence from randomised trials, but information on how effectiveness in reducing transmission scales with achieved changes in hand hygiene behaviour is lacking. this information is of critical importance when considering the potential value of substantially enhancing community hand hygiene frequency to help suppress covid-19. here, we developed a simple model-based framework for understanding the key determinants of the effectiveness of changes in hand hygiene behaviour in reducing transmission and use it to explore the potential impact of interventions aimed at achieving large-scale population-wide changes in hand hygiene behaviour. our analyses show that the effect of hand hygiene is highly dependent on the duration of viral persistence on hands and that hand washing needs to be performed very frequently or immediately after hand contamination events in order to substantially reduce the probability of infection. hand washing at a lower frequency, such as every 30 minutes or with a delay of 15 minutes after contamination events, may be adequate to reduce the probability of infection when viral survival on hands is longer, such as when hands are contaminated with mucus. immediate hand washing after contamination is more effective than hand washing at fixed-time intervals even when the total number of hand washing events is similar. this event-prompted hand washing strategy is consistently more effective than fixed-time strategy regardless of hand contamination rates and should be highlighted in hand hygiene campaigns. family members: wash hands with soap and water regularly, especially after coughing or sneezing, before, during and after food preparation, before eating, after toilet use, before and after caring for ill persons and when hands are visibly dirty. patients: wash hands immediately and thoroughly after coughing, sneezing, removing face mask. stay in a separate room from other family members. [11] ecdc rigorous hand-washing with soap and water >20 seconds, or alcohol-based solutions, gels or tissues is recommended in all community settings in all possible scenarios, especially after coughing or sneezing, disposal of used tissues. family members: wash hands frequently, especially after contact with the patient or with any surface frequently touched by the patient, e.g., before and after preparing food, before eating, after using the toilet, removing face mask/ gloves, handling waste. patients: wash hands immediately and thoroughly after coughing, sneezing, removing face mask. [12, 13] phe washing hands more often, especially after arriving at work or home, after blowing nose, coughing or sneezing, before eating or handling food. wash hands frequently with soap and water for 20 seconds or using hand sanitiser, especially after coughing/sneezing and disposal of used tissue. [14, 15] cdc wash hands often with soap and water for >20 seconds especially after being in a public place, or after blowing nose, coughing, or sneezing. clean frequently touched surfaces and objects daily (e.g., tables, countertops, light switches, doorknobs, and cabinet handles) using a regular household detergent and water. wash hands often with soap and water for >20 seconds or hand sanitizer, especially after going to the bathroom, before eating, and after blowing nose, coughing, or sneezing. always wash your hands with soap and water if your hands are visibly dirty. [16, 17] an immediate consequence of this conceptualisation is that the time interval between the hands becoming 78 contaminated and making infectious contact with the host's mucosa can have a critical impact on how 79 effective a given frequency of hand washing will be at interrupting transmission ( figure 2 ). if this time 80 interval is relatively long in the absence of hand hygiene, regular effective hand hygiene will have a 81 high chance of blocking potential transmission events (red diamonds in figure 2 panel a). in contrast, 82 if this time interval is short much more frequent hand hygiene will be needed to block an appreciable 4 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint 1. uniformly at fixed time intervals (fixed-time hand washing), or 89 2. with a delay after hand contamination events (event-prompted hand washing). hands of susceptible individuals are assumed to become contaminated at random. these contamination events are assumed to occur independently of each other, and to follow a poisson distribution with a mean of λ c events per hour. the probability of the virus persisting on hands at time t after contamination, , is assumed to decay exponentially with a half-life of t 1/2 . this is consistent with experimental data for influenza a (see [19] ). individuals touch their face at random leading to potential infection events that are assumed to occur independently of each other, and follow a poisson distribution with a mean of λ f events per hour. the probability that a single face-touching contact with contaminated hands actually leads to transmission is . assume the face-touching events occur at times t 1 , . . . , t f during the given time period t . then the cumulative probability of infection over the time period t is given by: 5 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 27, 2020. when available, parameter estimates were obtained from the literature. otherwise, we performed sen-98 sitivity analyses where parameters were varied within plausible ranges (see table 2 ). in the fixed-time 99 hand washing scheme, we varied time intervals between hand washing to be 5 min to 6 hours. for event-100 prompted hand washing, the delay of hand washing after hand contamination events was varied from 1 101 min to 6 hours. there is little published data on the rate of hand contamination events susceptible individuals are exposed 104 to when in contact with infected individuals who are shedding respiratory viruses, and none specific to 105 sars-cov-2. in a direct observation study conducted by zhang et al [20] , surface touching behaviour 106 in a graduate student office was recorded. approximately 112 surface touches per hour were registered. another study by boone et al [21] found that the influenza virus was detected on 53% of commonly 108 touched surfaces in homes with infected children. informed by these values, we took 60 events per hour 109 as the upper bound for the rate of hand contamination events λ c . we chose 1 event per hour as the lower 110 bound. in our main analyses, we used a rate of 4 hand contamination events per hour. to date, it is not known how long sars-cov-2 can persist on human fingers. in [19] , the survival 113 of influenza a on human fingers was experimentally investigated. we fitted exponential decay curves 114 to these results in order to determine the half-life of probability of persistence of h3n2 for two viral 115 volumes of 2 µl and 30 µl (see table 2 and supplementary material). in addition, we vary the half-life 116 of probability of persistence from 1 to 60 min in our analysis. model outcomes 118 the model output is the cumulative probability of a susceptible person becoming infected in twelve hours 119 and we will refer to it subsequently as simply the probability of infection. we investigated the impact 120 of hand washing on the probability of infection for different hand contamination rates. in addition, 121 we compared the two hand washing schemes (fixed-time vs. event-prompted) to find the optimal hand 122 washing strategy that will lead to the greatest reduction of the probability of infection. the model cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 27, 2020. . respectively), the same hand washing frequency decreases the probability of infection to 6.9 % and to 132 4.6 %, respectively. consequently, fewer hand washes are necessary to reduce the probability of infection 133 by 50 % for long compared to short durations of viral persistence (see figure s2 ). this observation can be 134 explained by the fact that the shorter the virus persists on hands, the shorter the intervals between hand 135 contamination and transmission events tend to be (with a higher transmission probability per contact, 136 see figure s4 ) and therefore, the less likely hand washing is able to interrupt infection events. figure s3 the second notable finding from the model is that event-prompted hand washing is more effective than 8 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint and 2% when hand washing is performed every 15 min and one minute after hand contamination events, 151 respectively. the differences between the two hand washing schemes are less pronounced if hand washing 152 is performed less frequently or with a longer delay after hand contamination events since the two hand 153 washing schemes become more similar. it follows that delays between hand contamination and hand 154 washing decrease the effect of hand washing on reducing the probability of infection. another important parameter that affects the effect of hand hygiene is the hand contamination rate. 157 figure 5 shows the increase in hand hygiene frequency required to half the probability of infection from 158 10% (no hand wash) to 5%. when hand contamination rate is relatively rare, at less than 10 times per . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. our study provides new insights into factors that affect the effectiveness of hand hygiene behaviour in 174 reducing the probability of infection. firstly, we found that the shorter the virus survives on hands, the 175 less effective increasing hand hygiene frequency is in reducing infection. the logic behind this is that 176 when the virus dies off quickly before hand washing is performed, the time intervals between hand con-177 tamination and transmission tend to be shorter and the respective transmission probability per contact 178 tends to be higher for the same cumulative probability of infection. secondly, contaminated surfaces are 179 crucial for the effect of hand hygiene. the more often hands become contaminated, the more frequently 180 hands need to be washed to reduce infection risk. lastly, when hands are not constantly contaminated, 181 event-prompted hand washing is more efficient than fixed-time hand washing given the same hand washing 182 frequency. this is because delays in hand washing after contamination of hands in fixed-time compared 183 to event-prompted hand washing tend to be longer, and, during this delay, susceptible hosts may become 184 infected through face-touching. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint hands of susceptible individuals are assumed to get contaminated at random. these contamination events are assumed to occur independently of each other, and follow a poisson distribution with a mean of λ c events per hour. the probability of the virus to persist on hands at time t after contamination, p (t), is assumed to decay exponentially with a half-life of t 1/2 . this is consistent with experimental data for influenza a (see [19] ). individuals touch their face at random leading to potential infection events that are assumed to occur independently of each other, and follow a poisson distribution with a mean of λ f events per hour. the probability that a single face-touching contact with contaminated hands actually leads to transmission is . assume the face-touching events occur at times t 1 , . . . , t f during the given time period t . then the cumulative probability of infection over the time period t is given by: we assume that when hand washing is performed after the last hand contamination event and before a 312 face-touching event at time t i , the respective probability of virus persistence p (t i ) is reduced to zero. probability of viral persistence on contaminated hands 314 the decay of the probability of viral persistence on contaminated hands is modeled as an exponential decay with probability distribution: where λ d is the decay constant. the probability that virus will die off within time t is given by the integral of the decay distribution function from 0 to t: the probability that the virus will persist at time t is one minus the probability that it will die off within the same period: the average survival time (or mean lifetime) is given by: 15 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. where λ d is the decay rate. the decaying quantity, n(t), represents the number of fingers with recoverable 316 infectious viral particles and is assumed to have an initial value of n 0 at time zero. in the experiment with 2 µl inoculum, 18 contaminated fingers from six individuals were tested for the 319 presence of infectious virus at 1, 3, 5, 15 and 30 min after initial contamination. figure s1 depicts the 320 data and the fitted curve for the 2 µl inoculum. the decay rate was estimated to be λ . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint the shorter the half-life of virus persistence, the higher the frequency of hand washing necessary in order 328 to prevent 50% of infections (see figure s2 ). in addition, the time intervals between hand contamination 329 and hand washes have to be shorter in order to prevent 50% of the infections (see figure s3 . 18 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint figure s4 shows that the shorter the virus persists on hands, the higher the probability of transmission 332 per face-touching contact has to be if the cumulative probability of infection is assumed to be fixed. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint minutes or the time delay of hand washing after hand contamination events is decreased to one or five 351 minutes. however, due to the the high rate of hand contamination events of every 4 minutes or every 352 minute, respectively, such an uptake seems infeasible. hence, when susceptible individuals are exposed 353 to continuous contamination, the best strategy would be to wash their hands as frequently as possible, 354 especially after touching potentially contaminated surfaces, and to reduce the rate of contamination by, 355 e.g., cleaning surfaces in their environment or isolating the infectious person. comparison of number of hand washes 358 figure s11 shows the average number of hand washes per hour for the two hand washing schemes in 359 the scenario used in the main analysis, i.e. for a hand contamination rate λ c = 4 hour -1 . for a fair 360 comparison between the two hand washing schemes, fixed-time hand washing should be compared to 361 event-prompted hand washing using approximately the same average number of hand washer per hour. for example, hand washing every fifteen minutes may be compared to event-prompted hand washing one 363 minute after hand contamination. 23 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 27, 2020. hand contamination events are assumed to occur on average 4 times per hour. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 27, 2020. . https://doi.org/10.1101/2020.05.26.20113464 doi: medrxiv preprint ignaz semmelweis and the birth of infection control hand hygiene and patient care: pursuing the semmelweis legacy key: cord-345991-d26y5291 authors: jing, jane lee jia; pei yi, thong; bose, rajendran j. c.; mccarthy, jason r.; tharmalingam, nagendran; madheswaran, thiagarajan title: hand sanitizers: a review on formulation aspects, adverse effects, and regulations date: 2020-05-11 journal: int j environ res public health doi: 10.3390/ijerph17093326 sha: doc_id: 345991 cord_uid: d26y5291 hand hygiene is of utmost importance as it may be contaminated easily from direct contact with airborne microorganism droplets from coughs and sneezes. particularly in situations like pandemic outbreak, it is crucial to interrupt the transmission chain of the virus by the practice of proper hand sanitization. it can be achieved with contact isolation and strict infection control tool like maintaining good hand hygiene in hospital settings and in public. the success of the hand sanitization solely depends on the use of effective hand disinfecting agents formulated in various types and forms such as antimicrobial soaps, water-based or alcohol-based hand sanitizer, with the latter being widely used in hospital settings. to date, most of the effective hand sanitizer products are alcohol-based formulations containing 62%–95% of alcohol as it can denature the proteins of microbes and the ability to inactivate viruses. this systematic review correlated with the data available in pubmed, and it will investigate the range of available hand sanitizers and their effectiveness as well as the formulation aspects, adverse effects, and recommendations to enhance the formulation efficiency and safety. further, this article highlights the efficacy of alcohol-based hand sanitizer against the coronavirus. the emergence of the covid-19 (coronavirus disease-2019) pandemic has risen to be a significant global public health concern and led to extensive use of hand disinfectants given its contagious nature. there was a total of 3.8 million reported cases affecting over 200 countries worldwide as of 7 may 2020 [1, 2] . covid-19 is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which can persist and remain infectious on surfaces for up to 9 days [3, 4] . the recent study reveals that transmission of sars-cov-2 is possible in the form of aerosol and fomite, and the virus can remain viable and infectious in aerosols for hours and on surfaces up to days, depending on the inoculum shed [5] . hence, it is crucial to interrupt the transmission chain of the virus through contact isolation and strict infection control tools [6] . following face masks, appropriate hand hygiene is of utmost importance as hands may be contaminated from direct contact with patients' contaminated from direct contact with patients' respiratory droplets from coughs and sneezes or indirect contact via surfaces, which may then facilitate the transmission and spreading of the disease [7] [8] [9] . the 2003 severe acute respiratory syndrome (sars) outbreak was caused by a novel human coronavirus (cov) (sars-cov) that could survive on surfaces for 24 to 72 h [10] . the studies on sars-cov outbreak settings showed that providing efficient handwashing facilities reduced transmission [11] . given the dangers imposed by this disease, the centre for disease control and prevention (cdc), the united states has promoted and encouraged hand hygiene through handwashing or use of hand sanitizer [12] . hand disinfectants are commercially available in various types and forms such as anti-microbial soaps, water-based or alcohol-based hand sanitizers, most often used in hospital settings. different types of delivery systems are also formulated-for instance, rubs, foams, or wipes ( figure 1 ). the world health organisation (who) recommends alcohol-based hand sanitizer (abhs) in line with the proven advantages of their rapid action and a broad spectrum of microbicidal activity offering protection against bacteria and viruses. however, the effectiveness against nonenveloped viruses is still debatable and questionable [7, [13] [14] [15] [16] [17] [18] . to date, most effective hand sanitizer products are alcohol-based formulations containing 62%-95% of alcohol as it is capable of denaturing the proteins of microbes and inactivating viruses [19, 20] . there are a few challenges and concerns with regard to this formulation in terms of fire hazards and skin toxicity due to high alcohol content [21] . this systemic review aims to investigate the range of available hand sanitizers and their effectiveness against the human coronavirus as well as the formulation aspects, adverse effects, and recommendations to improve the formulation of current hand sanitizers. this study was conducted according to the prisma recommendations [22] . we systematically reviewed the available literature in pubmed and google scholar, up to 2020. the search terms we used are hand sanitizers and alcohol and treatment and handwashing and virucide and bactericide and (cure or failure or mortality). a manual search was also performed. we set no year limit, and english is the only language we limit. the study selection based on effective treatment resulted in a potential eradication of pathogens. the data extracted from each study comprised the main characteristics of the study, such as the first author's name, year, study design, and country. out of many reports, we selected articles based on the hand disinfectant agents and their potential outcome suitable for the present viral pandemic. data were extracted by two authors based on the to date, most effective hand sanitizer products are alcohol-based formulations containing 62%-95% of alcohol as it is capable of denaturing the proteins of microbes and inactivating viruses [19, 20] . there are a few challenges and concerns with regard to this formulation in terms of fire hazards and skin toxicity due to high alcohol content [21] . this systemic review aims to investigate the range of available hand sanitizers and their effectiveness against the human coronavirus as well as the formulation aspects, adverse effects, and recommendations to improve the formulation of current hand sanitizers. this study was conducted according to the prisma recommendations [22] . we systematically reviewed the available literature in pubmed and google scholar, up to 2020. the search terms we used are hand sanitizers and alcohol and treatment and handwashing and virucide and bactericide and (cure or failure or mortality). a manual search was also performed. we set no year limit, and english is the only language we limit. the study selection based on effective treatment resulted in a potential eradication of pathogens. the data extracted from each study comprised the main characteristics of the study, such as the first author's name, year, study design, and country. out of many reports, we selected articles based on the hand disinfectant agents and their potential outcome suitable for the present viral pandemic. data were extracted by two authors based on the screening of the titles and abstracts obtained from the pubmed and google scholar database. the other authors have checked the materials to fulfil the criteria for the work. hand sanitizer can generally be categorized into two groups: alcohol-based or alcohol-free ( figure 2 ). an abhs may contain one or more types of alcohol, with or without other excipients and humectants, to be applied on the hands to destroy microbes and temporarily suppress their growth [23] . abhs can effectively and quickly reduce microbes covering a broad germicidal spectrum without the need for water or drying with towels. nevertheless, there are a few shortcomings with the effectiveness of abhs, such as its short-lived antimicrobial effect and weak activity against protozoa, some non-enveloped (non-lipophilic) viruses and bacterial spores [23] . screening of the titles and abstracts obtained from the pubmed and google scholar database. the other authors have checked the materials to fulfil the criteria for the work. hand sanitizer can generally be categorized into two groups: alcohol-based or alcohol-free ( figure 2 ). an abhs may contain one or more types of alcohol, with or without other excipients and humectants, to be applied on the hands to destroy microbes and temporarily suppress their growth [23] . abhs can effectively and quickly reduce microbes covering a broad germicidal spectrum without the need for water or drying with towels. nevertheless, there are a few shortcomings with the effectiveness of abhs, such as its short-lived antimicrobial effect and weak activity against protozoa, some non-enveloped (non-lipophilic) viruses and bacterial spores [23] . on the other hand, the alcohol-free sanitizer makes use of chemicals with antiseptic properties to exert the antimicrobial effects. these chemicals have a different mode of action and function according to their chemical functional groups (table 1 ) [24] [25] [26] . as they are non-flammable and often used at low concentrations, they are relatively safer to use among children as compared to abhs. abhs is available in different dosage forms, namely gel, liquid and foam. as each type has its own characteristics, a study was conducted to understand the impact on sensory attributes that may affect user's acceptance of the product and ultimately influence usage leading to hand hygiene compliance [27] [28] [29] . the overall result showed that gels and foams are more widely accepted compared to liquid, especially in terms of handleability, though the latter left a high clean feeling and took a shorter time to dry [30] . united states food and drug administration (usfda) has given the list of eligible antiseptic agents used in the non-prescription (also known as over-the-counter or otc) and listed in table 2 . this list is highly useful in selecting appropriate antiseptic active ingredients intended for use by health care professionals in a hospital setting or other health care situations outside the hospital [31] . recently, the united states pharmacopeia (usp) compounding expert committee (cmp ec) recommends the three formulations for compounding alcohol-based hand sanitizers for use during shortages associated with the covid-19 pandemic and listed in table 3 [32] . on the other hand, the alcohol-free sanitizer makes use of chemicals with antiseptic properties to exert the antimicrobial effects. these chemicals have a different mode of action and function according to their chemical functional groups (table 1 ) [24] [25] [26] . as they are non-flammable and often used at low concentrations, they are relatively safer to use among children as compared to abhs. abhs is available in different dosage forms, namely gel, liquid and foam. as each type has its own characteristics, a study was conducted to understand the impact on sensory attributes that may affect user's acceptance of the product and ultimately influence usage leading to hand hygiene compliance [27] [28] [29] . the overall result showed that gels and foams are more widely accepted compared to liquid, especially in terms of handleability, though the latter left a high clean feeling and took a shorter time to dry [30] . united states food and drug administration (usfda) has given the list of eligible antiseptic agents used in the non-prescription (also known as over-the-counter or otc) and listed in table 2 . this list is highly useful in selecting appropriate antiseptic active ingredients intended for use by health care professionals in a hospital setting or other health care situations outside the hospital [31] . recently, the united states pharmacopeia (usp) compounding expert committee (cmp ec) recommends the three formulations for compounding alcohol-based hand sanitizers for use during shortages associated with the covid-19 pandemic and listed in table 3 [32] . table 1 . chemical classification of commonly used disinfectants in hand sanitizer and their mechanism of antimicrobial action. examples mechanism of action denaturation of proteins in the plasma membrane chlorine compounds halogenation/oxidation of cellular proteins table 2 . list of hand antiseptic ingredients approved by the food and drug administration (fda) used in healthcare and over the counter (otc) [30] . healthcare personal hand rub abhs in the form of a spray which trigger stream aerosol solution allows direct contact of the alcohol solution with the target surface. however, there are several limitations associated with the sprays, including overspray, breathed by patients and flammability. ready-to-use alcohol "hand sanitizing wipes (hsw)" is a pre-wetted towelette containing disinfectants, antiseptics, surfactants, etc. in a sealed package ready for use in topical disinfection. the advantage of hsw is eliminating the possible contaminations and transfer of pathogen due to towelettes reuse. however, the longer storage time could increase the probability of losing antimicrobial/viricidal activity due to the possible binding of active ingredients onto the towelettes or by the degradation of the active ingredient [33] . alcohol 60%-95% y n y n y benzalkonium chloride y y y y n benzethonium chloride y y n y n chlorhexidine gluconate n n n n n chloroxylenol y y n y n cloflucarban y y n y n fluorosalan y y n y n hexylresorcinol y y n y n iodine complex (ammonium ether sulfate and polyoxyethylene sorbitan monolaurate) n y n y n iodine complex (phosphate ester of alkylaryloxy polyethylene glycol) y y n y n iodine tincture united states pharmacopeia (usp) y n n n n iodine topical solution usp y n n n n nonylphenoxypoly (ethyleneoxy) ethanoliodine y y n y n poloxamer-iodine complex y y n y n povidone-iodine 5%-10% y y n y n undecoylium chloride iodine complex y y n y n isopropyl alcohol 70%-91.3% y n y n y mercufenol chloride y n n n n methylbenzethonium chloride y y n y n phenol (equal to or less than 1.5%) y y n y n phenol (greater than 1.5%) y y n y n secondary amyltricresols y y n y n sodium oxychlorosene y y n y n triclocarban y y n y n triclosan y y n y n combinations: calomel, keeping hands clean is a fundamental and essential step to avoid getting sick while limiting the transmission of germs to others. cdc recommends handwashing with soap and water whenever possible as it remarkably reduces the amount of all types of microbes and dirt on the skin surface [15, 34] . both the soaps and alcohol-based sanitizers work by dissolving the lipid membranes of microbes, thereby inactivating them ( figure 3) . thus, the sanitizer serves as an alternative when the soap and water are not readily available. the suggested minimum alcohol content of 60% is needed for it to exert the microbicidal effect. as compared to soap, alcohol-based sanitizers do not eliminate all types of germs, including norovirus and clostridium difficile, the common pathogens that can cause diarrhoea [35, 36] . while most people prefer to use sanitizers as they come in handy, and assume that the sanitizers may not be as effective as the soap at killing germs, this is because people may not use a sufficient amount of sanitizers to clean the hands [37, 38] . the liquid may evaporate before it is evenly rubbed all over the hands, therefore compromising the efficacy of the sanitizers [37, 39] . also, the sanitizer may not work well when the hands are grossly dirty or contaminated with harmful chemicals [40] . diarrhoea [35, 36] . while most people prefer to use sanitizers as they come in handy, and assume that the sanitizers may not be as effective as the soap at killing germs, this is because people may not use a sufficient amount of sanitizers to clean the hands [37, 38] . the liquid may evaporate before it is evenly rubbed all over the hands, therefore compromising the efficacy of the sanitizers [37, 39] . also, the sanitizer may not work well when the hands are grossly dirty or contaminated with harmful chemicals [40] . although hand sanitizers may be less effective than soaps in some situations, it is undeniable that they are the preferred form of hand hygiene in healthcare settings. the use of alcohol-based sanitizer may improve the compliance of healthcare workers to hand hygiene practices as they are easily accessible and take less time to use. around 2.5-3 ml of liquid (equivalent to two pumps from a dispenser) is deposited on the palm and rubbed all over the surfaces of both hands for 25-30 s to maximize the efficacy of the sanitizer [41] . abhs contains either ethanol, isopropanol, or n-propanol. a concentration of 60%-95% of alcohol by volume is said to exhibit optimum bactericidal activity [42, 43] . the antimicrobial effect of alcohols is attributed to their ability to dissolve the lipid membranes and denature the proteins of microbes. alcohols have broad-spectrum antimicrobial activity against most vegetative forms of bacteria (including mycobacterium tuberculosis), fungi, and enveloped viruses (human although hand sanitizers may be less effective than soaps in some situations, it is undeniable that they are the preferred form of hand hygiene in healthcare settings. the use of alcohol-based sanitizer may improve the compliance of healthcare workers to hand hygiene practices as they are easily accessible and take less time to use. around 2.5-3 ml of liquid (equivalent to two pumps from a dispenser) is deposited on the palm and rubbed all over the surfaces of both hands for 25-30 s to maximize the efficacy of the sanitizer [41] . abhs contains either ethanol, isopropanol, or n-propanol. a concentration of 60%-95% of alcohol by volume is said to exhibit optimum bactericidal activity [42, 43] . the antimicrobial effect of alcohols is attributed to their ability to dissolve the lipid membranes and denature the proteins of microbes. alcohols have broad-spectrum antimicrobial activity against most vegetative forms of bacteria (including mycobacterium tuberculosis), fungi, and enveloped viruses (human immunodeficiency virus [hiv] and herpes simplex virus). however, they are ineffective against bacterial spores that are found most commonly in raw materials. the addition of hydrogen peroxide (3%) may be a solution to this issue, but handling with caution during production is required due to its corrosive nature [41] . for alcohol-free products, various antiseptics have substituted alcohol as the main active ingredient. the mechanism of action of alcohols and non-alcohol compounds have been summarized in table 4 . table 4 . mechanism of action of alcohols and non-alcohol compounds. alcohol denatures protein and lipid membrane of microorganisms. optimum concentration 60%-95%. hydrogen peroxide inactivates contaminating spores in the bulk solutions or excipients. • concentration is as low as 3%. similar to alcohol, chlorhexidine works by disrupting the arrangement of cytoplasmic membranes, thereby leading to precipitation of cell contents [44] . it is most effective against gram-positive bacteria and has modest activity against a gram-negative bacteria, as well as enveloped viruses [44, 45] . as chlorhexidine is cationic, it is advisable to avoid using chlorhexidine-containing products with natural soaps and hand creams that contain anionic emulsifying agents as they may cause inactivation or precipitation of chlorhexidine, thus reducing its efficacy [44] [45] [46] . chlorhexidine gluconate 0.12% is likely to have antiviral activity against the coronavirus as it does against other enveloped viruses [47] . chloroxylenol is a common agent as a preservative in cosmetics or as an antimicrobial agent in soap. the antimicrobial effect of chloroxylenol is attributable to its ability to deactivate enzyme systems and alter cell wall synthesis in microbes. it is good at killing bacteria and enveloped viruses but less active against pseudomonas aeruginosa [48, 49] . iodine was once an effective antiseptic used for skin disinfection. it can penetrate the microbial cell wall and form complexes with amino acids or unsaturated fatty acids to impair the synthesis of cellular components. nonetheless, due to its potential to cause skin irritation and discoloration, iodophors have come into play to replace iodine as the active ingredient in antiseptics. the fda has not cleared any liquid chemical sterilant or high-level disinfectants with iodophors as the main active ingredient [50] . iodophors are a combination of either iodine, iodide or triiodide, and a high molecular weight polymer carrier such as polyvinyl pyrrolidone. this carrier is responsible for improving the solubility of iodine, enhancing the sustained release of iodine, and minimizing skin irritation [51] . the degree of antimicrobial activity determined based on the amount of free iodine present in the structure. having said so, formulations with lower iodophor concentration may have significant antimicrobial activity as well because the amount of free iodine tends to increase after dilution [52] . both iodine and iodophors exhibit germicidal activity against a gram-positive, gram-negative, and spore-forming bacteria, as well as various fungi and viruses [53] [54] [55] . however, the concentration of iodophors used in antiseptics (e.g., povidone-iodine 5%-10%) is usually insufficient to achieve sporicidal action. furthermore, the nasal povidone-iodine formulation has shown acceptable tolerability and favorable risk/benefit profile to help mitigate the perioperative spread of covid-19 in patient decolonization [56] . quaternary ammonium compounds are composed of four alkyl groups connected to a nitrogen atom in the centre. the typical examples include benzalkonium chloride, benzethonium chloride, and cetyl peridium chloride. they act by adsorbing to the cytoplasmic membrane, thus causing leakage of the constituents. they are more active against gram-positive bacteria and lipophilic viruses. the activity against fungi, mycobacteria, and gram-negative bacilli is comparatively weak [15] . at low concentration, triclosan is bacteriostatic due to its harmful effects to bacterial enzymes responsible for the composition of fatty acid from cells wall and membranes. at high concentrations, triclosan disrupts the bacteria membrane, leading it to death [8, 57, 58] . it has good activity against gram-positive bacteria, including methicillin-resistant staphylococcus aureus, candida spp. and mycobacteria. the efficacy of triclosan may be affected by ph, use of emollients, and the ionic nature of certain skin formulations [58] . a lot of sanitizers also include humectant, for instance, glycerine, in the formulation to reduce the incidence of dry skin associated with the use of alcohol-based products as the alcohol can strip away sebum that helps to keep the skin moist. though fragrance and colorant added to improve the aesthetics, it is generally not recommended to do so due to the risk of allergic reactions [41, 43] . the skin is composed of three main layers: a superficial epidermis (50-100 µm), a middle dermis (≈2 mm), and an innermost hypodermis (1-2 mm). it constitutes the first line of defence against invading microorganisms while providing protection against mechanical impacts and preventing excessive loss of water from the body. the vital barrier function of the skin resides primarily in the uppermost epidermal layer, the stratum corneum (sc). the sc contains layers of corneocytes that are terminally differentiated from keratinocytes that make up the basal layer of epidermis [15, 59] . the adjacent corneocytes are interconnected by membrane junctions called corneodesmosomes to enhance the cohesion of the sc [60] . the lipids that are derived from the exocytosis of lamellar bodies during terminal differentiation of keratinocytes will fill up the intercellular spaces between the corneocytes, and they play a role in maintaining the cutaneous barrier function [61] . the layer underneath the sc is known as the keratinized stratified epidermis. it consists of melanocytes that produce melanin, a skin pigment that provides skin with its color and protects the skin from ultraviolet radiation. apart from that, langerhan's cells, which are involved in the immune response and merkel cells that are responsible for light touch sensation, can also be found within this layer [62, 63] . though the skin serves as a barrier that protects one against harmful microorganisms, it hosts a wide array of beneficial bacteria such as staphylococcus epidermis, staphylococcus aureus, micrococcus spp., propionibacterium spp. and corynebacterium spp. [64, 65] . these bacteria may help to prevent the colonization of pathogenic microbes by either competing with them for nutrients or stimulating the skin's defence system. under normal circumstances, they exhibit low pathogenicity. however, when the skin flora distribution is disrupted, for example, due to the long-term use of topical antibiotics or frequent hand washing, they may become virulent [66, 67] . to reduce the incidence of infection, the microbiota balance is restored and maintained through constant skin regeneration. the whole process takes about 28 days, starting from the mitotic division of basal epithelium to desquamation. when the dead keratinocytes in the sc are sloughed off, it takes away the microbes that colonized the skin surface. this continuous process significantly limits the invasion of bacteria while achieving a balanced growth among the microbial populations. the virus sars-cov-2 is termed due to of its genome sequence similarity to sars coronavirus (sars-cov) [68, 69] . the covs belong to the same genus beta coronavirus, sharing similar morphology in the form of enveloped, positive single-stranded rna viruses [70, 71] . these viruses can be deactivated by certain lipid solvents such as ethanol, ether (75%), chlorine-containing disinfectants, and chloroform, except chlorhexidine [70] . ethyl alcohol, at concentrations of 60%-80%, is a potent viricidal agent inactivating all the lipophilic viruses (e.g., influenza, herpes and vaccinia virus) and many hydrophilic viruses (e.g., adenovirus, enterovirus, rhinovirus, and rotaviruses but not hepatitis a virus (hav) or poliovirus) [32] . the 2015 who model list of essential recommended ethanol at 80% (v/v) and isopropyl alcohol at 75% (v/v) under the category 'disinfectant: alcohol-based hand rub' [72] . ethanol (60%-85%) appears to be the most effective against viruses compared to isopropanol (60%-80%) and n-propanol (60%-80%) [23] . the study conducted with who-recommended alcohol-based formulations demonstrated a strong virucidal effect against emerging pathogens, including zikv, ebov, sars-cov, and mers-cov [73] . another study conducted in germany found that the ethanol in the concentration of 42.6% (w/w) was able to destroy sars coronavirus and mers coronavirus within 30 s [74] . the efficacy of various alcohol-based sanitizers at different concentrations was also investigated in several studies, as shown in table 5 . rf: reduction factor (calculated as the difference in the quotient of control titration and after incubation of the virus with the disinfectant). higher rf value indicates higher virus reduction potential. log 10 value of ≤1 is not significant or ineffective, log 10 value of 1-2 is indicative/contributable effective, log 10 value of 2-4 is moderately effective, and log 10 value of ≥4 is highly effective. undetectable level indicates a higher potential than is demonstrated. the most commonly reported skin reactions with the use of abhs are irritant contact dermatitis (icd) and allergic contact dermatitis (acd) [76, 77] . the symptoms of icd can range from mild to debilitating with manifestations like dryness, pruritus, erythema and bleeding, if severe. as for acd, the symptoms can either be mild and localized or severe and generalized, with most severe forms of acd being manifested as respiratory distress or other anaphylactic symptoms [78, 79] . sometimes, it may be difficult to distinguish between icd and acd due to the overlap and similarities of symptoms. hand hygiene products such as sanitizer and soaps can be damaging to the skin through several mechanisms: denaturation of the stratum corneum proteins, alteration of intercellular lipids, decrease in corneocyte cohesion and reduction of stratum corneum water-binding capacity [80, 81] . the biggest concern is the depletion of the lipid barrier, especially with repeated exposure to lipid-emulsifying detergents and lipid-dissolving alcohols as it may penetrate deeper into the skin layers and change the skin flora, resulting in more frequent colonization by bacteria [82] [83] [84] . in order of decreasing frequency of icd including handwashing soaps are iodophors, chlorhexidine, chloroxylenol, triclosan and alcohol-based products. among the alcohol-based formulations, ethanol has the least skin-irritant property compared to n-propanol and isopropanol [21] . there are, however, other contributing factors that increase the risk of icds such as lack of use of supplementary emollients, friction due to wearing and removal of gloves and low relative humidity [85] [86] [87] . abhs also has a drying effect on hands which can further cause the skin to crack or peel [88] [89] [90] . on the other hand, acd is caused by allergic reactions towards certain agents in the formulations such as iodophors, chlorhexidine, triclosan, chloroxylenol and alcohols [91] . individuals with allergic reactions to alcohol-based preparations may have true allergy to alcohol or allergy to impurity, aldehyde metabolite or other excipients like fragrances, benzyl alcohol, parabens or benzalkonium chloride [29, 92, 93] . the adverse effects caused by sanitizer or handwashing soaps can be easily prevented by identifying the trigger and countered with appropriate measures using one or a combination of following methods: selecting products with a less irritating agent, moisturizing skin after hand sanitation and avoiding habits that may cause or aggravate skin irritation [29, 41, 93, 94] . when frequent hand cleansing is expected, for instance, among healthcare workers, it is preferable to select products that have a good balance between effectiveness, safety and compatibility with all skin types. the concerns about drying and irritant effects of alcohol or certain antiseptic soaps may hinder the acceptance and ultimate use of these preparations [52] . hence, to reduce this problem, abhs containing humectants or emollients can be used instead [95] . in recent years, novel water-based antiseptic lotions are also being studied such as that using benzethonium chloride, which not only addresses the issue regarding cutaneous adverse effects but also broadens the efficacy against viruses and tackles concerns about flammability associated with conventional abhs [76] . temperature and humidity are considered as significant contributors to the risk factors of dermatitis. the retention of skin moisture is longer in tropical countries and places with higher relative humidity compared to cold, dry environments [96] . this aspect calls for a varying need of emollients concerning respective environmental conditions and climates according to geographical locations. some individuals, such as the elderly and healthcare workers who often wear occlusive gloves, are more prone to dry skin. therefore, it is a good practice for these high-risk individuals to use moisturizers containing humectants, fats or oils to enhance skin moisture and improve skin barrier function [96] . proper hand hygiene by washing hands or using alcohol-based sanitizer is one of the most critical measures to prevent direct or indirect transmission of the covid-19 as it reduces the number of the viable sars-cov-2 virus on contaminated hands. there are five instances that call for hand hygiene: before and after having direct contact with patients, before handling invasive devices for patient care, after exposure to body fluids or excretions, after contact with objects including medical appliances within proximity of the patient, and before starting any aseptic task [96] . the cdc recommends washing hands with soap and water whenever possible because handwashing reduces the amounts of all types of germs and chemicals on hands [97] . if soap and water are not available, using a hand sanitizer with a final concentration of at least 60% ethanol or 70% isopropyl alcohol inactivates viruses that are genetically related to, and with similar physical properties as, the covid-19. the action of handwashing can mechanically remove the microorganisms, but the removal of resident pathogens is more effective when hands are washed with preparations containing anti-microbial agents [96] . according to the policies and procedures on cdc, who and the infection control by ministry of health malaysia, the recommended duration for the entire handwash procedure spans between 40 to 60 s using the standard 7-step technique. comparatively, sanitizer containing at least 60% alcohol is more effective in destroying the microorganisms than handwashing with anti-microbial soaps due to their ability to inactivate and destroy the microbes [96] . however, it should be noted that the abhs may not be as effective if the hands are visibly soiled, dirty or greasy, so handwashing with soap and water is preferred under these circumstances. the duration to rub sanitizer all over the hand surfaces is approximately 20 to 30 s [96] . proper hand hygiene is one of the essential infection control strategies as it can undeniably lower the likelihood of direct or indirect transmissions of microorganisms. the use of abhs is becoming more common because of their rapid action and efficiency in killing microorganisms, mainly when handwashing using soap and water is not practical or convenient. there are, however, some situations in which handwashing is preferred as abhs are less effective when the hands are visibly dirty or stained and cannot cover certain kinds of pathogens. it is vital to select abhs with the appropriate amount of alcohol and practice the correct hand hygiene technique when cleaning hands to ensure all the microorganisms are effectively killed. author contributions: t.m. and r.j.c.b. conceptualized the purpose of the review. j.l.j.j. and t.p.y. jointly extracted the articles and involved in the initial preparation of manuscript. j.r.m. and n.t. cross-checked the extracted data which was further reviewed and edited by t.m. all authors have read and agreed to the published version of the manuscript. covid-19 coronavirus 2019-ncov statistics update (live): 4,122,912 cases and 280,337 deaths situation update worldwide persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 survival of influenza virus on human fingers advisors of expert sars group of hospital authority effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs preferences of possible people inactivation of surrogate coronaviruses on hard surfaces by health care germicides why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others? severe acute respiratory distress syndrome (sars): a critical care perspective efficacy of alcohol-based hand sanitizers against fungi and viruses morbidity and mortality weekly report guideline for hand hygiene in health-care settings; recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force development and virucidal activity of a novel alcohol-based hand disinfectant supplemented with urea and citric acid potential role of hands in the spread of respiratory viral infections: studies with human parainfluenza virus 3 and rhinovirus 14 microbicides and the environmental control of nosocomial viral infections alcohol based hand sanitizers: assurance and apprehensions revisited virucidal activity of a new hand disinfectant with reduced ethanol content: comparison with other alcohol-based formulations systematic review of studies on compliance with hand hygiene guidelines in hospital care preferred reporting items for systematic reviews and meta-analyses: the prisma statement antiseptics and disinfectants: activity, action, and resistance te giffel, m.c. pathogen resistance and adaptation to disinfectants and sanitisers mechanisms of inactivation and resistance of spores to chemical biocides effect of topical treatments on irritant hand dermatitis in health care workers compliance with hand disinfection and its impact on hospital-acquired infections skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use impact of hand sanitizer format (gel/foam/liquid) and dose amount on its sensory properties and acceptability for improving hand hygiene compliance food and drug administration safety and effectiveness of health care antiseptics; topical antimicrobial drug products for over-the-counter human use. final rule compounding alcohol-based hand sanitizer during covid-19 pandemic efficacy of disinfectant-impregnated wipes used for surface disinfection in hospitals: a review hand hygiene in healthcare settings use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern new england hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of clostridium difficile efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers reduction in the incidence of influenza a but not influenza b associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial a kinetic study using evaporation of different types of hand-rub sanitizers do workplace and home protective practices protect farm workers? findings from the "for healthy kids" study world health organisation. who guidelines on hand hygiene in health care: first global patient safety challenge: clean care is safer care; world health organisation chemical disinfectants-guideline for disinfection and sterilization in healthcare facilities guide to local production: who-recommended handrub formulations; world health organisation apic guidelines for handwashing and hand antisepsis in health care settings. ajic am disinfection, sterilization and preservation (5th ed) the effect of handcream on the antibacterial activity of chlorhexidine gluconate an overview of their replication and pathogenesis guideline for use of topical antimicrobial agents. ajic am an approach for selection of health care personnel handwashing agents guideline for disinfection and sterilization in healthcare facilities poly(vinylpyrrolidone)-a versatile polymer for biomedical and beyond medical applications iodophor antiseptics: intrinsic microbial contamination with resistant bacteria an in-vitro evaluation of the activity of povidone-iodine against nosocomial bacterial strains in vitro efficacy of povidone-iodine solution and cream against methicillin-resistant staphylococcus aureus preliminary study of test methods to assess the virucidal activity of skin disinfectants using poliovirus and bacteriophages perioperative covid-19 defense: an evidence-based approach for optimization of infection control and operating room management a review of effectiveness and safety in health care settings antimicrobial chemicals associate with microbial function and antibiotic resistance indoors structure and function of the epidermal barrier lamellar bodies: the key to cutaneous barrier function langerhans cells-programmed by the epidermis merkel cells: a collective review of current concepts skin microflora and bacterial infections of the skin skin microbiota: a source of disease or defence? the skin microbiome attachment to and entry of microorganisms into the body a new coronavirus associated with human respiratory disease in china a pneumonia outbreak associated with a new coronavirus of probable bat origin evaluation and treatment coronavirus annex 1 19th who model list of essential medicines virucidal activity of world health organization-recommended formulations against enveloped viruses, including zika, ebola, and emerging coronaviruses efficacy of ethanol against viruses in hand disinfection efficacy of various disinfectants against sars coronavirus prevention of surfactant-induced irritant contact dermatitis surgical glove perforation and the risk of surgical site infection changes in bacterial flora associated with skin damage on hands of health care personnel how irritant is alcohol? low rates of cutaneous adverse reactions to alcohol-based hand hygiene solution during prolonged use in a large teaching hospital skin barrier integrity and natural moisturising factor levels after cumulative dermal exposure to alkaline agents in atopic dermatitis the temperature effect of in vitro penetration of sodium lauryl sulfate and nickel chloride through human skin temperature dependency of skin susceptibility to water and detergents safety and efficacy of the antiseptic chlorhexidine gluconate alcohol dermatitis: allergic contact dermatitis and contact urticaria syndrome: a review adverse reactions associated with an alcohol-based hand antiseptic among nurses in a neonatal intensive care unit contact urticaria from benzyl alcohol presenting as intolerance to saline soaks contact allergy to cosmetics: causative ingredients allergic contact dermatitis from benzyl alcohol during topical antimycotic treatment skin care: an essential component of hand hygiene and infection control physiologic and microbiologic changes in skin related to frequent handwashing assessment of two hand hygiene regimens for intensive care unit personnel skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel environmental risk factors and their role in the management of atopic dermatitis medical development division; ministry of health malaysia. policies and procedures on infection control clean hands save lives funding: this research received no external funding. the authors declare that they have no conflict of interest. key: cord-004971-jwpb7862 authors: kagan, lori j.; aiello, allison e.; larson, elaine title: the role of the home environment in the transmission of infectious diseases date: 2002 journal: j community health doi: 10.1023/a:1016378226861 sha: doc_id: 4971 cord_uid: jwpb7862 the purpose of this paper is to examine current health care literature (1980–2000) regarding the microbiology of the home environment, to summarize evidence of transmission within the home, and to assess effectiveness of cleaning practices and products. the home environment, particularly the kitchen and bathroom, serves as a reservoir of large numbers of microorganisms, particularly enterobacteriacae,and infectious disease transmission has been demonstrated to occur in 6–60% of households in which one member is ill. current food preparation and cleaning practices provide multiple opportunities for intra-household member spread. routine cleaning is often sufficient, but in cases of household infection, may not adequately reduce environmental contamination. the effectiveness of disinfectants varies considerably and depends on how they are used as well as their intrinsic efficacy. the behavioral aspects of infection prevention in the home (e.g., foodhandling and cleaning practices) warrant increased public attention and education. during the past few decades, research on the epidemiology of infections has focused on hospitals, day care facilities, and schools, but little attention has been paid to the home. recent events, including widespread media coverage of foodborne outbreaks and increased marketing of a variety of antibacterial products for personal hygiene and hard surface disinfection, have resulted in a resurgence of interest and public concern about hygiene and cleanliness in the home. 1 hygiene refers to conditions or practices by which people maintain or promote health by keeping them and their surroundings clean. the question that persists is: how do house-hold cleanliness and personal hygiene affect the risk of infectious disease transmission? the purpose of this paper is to examine current health care literature regarding the microbiology of the home environment, to summarize evidence of transmission within the home, and to assess the effectiveness of cleaning and disinfecting practices and products in controlling transmission. it is our intention that this information will provide perspective regarding microbial risks in the home environment and a basis for developing more appropriate strategies for home hygiene based on what has been shown to effectively reduce infection risk rather than on fear or speculation. database, and columbia university's on-line catalogue were searched for research articles related to home hygiene during the years 1980-2000. key words included: home hygiene, domestic hygiene, food hygiene, and crosscontamination. open searches, using the same key words, also were conducted on internet search engines, including yahoo and excite. the search was restricted to developed countries, and only to articles in english or with english abstracts. excluded were articles pertaining to assisted living facilities, nursing homes, schools, and hospitals. studies have shown that areas in the home, particularly the kitchen, bathroom and possibly the laundry, can serve as reservoirs for microbial colonization. dirty dish rags, cloths and wet sponges have been shown to spread microbial contamination throughout the kitchen. [2] [3] [4] [5] [6] changes in laundering processes have also made transmission of disease via the washing machine a possibility. [2] [3] [4] 7 despite the fact that globalization of food distribution and international travel can transport microorganisms around the world in a matter of hours, in england, wales, and the netherlands 80% of salmonella and campylobacter infections are acquired in the home. [8] [9] further, social and demographic changes have increasingly led to the care of certain "at risk" groups within the home, not only neonates and the elderly, but other per-sons with compromised immune systems as well. in the united states, 20% of the population is estimated to fall into these categories. 10 in one of the early studies of the domestic kitchen, de wit et al. used an indicator organism, escherichia coli k12, to determine the extent of cross contamination from frozen chickens. cross-contamination occurred in a large proportion of those kitchens surveyed and in many cases the indicator organism persisted even after washing and rinsing of the kitchen surfaces. 11 scott et al. measured numbers and types of bacteria at various sites in more than 200 english homes. the highest counts were isolated from wet areas such as u-tubes, kitchen sink, draining board, cleaning cloths and mops, and dishcloths, and pseudomonads were isolated in over 90% of the homes. 2 in a subsequent study enterobacteriaceae were detected in 69% of the homes surveyed. 4 contaminated dishcloths and other cleaning utensils also may act both as reservoirs and disseminators of pathogenic organisms. 2, 6 although drying reduces the number of organisms on clean, laminate surfaces, large numbers of bacteria have been recovered from contaminated surfaces and both clean and soiled cloths as much as 24 to 48 hours after drying. 3 thus, drying alone is not sufficient to eliminate contaminating organisms. further, finger contact with contaminated surfaces and cloths resulted in the transfer of large numbers of organisms to the hands. 3 cloths used for cleaning and/or drying kitchen utensils may transfer contamination throughout the kitchen especially when the same cloth is used for multiple purposes. in some households, the same cloth is used to wash cooking and eating cutlery and then to wipe down the drain board and counters. 4 since plain soap does not necessarily kill microorganisms, soap and water cleaning of contaminated surfaces and hands may actually spread microbial contamination in the environment. 12 speirs et al. sampled 46 kitchens including the following key sites: worktop, chopping board, draining board, sinks, water tap handles, insides of rubber gloves, refrigerator shelf, and dish washing cloth. they isolated various enterobacteria including enterobacter cloacae, klebsiella pneumoniae and escherichia coli. in addition, bacillus subtilis, pseudomonas aeruginosa, staphylococcal and micrococcal species were isolated. the highest counts were found in the wet areas around the sink and the cloths used for wiping and/or drying kitchen surfaces and appliances. 4 in another study, the sink drain was the most contaminated site, harboring 5.9-6.2 log 10 (>99.999% reduction) of microorganisms. 13 enriquez et al. studied 140 cellulose sponges and 56 cotton dishcloths from households in four u.s. cities and isolated 23 and 13 different bacterial species, respectively. most commonly isolated were pseudomonads, but salmonella was also isolated in 15.4% of the sponges and 13.8% of the cloths. other commonly isolated gram-negative bacteria included species of enterobacter, serratia, and klebsiella. 5 salmonella can be transferred to sponges and towels and survive there, resulting in contamination of other areas of the kitchen. 6 specific risk factors for domestic outbreaks of foodborne pathogens include improper food storage, undercooking, and cross-contamination, which may be responsible for 30% of salmonella outbreaks in the home. 14 during food preparation salmonella can be spread throughout the workspace by such actions as whisking batter; bacteria have been found one meter away from each side of the site. powered cooking equipment like the electric blender can also lead to widespread distribution, up to a 3-4 meter radius around the site. in experiments with chickens contaminated with salmonella and campylobacter, a variety of sites in the kitchen, including cutting boards, sinks, handles, faucets, and work areas tested positive after the usual meal preparation procedures were used. 14, 15 in a case control study of food preparation, salmonella was isolated from dishcloths not only in case homes in which salmonella infection persisted but also in control homes. salmonella from dried foods that have contact with moist foods, such as fruit or meat, can transfer within 5 seconds to the wet foods. within a few hours potentially infective doses can be reached as the bacteria multiply under moist conditions. 14 temperature of the water used for "washing up" can also influence microbial survival. for dishes washed by hand, the dishwashing water temperature often is below 50°c at the start and will continue to drop during the dishwashing process. this temperature is not high enough to destroy most organisms. a few studies have demonstrated that when sterile cookware was washed in water inoculated with salmonella or campylobacter, transfer of the pathogen to the dishes occurred. 6, 14 bathroom like the kitchen, the bathroom can be a reservoir of large numbers of microorganisms, particularly in wet areas. in homes in which a family member had salmonellosis, four of six toilets tested positive for salmonella under the recess of the toilet bowl rim, an area difficult to reach with domestic toilet cleaners. in one toilet, salmonella was still present four weeks after the infection, despite the use of cleansers. after artificial contamination of the toilet, flushing led to contamination of the toilet seat and lid, and in one instance salmonella was isolated from an air sample taken after flushing. 16 there is limited evidence of antibiotic-resistant organisms being present in the home environment. in both the bathrooms and the kitchens of 25 randomly selected homes in north carolina, four of 58 enterococcal isolates were vancomycin-resistant and one of 17 escherichia coli isolates was ampicillin-resistant. klebsiella and enterobacter strains had the highest frequency of resistance to ampicillin, and pseudomonal strains were uniformly susceptible to 4 of the 10 tested antibiotics. rutala et al. concluded that in comparison to organisms causing clinical infections in hospitals, those isolated in homes are less likely to be antimicrobial resistant. 13 while the kitchen and the bathroom are logical places for the introduction and transmission of pathogens, one area of the home that may seem less likely to allow the survival and dissemination of microorganisms is the washing machine. various common laundering practices allow bacteria at varying levels to remain in laundered items. standard detergent washing and rinsing practices do not always produce large reductions in microbial contamination. damp cloths that had been washed in detergent and then stored at room temperature over a 24-hour period showed an increase in contamination indicative of the survival and multiplication of microbes. drying was the most reliable method of decontamination when carried out at a temperature of 80°c for 2 hours. 17 in a study to evaluate the survival of bacteria and enteric viruses during washing and drying as performed in u.s. homes, sterile cotton swabs were inoculated with mycobacterium fortuitum, salmonella typhimurium, staphylococcus aureus, e. coli, rotavirus sa1, hepatitis a virus, and adenovirus type 40. the contaminated swabs were then added to sterile cotton underwear, t-shirts, and a pillowcase that contained an organic load typical of homes. all test organisms survived the wash process; wash and rinse cycles alone reduced enteric viruses by 87-98% and bacteria by >99%. during the drying cycle, viruses were more resistant to killing than bacteria. drying was most effective, in decreasing order, for s. typhimurium, s. aureus, and m. fortuitum. detectable levels of e. coli were not found after drying. together, washing and drying reduced all bacteria by at least 99.99%, adenovirus type 40 by 99.91%, hepatitis a virus by 99.8% and rotavirus by 98.6%. the test organisms contaminated other laundry in the machine, as well as the washing machine itself, which led to the contamination of subsequent loads of laundry. 18 using the petrocci and clarke (1969) method, 19 several powder and liquid laundry detergents that are now on the market were tested for activity against s. aureus and k. pneumoniae from wash water and fabric (table 1 ; personal communication, j. kain, procter and gamble, cincinnati, oh, august 2001) sanitizing powder detergents reduced s. aureus and k. pneumoniae in the laundry fabric by >99%. all other laundry detergents were less active. test products were all commercially available detergents with built in oxygen-based bleach systems. all products were purchased at local grocery stores in the cincinnati ohio area during 1998. no additional laundry additives, such as chlorine bleach, were tested either alone or in conjunction with detergents. 2 percent reduction (% reduction) refers to the calculated reduction in bacteria relative to a water + 0.5% polysorbate 80 baseline control. polysorbate 80 was added to the water as a non-toxic surfactant control to improve the relevancy of organism removal characteristics of the control relative to the high surfactancy test treatments. 3 a "sanitizing detergent with oxygen bleach" is one that meets us epa criteria for sanitization claims and a "non-sanitizing detergent with bleach" is a detergent that has a bleaching ingredient that may also have antimicrobial properties but not at the concentration and in the formulation matrix of this detergent and, therefore, does not meet us epa's criteria for sanitization claims. (unpublished data. d. j. kain, principal scientist, the procter and gamble company, cincinnati, oh, 9/01). although there are large numbers of microorganisms present in the home, it does not necessarily follow that this will result in infectious disease transmission. in this section, routes of transmission and evidence of actual transmission in the home are reviewed. bacteria, viruses, and fungi exist throughout our environment and can be transmitted to individuals through a variety of methods. direct contact includes person-to-person spread or contact with blood and other body fluids, such as occurs in fecal-oral spread. endogenous infection occurs when an individual contaminates one region of the body with microbial flora from another area. other modes of transmission include contact with droplets and airborne spread by droplet nuclei. 20 indirect contact is transmission through a contaminated intermediate object. usually, the intermediary is the hands. for example, a parent who changes a diaper of a baby infected with shigella and proceeds to prepare a meal for the family without handwashing could transmit the pathogen to the entire family. another example of indirect transmission is use of a cutting board to prepare raw chicken and then to slice fresh fruits and vegetables. common source transmission is often responsible for e. coli o157:h7 outbreaks caused by consuming undercooked, contaminated meat. although we did not find any data published between 1980-2000 regarding viral contamination in the home, viruses are a major cause of common illnesses and can survive in the home environment. worldwide, respiratory syncytial virus (rsv) is the primary cause of childhood viral respiratory infection. 20 rsv is transmitted via inanimate objects and direct contact with infected persons. 21 the virus is capable of surviving for a number of hours on inanimate objects and surfaces, providing ample opportunities to contaminate the hands of caregivers. contaminated hands can indirectly spread the virus to others in the home, including the caregivers if they touch their eyes or nose without handwashing. while barrier precautions have proven effective in lowering the rates of transmission in a hospital setting, goldmann asserts that it is entirely probable that careful handwashing after contact with infected infants would have been equally effective. 20 perhaps more widespread than rsv among people of all ages is the common cold. children can expect to average 4 to 8, and adults, three to five episodes per year. there are more than 100 serologic types of rhi-novirus, and contracting one type provides no immunity against another. 20 influenza is spread via airborne nuclei droplets, but the most likely route of transmission of rhinovirus is contaminated hands. 22 in the united states, the second most common community infection is gastroenteritis. an important cause of gastroenteritis is rotavirus, which is transmitted by the fecal-oral route and possibly through respiratory spread and contaminated hands and surfaces. rotavirus has been implicated in outbreaks in hospitals, daycare centers, schools, and nursing homes. there is the potential for transmission of rotavirus within the home since it is present on hands, various surfaces and objects. 23 other gastrointestinal pathogens, such as hepatitits a virus, parvovirus, adenovirus, and other enteroviruses follow a similar transmission pattern as rotavirus. 24, 25 hepatitis a, for example, has been implicated in numerous foodborne outbreaks and in various settings such as hospitals, day-care centers, and schools. 26 it is commonly spread via contaminated food and water. in laboratory experiments, bidawid et. al simulated cross contamination of fresh lettuce with hepatitis a from fingers of adult volunteers. 27 the potential for cross-contamination in the kitchen has already been briefly discussed. when not properly cleaned and/or disinfected, countertops, cutting boards, and other kitchen surfaces provide an optimum milieu for survival of microbes. 11 according to the centers for disease control and prevention, between 1983-1992 the primary food preparation practices contributing to foodborne disease were improper storage temperatures and poor personal hygiene of the food handler, 28 and these faulty practices are common in the home. in a study of kitchens in 40 australian homes, daily practices were videotaped over the course of 1 to 2 weeks. the most common unhygienic practices viewed included infrequent and poor handwashing technique, lack of handwashing prior to preparing meals, pets in the kitchen, hand contact with the face, mouth, nose, and hair during food preparation, and an all-purpose towel for hands and dishes. in addition to these lapses in hygiene, deli meat was left outside the refrigerator and uncovered for 2 hours; a dish towel that had fallen to the floor and been stepped on was subsequently used to wipe off the counter; and a dishtowel was also used to cover cooked meat and thereby cross-contaminate it. 29 practices caught on film in american homes did not differ substantially from their australian counterparts. the same towel used to wipe up raw meat juice was then used to dry washed hands. in only 1 in 4 homes were raw meat and seafood properly stored on the bottom shelf of the refrigerator so as to prevent dripping liquids from contaminating other foods; 35% of those preparing meatloaf undercooked it, 42% undercooked the chicken, and 17% did not completely cook the fish. 30 further, the american society for microbiology conducted a telephone survey of more than 7,000 people in the united states. eighty-one percent of respondents claimed to wash their hands prior to handling or eating food. after petting an animal, 48% reported that they do not wash their hands, nor do 33% after coughing or sneezing, or 22% after handling money. 31 in a telephone survey conducted in australian homes, 40% of respondents allowed raw meat to thaw at room temperature, 85% cooled cooked food to room temperature prior to refrigeration, and close to 70% did not know the right temperature for refrigeration of perishables. 32 in addition, 1 in 4 respondents did not recognize handwashing as important in the reduction of cross-contamination and foodborne illness. 32 based on these findings, it is likely that everyday activities in the home will result in microbial spread. a study of the transfer of serratia rubidea and the virus prd-1 from common household articles to the hands confirmed that infection is possible from daily contact with contaminated objects. 33 transmission of the bacterium and the virus were demonstrated on telephone receivers, faucet handles, and sponges, and transfer to hands was highest from hard, nonporous surfaces. 34 if a small amount of stool from a person infected with salmonella were transferred from the individual's contaminated hands to the receiver, the next user could pick up >10 5 colony-forming units (cfu) on his/her fingertips, and could transfer >3.5 × 10 4 cfu, or 35% of the total, to the mouth, a dose sufficient to cause disease. 33 after wringing out a household sponge, 10 5 -10 6 bacteria and viruses were found on the hands of test subjects. 34 in another study, bacteriophage [phis] x174 was applied to door handles and the hands of volunteers. test persons touched the handles and shook hands with the volunteers. the hands of the test persons were then sampled for the virus. both skin surfaces and contaminated door handles were efficient sources for transfer. up to 14 people became contaminated after touching the same door handle, and subsequent transmission was traced to six additional people from these primary contacts. 35 each year 76 million americans develop food poisoning, 29 and about 20% of reported foodborne illnesses occur in the home. 30 ninety percent of salmonella infections are thought to be associated with the home environment. 28 in the uk, cross-contamination has been implicated in about 6% of foodborne outbreaks within the home, while poor hand hygiene is responsible for about 4%. 36 in addition, it has been estimated that cross-contamination in the home contributed to 14% of salmonellosis outbreaks. 36 in a household in which one person has been sick with salmonella, it has been estimated that there is a 60% chance that at least one other member of the household will also be infected. 8 both hands and inanimate surfaces are responsible for the cross-contamination that leads to secondary infections in the home. other bacteria and viruses transmitted via the fecaloral route most likely spread throughout the home in the same manner. in another study, the home environment was implicated in the spread of salmonellosis among children under four years of age. 37 isolates were obtained from children infected with salmonella and samples were taken from multiple locations in the home. pulsed-field gel electrophoresis patterns showed identical serotypes from the index case and the home environment. isolates which exhibited identical serotypes were found in locations such as vacuum cleaner, dirt surrounding front door, and refrigerator shelf as well as in household members and pet animals. children can carry the infections acquired in nursery schools or play groups into the home, where up to 50% of household members may become infected via cross-contamination. 8 in a study of an outbreak of diarrhea caused by e. coli o157 in new jersey, 80% of contaminated hamburgers were consumed in the home. 38 while the home may not have been the primary source of contamination, proper cooking may have prevented the spread of the organism. the use of communal laundry facilities also has been correlated with the transmission of microbes and higher rates of infectious disease symptoms among household members. 39 in this study, a variety of home hygiene practices in 398 households were examined, including personal hygiene, food handling and general cleaning and laundry practices. in a logistic regression analysis of these potential risk factors only communal laundry practices (p = 0.009) and lack of bleach (p = 0.04) were significantly associated with increased risk of infectious illnesses among household members. in households in which one member had a primary infection of campylobacter jejuni, 15% of household contacts were symptomatic during the same time period. while most instances were attributed to a common source, intrafamilial spread of infection was implicated in 6/21 (28.6%) cases. 40 a welsh study concluded that the secondary household transmission rate for sporadic shiga toxin-producing e. coli o157 (stec o157) infection was between 4% and 15%. 41 in another study, colonization of one family member with s. aureus had no bearing on the observed carriage rate of another family member. when both child and guardian were colonized with methicillin resistant s. aureus, however, the same strain was most often seen, indicating that transmission between household members probably occurred. 42 recently, risk models such as the hazard analysis and critical control point (haccp) and quantitative microbial risk assessment (qmra) based on early detection and prevention of future health risks within the home and community have been proposed. 12, 43, 44 cleaning refers to the mechanical removal of dirt and soil from an object or area. disinfection, on the other hand, is the chemical destruction, inactivation, or killing of microbes. detergents and water are the preferred products for cleaning; products containing substances such as alcohol, bleach, quaternary ammonium compounds , and phenolics can be disinfectants depending on the formulation and use of the product. under normal conditions, cleaning is adequate for households, but in some circumstances such as an outbreak or the handling of potentially contaminated food, disinfection may be indicated. in a study designed to test the effectiveness of a variety of household products against several enteric bacterial pathogens, commercial products containing ammonia resulted in a 4-6 log reduction and phenolic and alcohol based products were associated with a reduction of 4 logs. baking soda and vinegar were generally ineffective (<3 log reduction). the commercial disinfectants inactivated both antibiotic-susceptible and resistant bacteria. 46 in another study, only bleach was effective against s. aureus, salmonella typhi, and e. coli. while concentrated ammonia and vinegar were effective against s. typhi and e. coli, none of the other productsborax, ammonia, baking soda, vinegar, or dishwashing detergent-demonstrated antimicrobial activity against s. aureus. 47 four disinfecting agents were evaluated for their ability to prevent the transfer of a human rotavirus from stainless steel disks to the fingers of volunteers: disinfectant spray (0.1% o-phenylphenol and 79% ethanol), domestic bleach (6% sodium hypochlorite diluted to 800ppm of free chlo-rine), quaternary ammonium-based product (7.1% quaternary diluted 1: 128 in tap water), and a phenol-based agent (14.7% phenol diluted 1:256 in tap water). viral reductions on disks treated with the disinfectant spray were >99.9%, 97.9% for bleach, 95% for phenolic, 54.7% for quaternary, and 52.3% with tap water. virus was not detected on the fingers that had contact with disks treated with disinfectant, bleach, and phenolic, but contact with tap water or quaternary-treated disks resulted in transfer of 5.6% and 7.6% of the residual virus, respectively. 23 the same products were tested against rhinovirus. after 1 to 10 minutes of contact with the virus, the alcohol and phenolic-based disinfectant spray reduced virus infectivity by >99.9%. virus was not detected on the fingers of volunteers who had contact with the treated disks. bleach reduced the viral load by 99.7% after 10 minutes of contact, and once again no detectable virus was transferred to fingers. the quaternary-based product inactivated only 14.7% of the virus, and the phenolic only 62.3%. contact with the quaternary-based treated disk resulted in the transfer of 8.4% of the residual infectious virus, while the phenolic-treated disks resulted in the transfer of 3.3%. 48 a particularly impressive study was one in which 8 volunteers licked dried human rotavirus that had not been treated with anything, and all became infected. an alcohol and phenolic-based disinfectant spray applied to the virus interrupted the transfer of the virus; none of the 14 volunteers who consumed the spray-treated virus became infected, whereas 13 of 14 who ingested the unsprayed virus became infected. 49 disinfection in the home is dependent not just on the product, but also on how it is applied. during a 30 week study in arizona, 15 homes were supplied with a variety of disinfectant products, but no specific use instructions were given. subsequently, most of the disinfectants were removed, specific ones were introduced, and a cleaning schedule was established. while the greatest reductions in coliforms occurred after initial introduction of products, introduction of the cleaning schedule led to even greater microbial reductions in the 14 kitchen and bathroom sites studied. 50 these results are consistent with the findings of an earlier study demonstrating that disinfectants used in a timely manner after contamination by food or hands reduced further contamination. 51 kitchen. studies in the uk have demonstrated that cleaning with detergent and hot water alone did not significantly reduce campylobacter and salmonella from contaminated kitchen areas. however, when cleaning was supplemented with hypochlorite there was a significant reduction in the number of bacteria from contaminated sites. in addition, detergent and water washing of dishware was only effective if followed by a rinsing process. 15 in fact, soap and water can actually increase contamination in the home when not followed by rinsing. 52 this suggests that when rinsing is impractical or not feasible, cleaning alone may be insufficient and disinfection may be indicated. in the uk, antibacterial dishwashing liquid has been shown to effectively reduce numbers of recoverable microorganisms on dishes, but not on used sponges. 53, 54 zhao et al., inoculated raw chicken with an indicator organism, enterobacter aerogenes. the same cutting board was then used to prepare chicken and chop raw vegetables, and 10 3 -10 4 cfu of bacteria was transferred to the vegetables. treating the cutting board with a kitchen disinfectant after preparing the chicken reduced the transmission of bacteria to almost undetectable levels. 55 disinfection in conjunction with paper towel wiping are reported to be the best procedure for cleaning surfaces contaminated with raw meat. 56 laundry. standard laundry practices have changed over the years, and may also contribute to the transmission of microbes in the home. people less frequently hang their clothing and linens outside where the sunlight can aid in denaturing many of the microbes, and ironing, which allows steam to penetrate and reduce the microbial load in the fabric, has become less common. finally, lower water temperatures with smaller volumes of water are used for washing. 7, 8 jaska and fredell (1980) found no significant differences between a phosphate or a phosphate substitute detergent on s. aureus survival on laundered fabrics and reported that the most important predictor of bacterial reduction in the laundry was the water temperature. 57 the temperature of the water used for washing does not seem to affect the bacterial counts in the fabric in the presence of sodium hypochlorite bleach; that is, both hot and cold water in combination with the bleach cycle are equally successful in reducing bacteria counts, 58, 59 but in the absence of bleach, warmer washing temperatures (55°c) are more effective 60 and colder temperatures may increase the cross-contamination rate of articles washed together. 61 hence, attaining maximal bacterial reductions in both the machine and fabrics depends both on bleach and the water temperature. [58] [59] [60] 62 although relying on wash water temperatures to achieve meaningful bacterial reductions is impractical in north america since water heaters are typically set at 120&scedil;c, sodium hypochlorite bleaches for compatible fabrics and newer laundry products containing oxygenated bleach which can be used on colored fabrics will achieve such reductions. bathroom. in the bathroom, splashing and aerosol droplets are responsible for transfer of some contamination from toilets and sinks to surrounding areas in the bathroom, but a chlorine block effectively reduced the level of contamination in the toilet. surrounding areas, however, were not affected by the chlorine, suggesting that direct shedding or hand contact was responsible for contamination of the toilet seat, handle, and floor. 63 a summary of studies of the activity of various household cleaning and disinfecting products are summarized in table 2 . this body of research suggests that a product containing an ingredient with disinfectant properties, such as alcohol, bleach or a phenolic, may be indicated for home use if a household member is ill with an infectious disease or in other high-risk situations. reviews of studies linking hand hygiene and reduced risk of infection have been recently published. 64, 65 the major benefits of hand hygiene for the general public is for prevention of infectious agents found transiently on hands and spread by the fecal-oral route and from the respiratory tract. 22, 66 in general, non-antimicrobial soaps are adequate to reduce such transient flora, but in 11 experimental studies reviewed by keswick et al., use of antimicrobial soaps was associated with significant reductions in rates of superficial cutaneous infections. another 15 experimental studies reviewed demonstrated a reduction in bacteria on the skin with use of antimicrobial soaps, but none of these studies assessed rates of infection as an outcome. 67 increasing public awareness stimulated by several highly publicized and serious outbreaks from commercially prepared foods has raised questions about food safety and the appropriate hygienic practices of food handlers. this concern extends to others such as child care providers, educators, sales personnel, and homemakers who have physical contact with members of the public. despite public awareness, however, hand hygiene as practiced by the general public does not meet recommended standards-members of the public wash too infrequently and for very short periods of time. 68 a single recommendation for hand hygiene practices in the home is probably inappropriate. hand hygiene is clearly indicated before and after behaviors that are associated with microbial contamination, especially including toileting, diapering, and preparing or eating food. options for hand hygiene include plain soap and water or use of an antiseptic. generally, plain soaps do not kill microorganisms but rather wash them off with friction and rubbing, removing the majority of microorganisms. for general home use when household members are healthy, plain soaps are often considered to be sufficient. 69 many antiseptic products are available over-the-counter, and are often labeled "antibacterial." these are detergent-based, requiring a traditional handwash with water. non detergent-based antiseptic products are waterless hand rinses, gels or wipes, which usually contain alcohol. they are also readily available to the public over the counter, can be used when no running water or towels are available, and, similar to antiseptic hand washes, have rapid and broad spectrum activity and excellent microbicidal characteristics. such products, however, are not a substitute for handwashing when the hands are physically soiled, since they are not good cleaning agents. 70, 71 alcohol-based products may be most beneficial in circumstances where immediate antimicrobial activity is needed after encounters that result in a high probability of contamination and where soap, running water, and/or clean towels are not readily available. because the skin is the most important and first-line barrier to infections, it is vital that the skin of the hands be kept as intact and healthy as possible. the skin's water content, humidity, ph, intracellular lipids, and rates of shedding each play a role in retaining the protective barrier properties of the skin, and these factors are affected by hand hygiene. for example, changes in skin ph associated with handwashing may pose a concern since some of the antibacterial characteristics of the skin are associated with its normally acidic ph. some soaps can result in longstanding changes in skin ph, reduction in fatty acids, and, subsequently, changes in the microbial flora. 72, 73 hence, some hand hygiene practices such as frequent washing with detergents can result in skin dryness, irritation, cracking and other problems. moisturizers prevent dehydration, damage to barrier properties, desquamation, and loss of skin lipids, restore the water-holding capacity of the keratin layer, and increase the width of corneocytes. 74, 75 they may even help to prevent the transmission of microorganisms from the hands. 76, 77 for those individuals with dry or damaged skin on the hands, it is important to use emollients or lotions to replace lost fatty acids and keep the hands hydrated. several recent reviews regarding hand and skin hygiene have been published. for additional information, the reader is referred to references. 78, 79 since hands serve as one primary mode of fecal-oral and respiratory transmission, specific indications for use of antiseptic hand products in the general public occur when: • there is close physical contact with individuals at high risk for infection (e.g., neonates, the very old, or immunosuppressed); • an individual is infected with an organism and may potentially transmit the agent by the direct contact route (diarrhea, upper respiratory infection, skin infections) or in close physical contact (touching) with infected individuals; • an individual is working in a setting in which infectious disease transmission is likely (food preparation, crowded living quarters such as chronic care residences, prisons, child care centers, and preschools). the purpose of this paper was to examine research literature from the last twenty years to determine the potential role of the home environment in the transmission of infectious disease. kitchens, bathrooms, and washing machines harbor a wide range of potential pathogens, and routine practices within these areas of the home can either prevent or facilitate cross-contamination within the home. the potential for transmission of microbes in the home exists, and several studies have demonstrated that transmission does occur. hence, even though infectious risks in the home may be less than in healthcare settings such as the hospital or nursing home, they are certainly present. commercial disinfectants and cleaning products vary in their ability to remove microbes from household surfaces, but successful strategies for reducing microbial risks in the home include both adequate cleaning practices and appropriate use of cleaning and disinfection products. care should be taken to use these products according to instructions in order to maximize removal. in general, these products clearly have a role as part of an overall hygiene strategy within the home. lastly, the behavioral aspects of infection prevention in the home such as food handling practices, warrant increased public attention and education. the gospel of germs: men, women and the microbe in american life an investigation of microbial contamination in the home the survival and transfer of microbial contamination via cloths, hands and utensils a study of the microbial content of the domestic kitchen bacteriological survey of used cellulose sponges and cotton dishcloths from domestic kitchens. dairy campylobacter spp. in the kitchen: spread and persistence impact of changing societal trends on the spread of infections in american and canadian homes hygiene issues in the home foodborne disease surveillance in england and wales; 1989-1991 hygiene in the domestic setting: the international situation cross-contamination during the preparation of frozen chickens in the kitchen a risk assessment approach to use of disinfectants in the community evaluation of antibiotic resistant bacteria in home kitchens (abstract) can consumers prevent the spread of foodborne pathogens in domestic kitchens? proceedings of euroconference the effectiveness of hygiene procedures for prevention of cross-contamination from chicken carcases in the domestic kitchen survival of salmonella in bathrooms and toilets in domestic homes following salmonellosis investigations of the effectiveness of detergent washing, drying and chemical disinfection on contamination of cleaning cloths cross contamination and survival of enteric pathogens in laundry proposed test method for antimicrobial laundry additives transmission of viral respiratory infections in the home modes of transmission of respiratory syncytial virus hand-to-hand transmission of rhinovirus colds interruption of rotavirus spread through chemical disinfection transmission of rotavirus and other enteric pathogens in the home foodborne viral illness-status in australia spread and prevention of some common viral infections in community facilities and domestic homes contamination of foods by food handlers: experiments on hepatitis a virus transfer to food and its interruption impact of changing consumer lifestyles on the emergence/reemergence of foodborne pathogens a video study of australian domestic food-handling practices food safety mistakes caught on tape: food and drug administration america's dirty little secret-our hands a national australian food safety telephone survey studies show that some diseases could easily be transmitted from common articles in the home and community comparative transfer efficiency of bacteria and viruses from common fomites to hands and from the hand to the lip transmission of viruses via contact in ahousehold setting: experiments using bacteriophage straight phix174 as a model virus cross-contamination and infection in the domestic environment and the role of chemical disinfectants the home environment and salmonellosis in children risk factors for sporadic infection with escherichia coli o157:h7 home hygiene practices and infectious disease symptoms among household members epidemiological investigations on campylobacter jejuni in households with a primary infection sporadic stec o157 infection: secondary household transmission in wales familial carriage and transmission of s. aureus colonizing children and their guardians application of haccp to identify hygiene risks in the home quantitative microbial risk assessment consumer and market use of antibacterials at home antimicrobial activity of home disinfectants and natural products against potential human pathogens efficacy of sodium hypochlorite bleach and "alternative" products in preventing transfer of bacteria to and from inanimate surfaces chemical disinfection to interrupt transfer of rhinovirus type 14 from environmental surfaces to hands prevention of surface-to-human transmission of rotaviruses by treatment with disinfectant spray reduction of faecal coliform, coliform and heterotrophic plate count bacteria in the household kitchen and bathroom by disinfection with hypochlorite cleaners characterization and quantification of bacterial pathogens and indicator organisms in household kitchens with and without the use of a disinfectant cleaner evaluation of disinfectants in the domestic environment under 'in use' conditions a joint conference by the international scientific forum on home hygiene and the public health laboratory service a joint conference by the international scientific forum on home hygiene and the public health laboratory service development of a model for evaluation of microbial cross-contamination in the kitchen a joint conference by the international scientific forum on home hygiene and the public health laboratory service impact of detergent systems on bacterial survival on laundered fabrics effect of water temperature on bacterial killing in laundry bacteriological quality of fabrics washed at lower-than-standard temperatures in a hospitallaundry facility factors affecting the bacteriological contamination of commercial washing machines the disinfectant action of low-temperature laundering aseptics and aesthetics of chlorine bleach: can its use in laundering be safely abandoned? a bacteriological investigation of the effectiveness of cleaning and disinfection procedures for toilet hygiene a causal link between handwashing and risk of infection? examination of the evidence hand washing: a ritual revisited handwashing education can decrease illness absenteeism antimicrobial soaps: their role in personal hygiene in aly r, beutner kr, maibach h. cutaneous infection and therapy asm inagurates nationwide public education effort apic guideline for handwashing and hand antisepsis in health care settings disinfection, sterilization and preservation, 5 ed. 2001. philadelphia: lippincott, williams and wilkins assessment of two hand hygiene regimens for intensive care unit personnel influence of repeated washings with soap and synthetic detergents on ph and resident flora of the skin of forehead and forearm. results of a cross-over trial in health probationers qualitative and quantitative investigations on the resident bacterial skin flora in healthy persons and in the non-affected skin of patients with seborrheic eczema irritant dermatitis. new clinical and experimental aspects efficacy of protective creams and/or gels staphylococcal infection in a maternal hospital: epidemiology and control the persistence and penetration of antiseptic activity skin hygiene and infection prevention: more of the same or different approaches? hygiene of the skin: when is clean too clean? stability and bactericidal activity of chlorine solutions compatitive testing of disinfectant and antiseptic products using proposed european suspension testing methods inactivation of particle-associated coliforms by chlorine and monochloramine laboratory studies of disinfectants against legionella pneumophila chemical disinfection of non-porous inanimate surfaces experimentally contaminated with four human pathogenic viruses mechanism of chlorine inactivation of dna-containing parvovirus h-1 the inactivation of foot-and mouth disease virus by chemicals and disinfectants hantavirus infection-southwestern united states: interim recommendations for risk reduction chemical disinfection of human rotavirus-contaminated inanimate surfaces uses of inorganic hypochlorite (bleach) in health-care facility the effect of blood on the antiviral activity of sodium hypochlorite, a phenolic, and a quaternary ammonium compound comparative studies on the detoxification of aflatoxins by sodium hypochlorite and commercial bleaches feasibility of a combined carrier test for disinfectants: studies with a mixture of five types of microorganisms the effect of disinfectants on a geosmin-producing strain of streptomyces griseus key: cord-300965-ivczo1a7 authors: brown, m. m. title: don’t be the “fifth guy”: risk, responsibility, and the rhetoric of handwashing campaigns date: 2017-08-29 journal: j med humanit doi: 10.1007/s10912-017-9470-4 sha: doc_id: 300965 cord_uid: ivczo1a7 in recent years, outbreaks such as h1n1 have prompted heightened efforts to manage the risk of infection. these efforts often involve the endorsement of personal responsibility for infection risk, thus reinforcing an individualistic model of public health. some scholars—for example, peterson and lupton (1996)—term this model the “new public health.” in this essay, i describe how the focus on personal responsibility for infection risk shapes the promotion of hand hygiene and other forms of illness etiquette. my analysis underscores the use of constitutive and stigmatizing rhetoric to depict individual bodies, rather than environments, as prime sources of infection. common among workplaces, this rhetoric provides the impetus for encouraging individual behavior change as a hedge against infection risk. i argue, though, that the mandating of personal responsibility for infection risk galvanizes a culture of stigma and blame that may work against the aims of public health. signal that a pandemic [was] imminent.^so, the 100th day's headlining issues of economic recovery, job creation, and the wars in afghanistan and iraq came second to obama's discussion of h1n1, the pandemic strain of the influenza virus. obama opened his remarks, for example, by outlining the steps that his government had taken to protect the american people from the devastations of outbreak. 1 measures adopted to fend off h1n1 included carefully monitoring the spread of the novel strain and stockpiling medical supplies and drug treatments. on the advice of public health experts, the u.s. government had also considered closing public schools in response to suspected or confirmed cases. obama also urged parents and employers to develop contingency plans if the spread of h1n1 led to massive workplace and school closures. band finally,^obama continued, bi've asked every american to take the same steps you would to prevent any other flu: keep your hands washed, cover your mouth when you cough, stay home from work if you're sick, and keep your children home from school if they're sick.^adopting these various forms of illness etiquette, obama implied, demonstrated one's assumption of personal responsibility in response to the heightened risk of infection. this essay contributes to the ongoing examination among rhetoricians of health and medicine of constructions of responsibility and risk. 2 specifically, i explore the centrality of a rhetoric of personal responsibility to discursive efforts to manage infection risk. health humanities scholars and rhetoricians of health and medicine share a common concern for the ethical issues that arise from risk-management exercises undertaken in the name of public health. 3 practitioners, too, have a stake in more detailed understandings of the impact of risk discourse on the formation of health subjectivity. however, as keränen (2014b) explains in the health humanities reader, ba rhetorical perspective focuses on how specific symbolic patterns structure meaning and action^in health and public-health contexts (37). writing for this journal, for example, ding (2014b) stresses the economic and sociocultural effects of media portrayals of bat risk^populations during severe acute respiratory syndrome (sars). 4 my essay contributes to this scholarship with an account of how messaging that seeks to engage publics in outbreak management shapes their perceptions of responsibility and risk, not to mention of public health. as i argue, handwashing campaigns reinforce an individualistic model of public health, one premised to a significant extent on the necessity of behavior change rather than structural intervention. some scholars-for example, peterson and lupton (1996) -term this model the bnew public health.p ersonal responsibility serves essential functions in response to the threat of infection. however, the mandating of personal responsibility for infection risk has the potential to galvanize a culture of stigma and blame. too narrow a focus on personal responsibility may also diminish perceptions of the effectiveness of improved structural supports for those infected. during h1n1, for example, universal paid sick leave became a topic of debate, serving as a reminder of the need for an environment supportive of individual efforts to manage infection risk. in this essay, i characterize hand hygiene promotion as both a bconstitutive rhetoric^and a bstigmatizing rhetoric.^whereas a constitutive rhetoric encourages action through the cultivation of subjectivity, a stigmatizing rhetoric uses stigma to shape perceptions-also typically for the sake of influencing behavior change. i also describe how scholars of rhetoric of health and medicine have employed these two theories and explain their value to health humanities practitioners and scholars. i then examine the uses of constitutive and stigmatizing rhetoric in a u.s. state-level campaign to enforce bhygienic norms^(including, importantly, hand hygiene) within the workplace. my analysis reveals the centrality of stigma and blame to these efforts to encourage the assumption of personal responsibility. research on hand hygiene promotion finds that handwashing campaigns have a proven impact on health behaviors and thus, by extension, on health outcomes. so, why might those of us who have been exposed to these campaigns concern ourselves, perhaps unnecessarily, with their implications for our views of risk, responsibility, and public health? the reason i turn to in my conclusion is that the rhetorical means used to encourage personal responsibility may obscure perceptions of more effective approaches to the management of infection risk. handwashing campaigns also create opportunities to profit from and even exploit the stigma and blame that these texts associate with failures of personal responsibility. my goal, then, is mainly to explore the limits of personal responsibility-not just as an approach to infection risk, but more generally as a cornerstone of twenty-first-century public health. personal responsibility may be a cornerstone of public health, but hand hygiene promotion is an especially persuasive vehicle for popularizing an individualistic conception of infection risk. by bhand hygiene promotion,^i mean efforts to instruct a broad, lay public in hygiene practices typically used to reduce the transmission of disease-causing pathogens in hospitals and clinics. in this essay, i use bhandwashing campaigns^and bhand hygiene promotionî nterchangeably to describe the discursive encouragement of this habit. i also focus mainly on hand hygiene promotion within north america, where amid h1n1 handwashing campaigns and hand hygiene products alike became endemic. commenting on this trend in a new yorker essay, owen (2013) links the phenomenal success of gojo industry's blockbuster hand sanitizer, purell, to anxieties about infection risk. 5 today, hand sanitizer is a product category in its own right, and its popularity is sometimes regarded critically as both indicative of and responsible for a distinct shift in cultural perceptions of infection risk. 6 in my view, however, purell's unprecedented sales figures 7 are inextricably tied both to the increased promotion of hand hygiene in recent decades and to the ongoing individualization of public health. a drawback of undertaking a critique of hand hygiene is appearing to be against hand washing and other expressions of illness etiquette. hand hygiene is a vital form of infection control, and as such, it is also an ethical practice, particularly during an outbreak. rather than argue against hand hygiene, i explore the limits of hand hygiene promotion, as well as its implication in the deepening entrenchment of the new public health. in this respect, my essay draws its inspiration from the work of metzl, who in the introduction to his co-edited multidisciplinary anthology against health, writes that health is a bdesired state, but it is also a prescribed state and an ideological position^(2010, 2). the same argument applies to public health, which broadly speaking entails the strategic, organized effort to bpersuade a defined public to engage in behaviors that that will improve health or refrain from behaviors that are unhealthy^ (springston 2013, 713) . hand hygiene promotion especially invites further scrutiny because its prescriptive, ideological qualities far too often go unnoticed. hence, i focus my attention here on describing how handwashing campaigns benefit the overarching emphasis on personal responsibility for infection risk. an important precedent for my critique is plyushteva's analysis (2009) . 8 plyushteva examines the promotion of hand hygiene in developing countries, which she sees as having applications beyond the potential reduction high mortality rates due to infection. in fact, just as in north america, hand hygiene promotion directed at publics in developing countries aims to empower these publics to protect themselves from the risk of infection. since 2008, for example, global handwashing day has been celebrated annually on october 5. an initiative of the global public-private partnership for handwashing with soap (global ppphw), global handwashing day is bdedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases and save lives.^the celebration also presents ban opportunity to . . . encourage people to wash their hands^-or, as explained in a global handwashing day press release, to inspire personal responsibility. 9 in developing countries, hand hygiene promotion's emphasis on personal responsibility may affect perceptions of entitlement to care. indeed, global handwashing day presents infection risk as managed not through the provision of clean water or proper sanitation but rather through the adoption of appropriate personal measures. underwritten by an array of corporate sponsors, global handwashing day also teaches people living in developing countries to become faithful consumers of hand sanitizer and soap, just like their counterparts in developed countries. current sponsors include colgate-palmolive, procter and gamble, and unilever, all companies with a massive stake in the global marketplace for personal hygiene products. (corporate sponsors may also have influenced the naming of the global public-private partnership for handwashing with soap. even the scholarship produced by the researchers working for this partnership typically includes this addendum.) global handwashing day's instruction in the consumption of personal hygiene products, too, has ties to the overarching emphasis on personal responsibility that defines the new public health. hand hygiene is promoted as a bdo-it-yourself vaccine,^a hedge against infection risk (apparently) even in settings in which infection risk often stems from poor sanitation and lack of access to clean water. 10 of course, regardless of context, hygiene habits have a proven impact on the transmission of disease-causing pathogens. hand hygiene limits the spread of diarrheal and respiratory diseases, which are among the leading causes of child mortality in developing countries. 11 children thus comprise a key audience for global handwashing day, which seeks to transform them into bchange agents^who have the capacity to bpositively influence other people's health behaviours^ (global ppphw 2015) . however, as plyushteva observes, global handwashing day's celebration of the life-saving power of individual behavior change potentially obscures understandings of the structural factors that shape infection risk. in developing countries, for example, the spread of disease stems from lack of access to clean water and adequate waste disposal and not mainly from a lack of agency per se. in tying infection risk to the bsuboptimal behaviour of the poor^(2009, 428), handwashing campaigns in developing countries exacerbate longstanding power imbalances, potentially reinforcing rather than removing obstacles to meaningful change. at the same time, hand hygiene promotion in this context expands the global marketplace for personal hygiene products, forging new opportunities to profit from the intractable problem of infectious disease. plyushteva's analysis is helpful to my own because she draws attention to hand hygiene promotion's insidiousness and stresses its consequent potential to serve a range of motivations. some of these motivations in fact conflict with the aims of public health, particularly in developing countries. bat first glance,^she argues, bthe cause of handwashing appears as apolitical and uncontroversial as can be^(428). so unproblematic is hand hygiene, and so important are efforts to promote it, that the very few criticisms of global handwashing day have largely been ignored. 12 for her part, plyushteva takes issue with the celebration's stigmatizing of people in developing countries bas traditional or backward, or, in a teleological view of development, pre-modern^(424). hand hygiene's buncontroversial façade^(420) also obscures the reality that individual behavior change is only ever a bpartial solution^(429) to the spread of disease. efforts to quell the spread of disease through behavior change also depend on the implementation of structural interventions-changes that create an environment supportive of personal responsibility. (i return to these limitations of personal responsibility in my conclusion.) i quote plyushteva at length because hers is the most recent scholarly critique of contemporary, globalized efforts to promote hand hygiene promotion. 13 her writing establishes a precedent for my critique of north american handwashing campaigns, which may also do more, politically and economically, than simply diminish the risk of infection. circulated within workplaces, schools, transit hubs, airports, community centers, groceries stores, and shopping malls, handwashing campaigns portray individual bodies, and body parts, as dangerous vectors of infectious disease. what makes these bodies, and parts, dangerous is both that they spread infection and because the disease-causing pathogens they transmit remain invisible to the individuals who transmit them. as a caption for a handwashing poster created by yale university's emergency management department in 2009, in response to h1n1, puts it, byou've got a mystery on your hands.t aking the form of pamphlets, posters, transit ads, web infographics, social media campaigns, and public service announcements, these texts caution that the power to prevent (and spread) infection is in our hands. sales figures for hand sanitizer alone illustrate the impressive new revenue streams generated by this individualization of infection risk. even in developed countries, where the assumption of personal responsibility is less likely to be impeded by structural issues, hand hygiene promotion may nevertheless skew perceptions of contextual or social determinants of infection risk. most notable among these factors may be the availability of sick leave or the effects on susceptibility of feelings of anxiety or stress. hand hygiene promotion invariably serves two distinct purposes. at one level, as exercises in risk communication, handwashing campaigns satisfy the obligation to inform publics about how to diminish the risk of infection. the most effective display of hand hygiene promotion's function as a form of risk communication may be the infographics, often posted in public restrooms, that illustrate the handwashing procedures practiced by healthcare professionals. these infographics teach handwashing methods, but they also serve to emphasize the need for personal responsibility in public settings. indeed, at another level, many handwashing campaigns often serve more expressly rhetorical goals. the most effective-and the most problematic-is the use of hand hygiene promotion to exacerbate a whole host of negative emotions, from anxiety, distrust, fear, and doubt to nausea and disgust. some of the most prominent voices behind the turn to hand hygiene promotion, particularly in developed countries, have emphatically defended the rhetorical utility of public health campaigns that inspire feelings of disgust. 14 in my close reading, i focus more on this latter function of handwashing campaign-that is, its use to foster emotional states that predispose audiences to the adoption of personal responsibility. hand hygiene promotion's alignment with an axiom of neoliberalism-the emphasis on personal responsibility-is also worthy of further examination. harvey describes the typical characteristics of the neoliberal state and explains, the bsocial safety net is reduced to a bare minimum in favour of a system that emphasizes personal responsibility. personal failure is generally attributed to personal failings, and the victim is all too often blamed^ (2005, 76) . harvey's account stresses the economic advantages of the neoliberal emphasis on personal responsibility. indeed, a neoliberal approach to infection risk has both shifted attention away from costlier programs of outbreak management and accorded private stakeholders unparalleled economic advantages. arguably, the main benefactors of personal responsibility for infection risk are the corporations that develop and distribute products in support of illness etiquette. yet the recent popularity of hand sanitizer does more than reflect the successful marketing of hand hygiene as an antidote to both uncertainty and infection. rather, this shift in consumptive patterns also illustrates the tremendous impact of handwashing campaigns on a risk-oriented subjectivity. alongside promoting a habit that may reduce the transmission of disease, handwashing texts heighten awareness of those who fail in their duty to limit the spread of infection. noncompliance with the dictates of hand hygiene promotion becomes grounds not merely for blame but also for suspicion about a person's moral worth. contemporary handwashing campaigns thus form a constitutive rhetoric, a mode of rhetorical appeal that calls into existence a shared collective identity. within hand hygiene promotion, the collectivity identity called into existence is that of the health citizen for whom participation in containing an outbreak is a personal responsibility. 15 white describes bconstitutive rhetoric^(a term that he coined) as bthe central art by which culture and community are established, maintained, and transformed^ (1985, 28) . scholars use constitutive rhetoric to explain the discursive formation of new social and political subjectivities. in demonstrating how some rhetorics discursively constitute the very subjects they address, many critics follow charland's model of constitutive rhetoric (1987) . 16 into white's theory, charland incorporates burke's notion of identification (1969) and althusser's idea of interpellation, or bhailing^(1971). as charland observes, constitutive appeals produce and reinforce new subject positions (1987) . by responding to these appeals, individuals affirm their membership in the community. constitutive rhetoric has been a useful analysis for health humanities scholars and practitioners. 17 anthropologist joseph dumit, for example, argues that strategies employed in pharmaceutical discourse create new opportunities for marketing drugs by constituting the individual as a body at risk of disease (2012). the strategic constitution of bodily risk, dumit argues, is essential to keeping americans on bdrugs for life.^scholars of rhetoric of health and medicine have employed constitutive rhetoric to critique the interpellation of headache patients as well as of patients as narrative subjects (segal 2005 ). derkatch has used constitutive rhetoric to account for the maintenance of professional boundaries in medicine (2012), whereas kopelson has shown in response to breast cancer, public health organizations mobilize citizens as consumer-activists (2013). majdik and platt describe the health subject constituted by the marketing campaign for a genetic testing product (2012). interpellation has also been a productive means for scholars to describe how public health officials shape perceptions of risk and responsibility in response to outbreak (briggs 2004; davis, stephenson, and flowers 2011) . hand hygiene promotion presents an opportunity to examine the constitutive functions of efforts to foster personal responsibility for infection risk. handwashing campaigns transform perceptions of responsibility for disease outbreaks. they do so by situating the risk of infection in individual bodies. the adoption of illness etiquette in response to hand hygiene promotion thus signals at least a partial acceptance of the new public health. 18 because it singles out the individual bodies-and individual body partsthat spread infection, hand hygiene promotion might be understood as both a constitutive rhetoric and a bstigmatizing rhetoric.^proposed by metzl in against health (2010) and premised on the writings of goffman ([1963] 1986), a stigmatizing rhetoric derives its conception of the bhealthy^from portrayals of the bunhealthy.^in other words, notions of poor health shore up understandings of good health. as metzl asserts, within a stigmatizing rhetoric, the baffirmation of one's own health depends on the constant recognition, and indeed the creation, of the spoiled health of others^ (2010, 5) . taking up metzl's refrain, some of the contributors to the multidisciplinary anthology, against health, critique the centrality of stigmatizing rhetoric to a neoliberal model of public health. lebesco, for example, argues that u.s. anti-obesity campaigns reinforce the valuing of bgood citizens [who] take care of their own health^ (2010, 78) at the expense of those classified as overweight or obese. handwashing campaigns potentially display such a stigmatizing rhetoric whenever their promotion of hand hygiene casts it as a prosocial behavior rather than as merely a method of infection control. according to these stigmatizing texts, the failure to observe hand hygiene has profound consequences in addition to the potential for infection. created by the florida department of health in response to h1n1, the bfifth guy^campaign illustrates the use of a constitutive, stigmatizing rhetoric to endorse the assumption of personal responsibility for infection risk. i chose this campaign both because of its focus on the workplace and because its messages about risk and responsibility later saw replication in other states (for example, by the michigan department of health). 19 the fifth guy campaign includes an interactive website that hosts a series of public service announcements (psas). together, these psas underscore the need for personal responsibility by dramatizing the tensions that arise when someone in the workplace ignores his duty to limit the spread of infection. underlying the fifth guy, as i argue, is the message that infection risk is exacerbated mainly by the failure to assume personal responsibility. my close reading of the fifth guy also reveals an emphasis on feelings of anxiety, fear, and even self-doubt. as a stigmatizing rhetoric, the fifth guy foregrounds these negative emotions to shore up the value of personal responsibility-in particular, its role in the maintenance of good health. the florida department of health's campaign employs the notion of the bfifth guy^to single out the person who ignores rather than assumes personal responsibility. (my references to the bfifth guy^describe the campaign, whereas discussions of the bfifth guy^refer to its main character.) the campaign has a basis in a study conducted by the american society for microbiology (asm), which found that four out of five people do wash their hands after using the restroom. in this campaign, the fifth guy is not only male but also young, able-bodied, and white. the fifth guy seeks to billustrate a simple point-most people respect certain hygienic norms.^those who do not observe these norms become bthat one person everyone whispers about.^within the campaign's configuration of personal responsibility, displays of illness etiquette are represented as much measures of moral worth as they are forms of infection control. the bfifth guy,^further, is portrayed as at risk of both sickness and social quarantine-exclusion from the group because he poses a threat to public health. to stress the value of personal responsibility, video public service announcements (psas) both televised and posted online exaggerate as deviant the fifth guy's violation ignorance of a workplace's bhygienic norms.^played by comedic actor ben spring, the fifth guy is, not surprisingly, central to the campaign's narrative of personal responsibility. two of the three psas showcase ben's tendency to come to work sick, for him, a point of pride, and for his coworkers, a source of disdain. ben also coughs and sneezes without covering his mouth and nose with his elbow. the videos bcougher^and bsick at home^dedicate considerable footage to shots of ben coughing into his hands, onto food in the lunchroom, during meetings, and in the faces of his fellow coworkers. ben is quite clearly ignorant of his body as potentially-and, in most instances, quite literally-a source of infection risk to the people around him. however, the fifth guy is used to emphasize the necessity of his coworker's efforts to compensate for his ignorance. bhow would i describe ben to you? the next black plague,b en's manager tells the camera in one psa: bthey're gonna say, 'how did it happen, was it rats?' no, it was ben over at amalgamated, responsible for the death of europe.^ben's violations of the dictates of illness etiquette make him an object of disgust within his workplace. more importantly, when illness arises within a workplace, his coworkers come to regard ben's body as its likeliest source. in the fifth guy, attention is paid to ben's body not as a site of sickness-or, put differently, a site of suffering-but as a site of infection risk. this situating of infection risk in individual bodies teaches the importance of avoidance of certain others as potentially (or, in ben's case, it seems, inherently) vectors of infectious disease. ben's coworkers leave the lunchroom when he enters, refuse to shake his hand or give him high fives, and send emails and issue prank calls urging him to go home. in other words, ben is to be avoided because he embodies the risk of infection in public. so, in avoiding ben, his coworkers assume personal responsibility for infection risk. ben's failures in this respect in turn imply that those who succumb to infection have only themselves to blame, perhaps because they, too, ignored the dictates of illness etiquette. avoidance and exclusion, however, are not the only strategies endorsed as both infectioncontrol measures and displays of personal responsibility. in the fifth guy, hand hygiene represents a hedge against infection risk and its absence a violation of the dictum of personal responsibility. bjust another day in the office^illustrates this dual function. in this psa ben's poor hand hygiene habits graphically come to life in the form of a urinal he carries around the office after leaving the restroom. in one scene, ben proudly places his urinal on a coworker's desk while asking for some paperwork. in other scenes, he dances along the office's corridors, embracing his urinal in a mock tango. depicting poor hand hygiene as a urinal makes some sense from the perspective of theories of fomite transmission of infection. these theories explain that, unless properly sanitized, inanimate materials or objects can become contaminated with infectious agents such as influenza virus. similarly, poor hand hygiene-or a lack of hand hygiene-increases the likelihood of the transmission pathogens, both from contaminated surfaces to individuals and between individuals as well. 20 yet, the goal of ben's urinal appears not to be to instruct the workers of florida in the problem of fomite transmission. instead, by emphasizing ignorance of illness etiquette as akin to intentionality, ben's out-ofplace urinal serves as an object lesson in hand hygiene as an expression of personal responsibility. ben is stigmatized-literally marked-to distinguish him from those who observe their obligation to illness etiquette. certainly, the fifth guy teaches hand hygiene as a display of personal responsibility. yet the campaign also reveals another expectation of the new public health, and that is the enforcement of individual behavior change among the non-compliant. frequently lacking the ability to confront him directly, ben's coworkers take advantage of the opportunity to make their concerns known to the camera. byes, i'd say he's a walking pandemic,^the receptionist comments just seconds after ben has left the restroom with his urinal-germs in tow. bquite frankly,^says the coworker whose desk has been sullied by ben's metaphorical urinal hands, bhe scares me.^acknowledging that it can be difficult to reproach our colleagues, bjust another day^ends with the words of a voiceover narrator: bfour out of five people wash their hands in the restroom. could someone talk to the fifth guy?^strategies for doing so appear on the page of the bfifth guy^website on which bjust another day^is posted. tips include emailing your coworker one of the campaign videos with the comment, bhey, sure glad you're nothing like this^or giving him or her ba new nickname like 'big loogie' or 'thunder cough'.^as these rather passive-aggressive strategies suggest, the assumption of personal responsibility for infection risk also involves participation in its enforcement. nevertheless, in using stigma to underscore personal responsibility, the fifth guy potentially both validates anxieties about infection risk and reassures that risk can always be managed. those who regularly encounter infection in the workplace or witness handhygiene violations in public restrooms may feel vindicated by the campaign's mockery of ben, the boffice superspreader.^after all, as the campaign implies, only careless people spread disease. with care, infection can invariably be avoided. the fifth guy's attributions of intentionality may be the campaign's most problematic feature and not simply because such attributions may be likely to exacerbate interpersonal conflicts within public settings. the use of a constitutive, stigmatizing rhetoric has consequences for shared perceptions of infection risk. it is to these perceptions that i now turn my attention. three configurations of infection risk emerge from the fifth guy's encouragement of personal responsibility. first, the most serious risk depicted throughout the campaign is exposure to ben, who is a bwalking pandemic,^possibly even the source of plague. in implying that infection risk is determined mainly by exposure to others, this configuration places undue emphasis on the need for hypervigilance in interpersonal interactions. in ben's story, the assumption of personal responsibility for infection risk takes the form of a kind of citizenepidemiology, with everyone working to root out sources of infection. yet shy of engaging in self-quarantine, most people exercise only limited control over their exposure to others. perhaps in recognition of this fact, the bfifth guy^instructs in subtle pressures that might be applied to those individuals determined to be the potential source of infection-for example, through stigma. second, infection risk is determined largely by one's ability to control and manage certain behaviors. conversely, failure to change habits increases our risk. different scenes from the fifth guy illustrate this formulation of infection risk. motivated by the threat of ben's behavior, his coworkers more than once demonstrate for the camera different practices for limiting infection risk. in displaying their compliance with illness etiquette to the camera rather than to ben, his colleagues indicate the necessity of habitual and bodily responses to the management of infection risk. a third assumption is underscored within the numerous texts that together form the campaign's overarching message about risk and responsibility. in the fifth guy, a lack of knowledge increases one's risk of infection. ben, who displays ignorance of his duty to manage risk, teaches that being knowledgeable reduces the risk of infection (not to mention the threat of expulsion from the group). other elements of the campaign reinforce this equation of knowledge with the assumption of responsibility for infection risk. visitors to the bfifth guy^website can, for example, take a quiz that tests their bhygiene iq.^their scores determine bwhich person^they are in the workplace drama of illness and infection. yet, as anyone who takes the quiz may quickly realize, it is only possible to either be the bfifth guy( ignorant) or not the fifth guy (not ignorant). users who select the incorrect answer to a series of five questions are also goaded to correct their mistakes by the message, bwrong. who are you, the fifth guy?^most of these wrong answers correspond with ben's behaviors in different scenes from the campaign psas. the didacticism of the campaign's testing of hygiene iq raises the question: what knowledge, exactly, do audiences gain through exposure to the bfifth guy^and campaigns like it? perhaps most importantly, the formulation of knowledge as a defense against infection risk teaches an individualistic approach to risk management. within this conception, the complex problem of emerging infectious diseases is most effectively resolved through personal transformations of our daily habits, not to mention of our relationships to one another. in the coming decades, it seems likely that the containment of outbreaks will depend more and more on a program of risk communication that teaches individuals how to protect themselves against infection. within the new public health, this focus on behavioral change is frequently regarded mainly as an alternative to the implementation of costlier, more comprehensive forms of protection, treatment, and care. problematically, however, this encouragement of the personal responsibility for infection risk ignores the influence of contextual and environmental factors. complex economic and social factors, from social support networks to gender, ethnicity, race, and culture, shape and determine the health of populations. instead, even those campaigns that single out the person who (like ben) does not adhere to the dictates of illness etiquette imply equality in our susceptibility to (or risk of) infection. despite its shortcomings, critics have only occasionally spoken out against the emphasis on personal responsibility for infection risk and the neoliberal model of public health it entails. shortly after president obama advised americans to help fend off a global pandemic by washing their hands, for example, cohen wrote a new york times column about the ethical dimensions of the 100th-day address (2009). was obama's counsel to americans to do their part by washing their hands and staying home from work bmerely good manners,^cohen wondered. or, should his comments instead be understood as a moral injunction, with serious implications for how the nation would cope with the outbreak? put simply, is hand hygiene a matter of etiquette-or is it a matter of ethics? while etiquette may bhave a trivial impact on others,^cohen deemed obama's h1n1 advisory a matter of ethics bbecause it concerns the effect of our actions on other people.ŵ ashing one's hands removes harmful, disease-causing pathogens, making the endorsement of the act an bethical imperative, meant to mitigate the harm we might do to others.^that hand hygiene has a personal benefit does not make the habit any more ethical-just more desirable, perhaps, because self-care for the most part overlaps with care of others. yet in defending hand hygiene as an ethical imperative, cohen claimed that even this commonsense health habit has its limits. a program of risk management that depends for its success on the assumption of personal responsibility may similarly be too limited an approach to the problem of infection. as cohen put it, the dictates of illness etiquette, although bfundamentally ethical, are not universally applicable.^efforts to mobilize citizens against infection risk require an environment supportive of their participation. adequate supports must exist to ensure that citizens can bdo the right thing.^to illustrate the limits of personal responsibility, cohen discussed the example of labour law: some employees, particularly low-wage workers, risk losing pay or even getting fired if they stay home from work to avoid infecting their coworkers. if we expect individuals to act ethically, we have a societal obligation to protect them when they do-for instance, by guaranteeing paid sick days to all. (2009) during h1n1, concern about the ability of individuals to behave according to the dictates of public health led to the introduction in the u.s. congress of a bill that would require most employers to provide workers sent home with infections such as influenza a minimum of five paid sick days. paid sick leave, supporters argued, could even be a benefit to the economy, since the policy could both increase productivity and reduce the spread of illness and infection around the workplace. i quote cohen's comments at length because he is one of few critics to publicly speak out about the ethical issues that arise from the increasing encouragement of personal responsibility for infection risk. (even owen [2013] , in describing in detail the brise of purell,^shies away from too staunch a critique of the implications of the turn to hand hygiene promotion.) despite the appeal of the argument that infection risk can be managed mainly through individual behavior change, most exercises in risk management depend for their success on an environment supportive of these changes. in implying that infection risk may be equally distributed across populations, handwashing campaigns exclude the insights of decades of research on the social determinants of health and diseases. in this context, rhetoricians of health and medicine and health humanities scholars contribute meaningful investigations of the rhetoric of personal responsibility and specifically of its emphasis on fear, anxiety, distrust, stigma, and blame. such analyses are sure to deepen conversations among scholars and practitioners about the long-term implications of a seemingly uncontroversial enterprise-the promotion of hand hygiene. as mentioned at this essay's outset, i do not wish to question hand hygiene's efficacy as a form of infection control. myriad studies report on the impact of hand washing on the risk of infection with the majority suggesting that the habit significantly limits the transmission of communicable diseases. 21 to abandon hand hygiene because of concerns about the rhetoric used to promote makes no sense. far from opposing handwashing campaigns, i have illuminated their broader implication in the ongoing individualization and responsibilization of public health, which is also in essence a neoliberalization of public health. hand hygiene promotion, as my analysis suggests, moralizes the spread of infection, making its publics more sensitive to their capacity to sicken, and be sickened, by others. in the context of outbreak, such a perception both potentially lessens expectations of various kinds of support, for example in the form of employment or health benefits. this perception also creates new opportunities for those who stand to profit from the negative emotions often highlighted in messaging about personal responsibility for infection risk. as the target of handwashing discourse, one might thus be wary of the implications of the turn to hand hygiene as a universal antidote to the crisis of emerging infectious diseases. despite its seemingly neutral objective as a form of risk communication, hand hygiene promotion galvanizes a culture of stigma, blame, and distrust in response to the threat of infection. to what extent might these effects in fact inhibit the need for cooperation in the face of a catastrophic outbreak? handwashing campaigns transform perceptions of infection risk, casting illness as a personal failing. this is not to say that infection is not partly a consequence of poor hand hygiene, but the reality is just that. poor hand hygiene is only a contributing factor and not the root cause of the heightened risk of outbreak. it may thus be time to consider alternatives, or complements, to a neoliberal model of public health. personal responsibility has its advantages-that much is clear-but a more expansive approach might better facilitate the cooperation, and compassion, that infectious-disease outbreaks demand. endnotes 1 for the full text of president obama's remarks, see btranscript: president obama's 100th-day press briefing^(2009). 2 see, for example, keränen (2011) ; angeli (2012); ding (2014a; 2014b) . 3 keränen also stresses a common interest in the formation of publics, not just through the bofficial texts of biomedicine,^but also through the practices they adopt in response to these texts (2014, 104). 4 wald (2008) in turn proposes the theory of the boutbreak narrative^to describe the influences of both media and popular culture on responses to infectious disease-in particular, those responses that generate stigma or discrimination. 5 in fact, for a decade prior to sars, purell languished in obscurity (owen 2013, 30) . 6 see sadler (2009) , which incorporates critiques of hand-sanitizer use from health historians jacalyn duffin and nancy tomes, both of whom regard the product's popularity as tied to anxieties about infection risk. 7 while worldwide sales figures vary from one source to another, a cnn story reports that shipments of hand sanitizer tripled during h1n1, from 1 million kilograms to 3 million kilograms (rooney 2009) . a more recent report (fottrell 2013) states that u.s. sales of hand sanitizer reached $300 million in 2009, and have since averaged nearly $200 million per year. 8 plyushteva's (2009) critique of hand hygiene promotion in developing countries documents only the latest stage in a longer arc of handwashing campaigns developed to generate sales for hand soap. vinikas (1989) , for example, chronicles the creation by soapmakers of the 1920s and 1930s of the cleaning institute, which worked to increase soap sales by inculcating schoolchildren into personal hygiene habits. see, also, vinikas (1995) , which illuminates the significance to modern advertising of early-twentieth-century efforts to promote personal hygiene. 9 for the full text of this press release, see royal society for the protection of nature, bglobal handwashing day observed in yoeseltse mss in samtse.1 0 the quotations in this paragraph derive from globalhandwashing.org, the website for the global ppphw. for a recent systematic review of the impact of hand hygiene promotion in developing countries, see whom plyushteva quotes, openly criticizes hand hygiene promotion in kerala as a poor substitute for structural interventions, such as the improvement of sanitation systems or provision of clean water another important historical precursor to plyushteva's critique is tomes, which documents the work of latenineteenth and early-twentieth century public health advocates to transform lay understandings of the spread of infection. tomes points out that bentrepreneurs and manufacturers curtis's (2011) review of the emerging body of scholarship on the use of public health discourse to trigger a disgust response in order to motivate individual behavior change my view of health citizenship derives mainly from petersen and lupton (1996), but it also has loose ties to rose and novas' (2005) notion of biological citizenship argues that before the 1980 provincial referendum the government of quebec sought support for quebec's separation from canada by constituting the province's inhabitants as ba distinct peuple.^by voting in support of separation a constitutive perspective is also consistent with foucault's theory of subjectivity formation. for a discussion of foucault's significance to health humanities, see petersen which instructs americans to bkeep calm and wash [their] hands,^implying that in washing their hands, citizens consent to their duty to cooperate in the event of an outbreak the fifth guy campaign has also been the subject of social-marketing case studies which is transmitted by fomites. among others, wald (2008) stresses the role of popular culture in circulating certain conceptions of outbreak-views of causality that overstate the role of the individual in triggering an outbreak. similarly, many of the essays in a 2002 special issue of american literary history discuss the longstanding influence of popular culture on understandings some of the most frequently-cited references to studies in support of hand hygiene appear on bshow me the science bideology and ideological state apparatuses.^in lenin and philosophy and other essays translated by ben brewster bmetaphors in the rhetoric of pandemic flu: electronic media coverage of h1n1 and swine flu btheorizing modernity conspiratorially: science, scale, and the political economy of public discourse in explanations of a cholera epidemic a rhetoric of motives health promotion materials. the u.s. centers for disease control and prevention bconstitutive rhetoric: the case of the 'peuple québécois bflu fighters.^the new york times bcompliant, complacent, or panicked? investigating the problematisation of the australian general public in pandemic influenza control global handwashing day. deb group ltd bdemarcating medicine's boundaries: constituting and categorizing in the rhetoric of a global epidemic: transcultural communication about sars. carbondale: southern illinois university press drugs for life: how pharmaceutical companies define our health btalk to the fifth guy bhand sanitizer spread faster than the flu.^marketwatch bhygiene and health: systematic review of handwashing practices worldwide and update of health effects bchildren as handwashing agents of change.^the global public-private partnership for handwashing with soap. accessed stigma: notes on the management of a spoiled identity bconcocting viral apocalypse: catastrophic risk and the production of bio(in)security 2014b. b'this weird, incurable disease': competing diagnoses in the rhetoric of morgellons.^in health humanities brisky appeals: recruiting to the environmental breast cancer movement in the age of 'pink fatigue bfat panic and the new morality.^in against health: how health became the new morality bselling certainty: genetic complexity and moral urgency in myriad genetics bintroduction: why against health?^in against health: how health became the new morality bhands across america: the rise of purell the new public health: health and self in the age of risk btalk to the fifth guy: a lesson in social marketing.ĉ ases in public bthis benevolent hand gives you soap: reflections on global handwashing day from an international development perspective.^journal of health management bpresident obama's 100th-day press briefing.^2009. the new york times. accessed bhand sanitizer in short supply as swine flu hits.^cnn money. accessed bbiological citizenship.^in global assemblages: technology, politics, and ethics as anthropological problems bglobal handwashing day observed in yoeseltse mss in samtse bdo you really need hand sanitizer?^cbc news health and the rhetoric of medicine bpublic health campaign.^in sage encyclopedia of public relations bhandwash or eyewash? selling soap in the name of public private partnerships.^india resource center blife in a time of germaphobia.^the globe and mail the gospel of germs: men, women, and the microbe in american life soft soap, hard sell: american hygiene in an age of advertisement contagious: cultures, carriers, and the outbreak narrative bcurrent who phase of pandemic alert for pandemic (h1n1).^the world health organization g l o b a l a l e r t a n d r e s p o n s e ( g a r ) . a c c e s s e d 2 9 a p r i l 2 0 0 9 key: cord-277818-8w15dz20 authors: jaichenco, andre l.; lima, luciana cavalcanti title: infectious disease considerations for the operating room date: 2018-02-09 journal: a practice of anesthesia for infants and children doi: 10.1016/b978-0-323-42974-0.00050-1 sha: doc_id: 277818 cord_uid: 8w15dz20 the risk of infection transmission by anesthesia providers in their work area environment is reviewed. the dynamics of transmission and the strategies for preventing infection transmission in health care institutions are discussed. anesthesiologists have long been patient safety advocates and have taken on increasing responsibility for preventing health care–associated infections. anesthesia providers practice in a nonsterile environment within the operating room and have an impact on bacterial transmission and infection rates. understanding the characteristics of transmission elements provides the practicing anesthesiologist with methods to protect susceptible patients and themselves to avoid spreading infection. it is vital to have in place proper systems to remove contaminated air to minimize the risk of airborne pathogens being transmitted by children. preoperative patient skin and other bacterial reservoir decontamination and hand hygiene by anesthesia providers reduces contamination of the work area and iv access ports. hand hygiene is a well-known and effective solution to the problem of bacterial transmission within and across patients and is considered the most important and cost-effective individual intervention in the prevention of health care–associated infections in children and health care providers compliance with the current “5 moments” world health organization guidelines could make a major inroad into reducing provider hand and workspace contamination. surgical antimicrobial prophylaxis is an essential tool to reduce the risk of postoperative infections, and the anesthesia team plays a central role in ensuring the proper timing of drug administration. protocols, although effective, require continuous feedback and revision. the presence of a susceptible host is an important element in the chain of infection that paradoxically results from advances in current medical therapies and technology (e.g., children undergoing organ transplantation or chemotherapy, or extremely premature neonates) and the presence of children with diseases that compromise their immune systems (e.g., aids, tuberculosis, malnutrition, or burns). the organism may enter the host through the skin, mucous membranes, lungs, gastrointestinal tract, genitourinary tract, or the bloodstream via iv solutions, after laryngoscopy, or from surgical wounds. organisms may also infect the individual because of work accidents with cutting or piercing devices. the development of the rabbit hole that is the perioperative environment is not well understood by the majority of our general pediatric colleagues. similarly, the rabbit hole of the primary care clinic or the pediatric inpatient ward is not well understood by the majority of our anesthesiology colleagues. a pediatric patient may repeatedly enter the rabbit hole over the course of a hospital admission, a journey fraught with dangers of airway mishaps, respiratory and/or cardiac arrests, hemorrhage, profound anxiety and stress experienced by the young patient and his or her family, as well as infection risks. 1 anesthesiologists have long been patient safety advocates. it is not surprising that anesthesia providers in the 21st century have taken on increasing responsibility for preventing health careassociated infections (hais), including surgical site infections (ssis). anesthesia providers practice in a nonsterile environment within the operating room (or) and frequently contact areas of the patient known to have a high rate of contamination such as the axilla, nares, and pharynx. there are two recognized but poorly implemented interventions: preoperative patient skin and other bacterial reservoir decontamination and hand hygiene by anesthesia providers. 2 anesthesia providers have an impact on bacterial transmission and infection rates. specifically, anesthesiologists are known to contaminate their work environment within the or. contamination of the work environment includes contamination of intravenous (iv) access ports. without encouragement, anesthesiologists perform hand hygiene less frequently than once per hour during a case, but with reminders, the rate of hand hygiene is more frequent. improved hand hygiene reduces contamination of the work area and iv access ports from 32% to 8%, which in turn significantly reduces hais. 3, 4 the transmission of infection depends on the presence of three interconnected elements: a causative agent, a source, and a mode of transmission ( fig. 50.1 ). understanding the characteristics of each element provides the practicing anesthesiologist with methods to protect susceptible patients and themselves to avoid spreading infection. there has always been concern about the transmission of infectious agents to the patient from the anesthesiologist and vice versa. 5 in addition, there are many sites within the hospital environment where moist or desiccated organic material with the membranes. droplets remain suspended for only a short duration and distance from the source, but this may be affected by temperature, humidity, force of expulsion, and air currents. larger particle sizes contact the mucosa of the upper airway, whereas aerosols are capable of penetrating into the lower respiratory tract. infectious agents vary in their affinity for receptors in different regions of the respiratory tract. 9,10 when a person coughs, the exhaled air may reach a speed of up to 965 km/hour (600 mph). 11 however, because the droplets are relatively large, they tend to descend quickly and remain suspended in the air for a very brief period, thus obviating the need for special handling procedures for the or air. examples of droplet-borne diseases include influenza, respiratory syncytial virus (rsv), severe acute respiratory syndrome (sars), diphtheria, haemophilus influenzae, neisseria meningitidis, mumps, pertussis, rhinovirus, rubella, and ebola. droplet precautions include communication of infectious risk infection is influenced by the host defense mechanisms that may be classified as either nonspecific or specific: ■ nonspecific defense mechanisms include the skin, mucous membranes, secretions, excretions, enzymes, inflammatory responses, genetic factors, hormonal responses, nutritional status, behavior patterns, and the presence of other diseases. ■ specific defense mechanisms or immunity may occur because of exposure to an infectious agent (antibody formation) or through placental transfer of antibodies; artificial defenses may be acquired through vaccines, toxoids, or exogenously administered immunoglobulins. microorganisms are transmitted in the hospital environment through a number of different routes; the same microorganism may also be transmitted via more than one route. in the or, the three main routes of transmission are through the air and by direct and indirect contact. airborne infections that may infect susceptible hosts are transmitted via two mechanisms: droplets and droplet nuclei. droplet contamination is considered a direct transmission of organisms because there is a direct transfer of microorganisms from the colonized or infected person to the host. this generally occurs with particles whose diameters are greater than 5 µm that are expelled from an individual's mouth or nose, mainly during sneezing, coughing, talking, or during procedures such as suction, laryngoscopy, and bronchoscopy ( fig. 50.2 ). transmission occurs when the microorganism-containing droplets, expelled or shed by the infected person (source), are propelled a short distance (usually not exceeding 60 cm or about 2 feet through the air) and deposited on the host's conjunctivae or oral or nasal mucous droplet nuclei result from the evaporation of droplets while suspended in the air. unlike droplets, the nuclei have an outer layer of desiccated organic material and a very small diameter (1-5 µm) and remain suspended in air indefinitely. the microorganisms contained within these nuclei may be spread by air drafts over great distances, depending on the environmental conditions (dry and cold atmosphere, with limited or no exposure to sunlight favoring the spread). 12 in contrast to droplets, which are deposited on mucous membranes, droplet nuclei may enter the susceptible host by inhalation; examples of droplet nuclei-borne diseases include tuberculosis, varicella, and measles, zoster, smallpox, sars, and middle eastern respiratory syndrome. 10 direct and indirect contacts are the most significant and frequent methods of hospital infection transmission. this type of disease transmission involves direct physical contact between two individuals. the physical transfer of microorganisms from an infected or colonized person to a susceptible host may occur from child to health care provider or from health care provider to child during professional practice (e.g., venous cannulation, laryngoscopy, burn care, or suction of secretions). health care providers working in the or may be exposed to skin contamination by body fluids. this is an issue of grave concern because of the potential exposure of health care providers to patients with unrecognized infections, especially hepatitis b virus (hbv), hepatitis c virus (hcv), and human immunodeficiency virus (hiv). hepatitis b is a highly infectious virus that requires a small amount of blood (10 −7 -10 −9 ml) to transmit the disease. the incidence of skin contamination of anesthesiologists and related personnel by blood and saliva is substantial. one study examined 270 anesthetic procedures during 7 consecutive days. the blood of 35 patients (14%) contaminated the skin of 65 anesthesiologists in 46 incidents. of these contamination events, 28 (61%) occurred during venous cannulation. of anesthesiologists who had been contaminated by blood, 5 of 65 (8%) had cuts in the skin of their hands. 13 the importance of this observation is that seroconversion of health care providers has been reported after skin contamination by infected blood from hiv carriers 14 and hbv infection after blood splashing into health care workers' (hcws') eyes. 15 scabies, pediculosis, and herpes simplex are among the diseases most frequently transmitted by direct contact. [16] [17] [18] [19] [20] [21] [22] [23] meticulous hand washing before and after every patient contact and routine use of barriers such as gloves and eye protection are essential basic methods for protecting ourselves even during routine procedures such as starting an iv line or performing laryngoscopy. 4 indirect contact involves the transmission of microorganisms from a source (animate or inanimate) to a susceptible host by means of a vehicle (e.g., an intermediary object) contaminated by body fluids. tables 50.2 and 50. 3 provide examples of diseases associated with bodily fluids to which hcws may be exposed. the vehicle for transmission may be the hands of a health care provider who is not wearing gloves or a provider who fails to wash his or her hands after providing care to a child. 3, [24] [25] [26] this type of contact can also come from health care providers who touch (with or without gloves) contaminated monitoring or other patient care devices (e.g., blood pressure cuffs, stethoscopes, electrocardiographic cables, or ventilation systems [respirators, corrugated tubes, y-pieces, valves]) that are used without proper cleaning or disinfection between each use. [27] [28] [29] knowledge about the transmission of the spread of bacteria from patients to hcws' hands and to the hospital environment ( fig. 50 .3) has driven many interventions that have reduced patient risks for developing hais. 30 disease transmitted blood hbv, hiv, hcv, cmv, ebv, nanbh seminal fluid hiv, hbv, cmv vaginal discharge hiv, hbv, cmv saliva and sputum hsv, tb, cmv, respiratory diseases cerebrospinal fluid encephalopathic organisms (see table 50 30 characterization of the transmission dynamics of frequently encountered gram-negative bacteria in the anesthesia work area environment 32 demonstrates that the spread follows an epidemiologic pattern similar to that seen in icus and inpatient wards: from patient, to environment and hcws' hands, and to other patients ( fig. 50.4) . in this report, provider hands were less likely to serve as a transmitter of infection than contaminated environmental or patient skin surfaces. these findings have clinical implications for the risk of colonization and subsequent hcis-for example, ssis. this calls attention to the need to develop and enforce strict hand hygiene guidelines for personnel who are providing anesthesia care, but more importantly the need to increase compliance with environmental disinfection of the or (between cases and terminal cleaning), and to study further the directions of the spread of pathogens in the or and anesthesia work areas. this study unequivocally underscores our need to improve cleaning procedures in the or and equipment surfaces to reduce infection risk. there are also reports of equipment, fomites, and drugs (mainly propofol) that have resulted in hospital-acquired infections. 20, [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] propofol is widely used for both inpatient and outpatient anesthesia. this hypnotic agent is a nutrient-rich drug. it is hypothesized that propofol increases bacterial contamination of iv stopcocks and may compromise safety of iv tubing sets when continued to be used after propofol anesthesia. there is a covert incidence of iv stopcock bacterial contamination during anesthesia that is aggravated by the prior presence of propofol. propofol may increase the risk for postoperative infection because of bacterial growth in iv stopcock dead spaces. 52 other facets that may also contribute to infection include the following: ■ up to 40% of anesthetic equipment in direct or indirect contact with a child (blood pressure cuffs, cables, oximeters, laryngoscopes, monitors, respirator settings, and horizontal and vertical surfaces) may be contaminated with blood because of inadequate cleansing procedures between uses. 6,7,27,53,54 ■ in some institutions, up to 8% of the bain circuits that were reused without previous sterilization were contaminated. 55 ■ contamination of syringe contents has occurred with glass particles during ampule opening, which in turn may compromise the sterility of the contents, presumably because of the passage of bacteria contained on glass particles into the solution. 56-58 ■ iv tubing has both blood contamination as well as contamination by blood from syringes used to inject medications. this can occur with the absence of visible blood reflux in the tubing or syringe. simply replacing the needle on a syringe that will be reused is ineffective in preventing cross-infection; it is essential to not use the same syringe in multiple patients. 59 ■ refilling both glass and plastic syringes several times has also been shown to result in contamination of the contents; single use is therefore recommended. 59 studies on vancomycin-resistant enterococci established the importance of a domino effect of contamination in intensive care units (icus) and inpatient wards: spread of vancomycin-resistant enterococci that colonize patients' gastrointestinal tracts ("rectal carriage"), to patients' skin, to the hospital environment, to hands of hcws, and then to other patients. the skin contamination of patients with enteric organisms inspired the rather graphic description, the patient's "fecal patina." 31 also referred to as a "stool veneer," this coating with enteric organisms is limited not only to patients' skin but also extends to surfaces in the surrounding environment that are touched, and thereby contaminated, by patients and by hcws. the environmental contamination spreads out from the patient in a target-like concentric pattern, with the densest contamination closest to the rectum of patients who have rectal carriage of the problem bacteria. this interplay among the blood of a patient in an advanced disease stage or with a higher hiv viral load; a deep percutaneous injury; a procedure wherein the sharp was in the vein or artery of an infected source patient; an injury with a hollow-bore, blood-filled needle; and limited or delayed access to postexposure prophylaxis. after exposure, the risk of infection varies for specific bloodborne pathogens. for hbv, if the source patient has active hbv and the hcp do not already have immunity, the risk for infection after percutaneous injury is between 1% and 30%. if the source patient has active hcv, the risk of hepatitis c transmission is approximately 1.8% (range 0%-7%) after a percutaneous injury. if the source patient has hiv infection, the risk of hiv transmission is approximately 0.3% after a percutaneous exposure and 0.09% after a mucous membrane exposure. the risk of hiv transmission for an exposure with nonintact skin has not been determined and is estimated to be less than the risk after a mucous membrane exposure. 78 anesthesia staff lacking hbv protective antibodies are at great risk for acquiring the disease. 79, 80 these infection rates underscore the need for the use of "safe" needles and the need to advocate the use of "needleless" systems even though they are significantly more expensive. 81, 82 this also emphasizes the need for meticulous handling and disposal of needles and other sharp instruments, as well as the use of special "sharps boxes" designed to minimize accidental needlesticks (e.g., "mailbox"-type boxes that do not allow the hand to enter the disposal area). [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] [95] [96] [97] [98] the u.s. centers for disease control and prevention (cdc) has estimated that in the united states there are approximately 385,000 cutting and piercing accidents annually among hcp in hospitals; 25% of these occur in the or. 77 however, the actual prevalence is thought to be much greater, because many of these events are unreported. the distribution of these accidents among anesthesiologists is shown in fig. 50 .5a; the distribution of the items most frequently associated with cutting and piercing injuries in health care providers is shown in fig. 50 .5b. should such an accident occur (e.g., needle puncture, exposure to nonintact skin, or mucous membrane ■ needles that have been used for spinal or epidural anesthesia were contaminated with coagulase-negative staphylococci (15.7%), yeasts (1.5%), enterococci (0.8%), pneumococci (0.8%), and micrococci (0.8%), suggesting that there may be needle contamination despite standard skin preparation and cleansing. 68 it is unclear whether these skin organisms can be transmitted and cause an infection during administration of a neuraxial block. ■ blood and saliva frequently contaminate the skin of anesthetic personnel during routine anesthetic practice. 13 ■ violations of contemporary guidelines for preventing infections (e.g., hand washing, wearing gloves, surgical masks, ocular protection, scrubs, or syringe reuse) by anesthesiologists are frequent. 4 anesthesia staff are aware that they work in a potentially infectious environment, but they commonly do not adopt appropriate protective measures to reduce infections in both themselves and their patients (11%-99%). 27,69-71 percutaneous contamination from a cutting or piercing accident is the most effective means to transmit bloodborne pathogens. evidence suggests that this is the main route of hiv, hbv, and hcv infection, [72] [73] [74] especially if the injury is caused by hollow-bore needles that were used to draw blood or establish iv access. 75, 76 over 20 other bloodborne pathogens have been transmitted by this means, including those causing herpes, malaria, and tuberculosis. 77 the risk of exposure to blood and bloodborne pathogens is greater for health care personnel (hcp) than for people who do not work around blood. an exposure to infected blood, tissue, or other potentially infectious body fluids can occur by percutaneous injury or contact with mucous membrane or nonintact skin. the risk of infection after an exposure depends on a number of variables and appears to be greater with exposure to a larger quantity of blood or other infectious fluid; prolonged or extensive exposure of nonintact skin or mucous membrane to blood or other infectious fluid or concentrated virus in a laboratory setting; exposure to institutional administrative measures aimed at developing, implementing, and monitoring specifically designed accident prevention policies and procedures are important for reducing and preventing transmission of infectious agents in health care centers. to this end, centers should consider the following: 77,99,100 ■ include infection control as a major goal in the organizational mission statement and implement safety programs, both for patients and hcws. ■ provide sufficient administrative and financial support to carry out this mission. ■ provide sufficient administrative and financial support for the microbiology laboratory and implement an infection surveillance plan, especially for postsurgical infections. ■ establish a multidiscipline cross-functional team (e.g., a team manager, an epidemiologist, a representative from industrial health, and a person trained in quality control) to identify health and safety issues within the institution, analyze trends, assess outcomes, implement interventions, and make recommendations to other members of the organization. ■ provide sufficient administrative and financial support to develop and implement education programs for health care providers, patients, and their families. one positive example of such education is that anesthesiologists who have read the cdc's universal precaution guidelines for the prevention of occupational transmission of hiv and hbv have developed better hygienic practices. 69 ■ provide hcws with hepatitis a and b vaccine and document that an appropriate immunologic response was achieved. provide hepatitis a and b immune globulins (haig, hbig) for those exposed who do not have established immunity. 8 ■ provide a health care service for employees for counseling and postexposure prophylaxis should an exposure to hiv occur. 101 , there are now specific recommendations regarding immediate assessment of risk, assessment of the exposure source (chart review, inform the patient that an accident has occurred and ask permission to determine hbv, hcv, and hiv serologic status), and rapid initiation of appropriate antiviral treatment of the hcw. 82 it is advised to obtain as much information regarding the patient as possible-if the patient is known-to (1) obtain a sample of blood from the patient for determination of potential carrier state (table 50 .4) and (2) report to the health service for immediate institution of prophylaxis and follow-up ( air is delivered to each or from the ceiling, with downward movement toward several exhaust or return ducts near the floor. this design helps provide steady movement of clean air through the breathing and working zones. the aia has specific guidelines for the location of outside fresh air inlets to minimize contamination from exhaust systems and noxious fumes. a greater air inflow rate and a larger air-inlet area are desirable for contaminant control, but these approaches are detrimental to the thermal comfort of the staff and patient. 108 the aia recommends an air-change rate in an or of 20 to 25 air changes per hour (ach) for ceiling heights between 9 feet wound contamination in the or is the result of the patient's skin flora and bacteria shed on airborne particles from the or personnel. room ventilation affects the distribution of these airborne particles in four ways: total ventilation (dilution), air distribution (directional airflow), room pressurization (filtration barrier), and filtration (contaminant removal). as the air flows of the room increase, the greater the dilutional effect on airborne particles. balancing this phenomenon is important because while increased flow increases the effectiveness of air exchange, the resultant turbulent flow increases microbial distribution throughout the room. low-velocity unidirectional flow minimizes the spread of microbes in the room. directional flow can be inward, from the outside into the or (negative pressure), or outward, from the or to the outside (positive pressure). negative-pressure ventilation is used for highly infective rooms in the hospital (e.g., isolation rooms for tuberculosis patients), and positive-pressure ventilation is used for protective environments (e.g., ors and pep step 1: treat exposure site • use soap and water to wash areas exposed to potentially infectious fluids as soon as possible after exposure. • flush exposed mucous membranes with water. • flush exposed eyes with water or saline solution. • do not apply caustic agents, or inject antiseptics or disinfectants into the wound. step 2: report and document standard precautions 117 assume that any person or patient is potentially infected or colonized by microorganisms that could be transmitted and cause an infectious process. standard precautions must be implemented with all patients and include the following: ■ universal precautions-blood and body fluid precautions, developed to reduce bloodborne pathogen transmission ■ body substance isolation, designed to reduce the risk of pathogen transmission by moist body substances standard precautions are used to reduce the transmission of all infectious agents from one person to another, thus protecting health care providers and children against exposure to the most common microorganisms. standard precautions are implemented for any contact with blood and body fluids, secretions, and excretions (except sweat), whether or not they contain visible blood, as well as for any contact with nonintact skin, mucous membranes, and intact skin that is visibly soiled with blood and/ or body fluids. prevention is primary. all hcps should be familiar with standard precautions: wash hands frequently and thoroughly before and after patient care; use personal protective equipment: gloves, gowns, boots, shoe covers, eyewear, masks, and shields, as appropriate for the patient care situation; gloves must be worn when any kind of venous or arterial access is being performed; use sharps with caution: plan ahead (use sharps in a safe environment with a sharps container nearby), dispose of used sharps in puncture-proof receptacles immediately after use, do not recap needles, and use safety devices if available. all hcps should be vaccinated with the hepatitis b vaccine series and should undergo testing for hbsab response after completion of the series to document adequate protection. employees who have not gone through the vaccination series previously should be offered the hepatitis b series through their employer at no cost. 118 summaries of standard precautions, droplet precautions, airborne precautions, and contact precautions are available on line. 100, [119] [120] [121] hand washing overall hand hygiene compliance across health care providers remains less than 50%, with anesthesia providers identified as a particularly noncompliant group (one study found a compliance rate of only 23%). 122 bacterial contamination of anesthesia providers has been directly linked to high-risk bacterial transmission events to iv stopcocks and 30-day postoperative infections. 24 the vast majority of ssis are caused by staphylococcus aureus. transmission of specific staphylococcal phenotypes within and between patients is a major contributor to ssis and hais. 3, 4, 123 the role of anesthesia-provider hand contamination in transmission of enterococcus to the workstation and patient biome is concerning, even though it was not associated with actual infection, because of rising rates of antibiotic-resistant organisms and the observation that enterococcus is becoming a more prevalent pathogen. 3, 124 two approaches are indicated: improved methods of patient reservoir decontamination and more effective and frequent decontamination of provider hands. hand hygiene is a well-known and effective solution to the problem of bacterial transmission within and across patients. compliance with the current "5 moments" world health organization guidelines could make a major inroad into reducing provider hand and workspace contamination. one study found that only 20% of anesthesia providers demonstrated complete knowledge regarding who hand hygiene guidelines. 125 failure of providers to recognize prior contact with the environment and prior contact with the patient as hand hygiene opportunities contributed to this low percentage. several cognitive factors were associated (2.74 meters) and 12 feet (3.66 meters). some controversy exists between engineers and clinicians over the need for laminar airflow ventilation in the or to further minimize airborne infection. careful mathematical analyses of airflow suggest that laminar airflow is not necessary. clinical studies are confirmatory. similarly, the use of ultraviolet light to cleanse the room air is no longer recommended. 109 table 50 .8 shows the 2003 healthcare infection control practices advisory committee and cdc general recommendations for ventilation system specifications for the or. 12 children with tuberculosis require special consideration because of the high risk of occupational transmission of mycobacterium tuberculosis, 110, 111 especially after the emergence of multidrug-resistant strains (table 50.9 ). an easy preventive measure is to screen all children before coming to the or to determine recent exposure to infectious disease such as measles, mumps, rubella, and chickenpox because these infections can pose a significant risk to hcws and patients, especially those who are immunocompromised. 73, 106 another potential source for airborne spread of pathogens is through the anesthesia circuit; this may be reduced by the use of circuit filters. however, at present there are no regulatory requirements to use such devices, and performance characteristics vary widely. 28 • pep should be initiated within 2 hours of the exposure. • the eficacy of pep initiation is thought to diminish after 24 to 36 hours following an exposure. • if the fourth-generation combination hiv ag/ab assay is used to test the source patient, hiv follow-up testing can be completed 4 months after exposure. hand washing is considered the most important and costeffective individual intervention in the prevention of hais in children and health care providers. 126 its importance in medical practice had not been universally accepted, despite the pioneering work by oliver wendell holmes 127 (1843) and ignaz semmelweis 128 with a reduced risk of incomplete knowledge, including providers responding positively to washing their hands after contact with the environment, disinfecting their environment during patient care, believing that they can influence their colleagues, and intending to adhere to guidelines. these results suggest that anesthesia providers have knowledge deficits pertaining to opportunity-based hand hygiene in the intraoperative arena 125 hiv-positive class 1: asymptomatic hiv infection or known low viral load (e.g., <1500 ribonucleic acid copies/ml). hiv-positive class 2: symptomatic hiv infection, acquired immunodeficiency syndrome, acute seroconversion, or known high viral load. if drug resistance is a concern, obtain expert consultation. initiation of pep should be delayed pending expert consultation, and because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures. the recommendation "consider pep" indicates that pep is optional; a decision to initiate pep should be based on a discussion between the exposed person and the treating clinician regarding the risks versus benefits of pep. g if pep is offered and administered and the source is later determined to be hiv-negative, pep should be discontinued. recommendations for surgical hand preparation are as follows: remove rings, wristwatch, and bracelets before beginning surgical hand preparation (ii); artificial nails are prohibited (ib); sinks should be designed to reduce the risk of splashes (ii); 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); brushes are not recommended for surgical hand preparation (ib); 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); if the quality of water is not assured in the operating theatre, surgical hand antisepsis using an alcohol-based handrub is recommended before donning sterile gloves when performing surgical procedures (ii); when performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, typically 2-5 minutes. long scrub times (e.g., 10 minutes) are not necessary (ib); when using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer's instructions for application times. apply the product to dry hands only (ib); do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (ii); when using an alcoholbased handrub, use sufficient product to keep hands and forearms wet with the handrub throughout the surgical hand preparation procedure (ib); after application of the alcohol-based handrub as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves (ib). at present, alcohol-based handrubs are the only known means for rapidly and effectively inactivating a wide array of potentially harmful microorganisms on hands. the who recommends alcohol-based handrubs based on the following factors: evidencebased, intrinsic advantages of fast-acting and broad-spectrum microbicidal activity with a minimal risk of generating resistance to antimicrobial agents; 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, and so on); capacity to promote improved compliance with hand hygiene by making the process faster and more convenient; economic benefit by reducing annual costs for hand hygiene, representing approximately 1% of extra costs generated by an hci; minimization of risks from adverse events because of increased safety associated with better acceptability and tolerance than other products. 118 after hand washing, it is very important to dry the hands properly with appropriate paper towels, hot air flow, or both, because the level of pathogen transmission from a hcw's hands to a patient is greatly increased if the hands are wet. 141 sterile cloth towels are most frequently used in ors to dry wet hands after surgical hand antisepsis. several methods of drying have been tested without significant differences between techniques. 118 transmission may also occur from patients' wet sites, such as groins or armpits, or when a hcw gets his or her hands wet when opening parenteral solutions. it is critical for health institutions to establish written procedures and protocols to support adherence to the recommended hand hygiene practices. wearing clean or sterile gloves while caring for children is an effective means of reducing hais. gloves remain a supplementary barrier to infection that should not replace proper hand hygiene. more frequent (on average, 22 opportunities per patient-hour). the greatest adherence rate (59%) was observed in pediatrics, where the average intensity of patient care was smaller than elsewhere (on average, 8 opportunities per patient-hour). the results suggest that full adherence to guidelines is unrealistic and that easy access to hand hygiene at the point of patient care, (i.e., in particular, alcohol-based handrubbing) could help improve adherence to hand hygiene. perceived barriers to adherence with hand hygiene practice recommendations include skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with hcw-patient relationships, patient needs perceived as a priority over hand hygiene, wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information showing a definitive impact of improved hand hygiene on hai rates. 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 cross-transmission 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. the risk of pathogen transmission via the hands is proportional to the power of the number of times a child is touched. 140 table 50 .10 presents 1. wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids (ib) or after using the toilet (ii). 2. if exposure to potencial spore-forming pathogens is strongly suspected or proven, including outbreaks of clostridium difficile, hand washing with soap and water is the preferred means (ib). 3. use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations described in terms 4(a) to 4(f) listed below, if hands are not visibly soiled (ia). if alcohol-based handrub is not obtainable, wash hands with soap and water (ib). 4. perform hand hygiene: a. before and after touching the patient (ib); b. before handling an invasive device for patient care regardless of whether or not gloves are used (ib); c. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (ia); d. if moving from a contaminated body site to another body site during care of the same patient (ib); e. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient (ib); f. after removing sterile (ii) or nonsterile gloves (ib). 5. before handling medication or preparing food, perform hand hygiene using an alcohol-based handrub or wash hands with either plain or antimicrobial soap and water (ib). 6. soap and alcohol-based handrub should not be used concomitantly (ii). gloves protect patients by reducing health care provider hand contamination and the subsequent transmission of pathogens to other children, provided the gloves are changed after providing care to each child. additionally, when the use of gloves is combined with cdc standard precautions, they protect the health care provider against exposure to bloodborne infections or infections transmitted by any other body fluids, such as excretions, secretions (except sweat), mucous membranes, and nonintact skin. examination gloves are single-use and usually nonsterile. sterile surgical gloves are required for surgical interventions. some nonsurgical care procedures, such as central vascular catheter insertion, also require surgical glove use. in addition to their sterile properties, these gloves have characteristics of thickness, elasticity, and strength that differ from other medical gloves. the use of gloves in situations when their use is not indicated represents a waste of resources without necessarily reducing crosstransmission. the wide-ranging recommendations for glove use have led to very frequent and inappropriate use. indications for gloving and glove removal are shown in table 50 .11. situations that require and that do not require glove use are presented in fig. 50 .6. ranked consensus recommendations for the use of gloves, categorized according to the cdc/hicpac system, include the following 118, 142, 143 : ■ wear gloves in case of contact with blood or any other potentially infecting body fluid, such as excretions, secretions (except sweat), mucous membranes, and nonintact skin (ic). ■ remove the gloves immediately after providing care to a child. staff should not wear the same pair of gloves to take care of more than one child, nor should they touch the surfaces of any equipment, monitoring devices, or even light switches. ■ alcohol-based handrub dispensers and clean glove boxes (at least two sizes) should be in place near every patient care site (e.g., on top of every anesthesia cart, medication cart, or in the nursing station). ■ disposable gloves should not be washed, resterilized, or disinfected (ib). if gloves are reused, appropriate reprocessing methods should be in place to ensure the physical integrity of the gloves and their full decontamination (ii). ■ sterile gloves are much more expensive than clean, disposable gloves and should be used only for certain procedures, such as when hands are in contact with normally sterile body areas or when inserting intravascular or urinary catheters. clean gloves should be used during any other procedure, including wound dressing. ■ latex-free gloves should be worn when caring for children at risk for latex allergy. surgical antimicrobial prophylaxis is an essential tool to reduce the risk of postoperative infections, and the anesthesia team plays a central role in ensuring the proper timing of drug administration. 147, 148 the aim of the perioperative administration of antibiotics is to obtain plasma and tissue drug concentrations exceeding the minimal inhibitory concentration of those organisms most likely to cause an infection. this will reduce the microbial load of the intraoperative contamination; it is not the intent to cover all possible pathogens, because this can lead to the selection of drug-resistant bacteria. there have been few studies regarding the effectiveness of prophylactic guidelines for prevention of ssis in children. currently, prophylactic antibiotic guidelines exist for certain subsets of the pediatric surgical population, but there are no global recommendations, and the guidelines that exist are mostly based on studies from adults or from expert opinion. a retrospective study suggested that the appropriate use of antibiotic prophylaxis was a vital modifiable risk factor and may be the easiest factor to influence. primary failure to administer the correct dose of antibiotics at the appropriate time resulted in an almost 2-fold increase in the risk of developing an ssi. the importance of correct antibiotic usage and dosing plays a major role in decreasing risk of ssis in children. recommendations are provided for adult (age ≥19 years) and pediatric (age 1-18 years) patients. the guidelines do not specifically address newborn (premature and full-term) infants (table 50. although pediatric-specific prophylaxis data are sparse, available data have been evaluated for specific procedures. selection of antimicrobial prophylactic agents mirrors that in adult guidelines, with the agents of choice being first-and second-generation cephalosporins, reserving the use of vancomycin for patients with documented β-lactam allergies. while the use of a penicillin with a β-lactamase inhibitor in combination with cefazolin or vancomycin and gentamicin has also been studied in pediatric patients, the number of patients included in these evaluations remains small. as with adults, there is little evidence supporting the use of vancomycin, alone or in combination with other antimicrobials, for routine perioperative antimicrobial prophylaxis in institutions that have a high prevalence of methicillin-resistant s. aureus (mrsa). vancomycin may be considered in children known to be colonized with mrsa and decreases mrsa infections. 150 mupirocin is effective in children colonized with mrsa, but choice, alternative antibiotics should be administered to those children at risk of anaphylaxis to β-lactams, based on their history or diagnostic tests (e.g., skin testing). however, the incidence of severe allergic reactions to first-generation cephalosporins in children with reported allergy to penicillin is rare (but not zero) 158, 159 ; furthermore, skin testing does not reliably predict the likelihood of adverse reactions to cephalosporins in those with reported allergy to penicillin. [160] [161] [162] there is no evidence of any risk of cross-reactivity between penicillin and second-and thirdgeneration cephalosporins. for the most part, "allergies" to oral antibiotics that appear on children's charts (rash, vomiting, gastrointestinal disturbances) are reactions to the additives in the antibiotic formulation, including food dyes, fillers, and other compounds, or a manifestation of the underlying infection. iv administration of small test doses of the pure antibiotic in a fully monitored (and anesthetized) child will determine whether the child is at risk for an allergic reaction to the antibiotic. in the case of surgical procedures where antibiotic prophylaxis is mainly directed at gram-positive cocci, children who are truly allergic to β-lactams (cephalosporins) should receive either vancomycin or clindamycin. 163 however, in those children where the history is consistent with either an ige-mediated penicillin allergy (urticaria, angioedema, anaphylaxis, bronchospasm) or a severe non-igemediated reaction (interstitial nephritis, toxic epidermal necrolysis, hemolytic anemia, or stevens-johnson syndrome) it is advisable to switch out the cefazolin. cross-sensitivity occurs when the r1 side chains of the penicillins and cephalosporins are similar, which perhaps surprisingly is not the case with cefazolin. cephalosporins with r1 side chains similar to penicillins include cephalexin, cefaclor, and cefadroxil. the risk associated with use of first-or second-generation cephalosporins with dissimilar side chains, or third-or fourth-generation cephalosporins, "appears to be very low in patients with mild-to-moderate reactions to penicillin g, ampicillin, or amoxicillin. dismissing cefazolin use when there is a vague history of any penicillin allergy should be reconsidered." 155 indications for prophylactic antibiotics surgical wounds are classified into four categories (table 50 .13). the use of antibiotic prophylaxis for postoperative infections is well established for clean-contaminated procedures. within the clean category, prophylaxis has been traditionally reserved for surgical procedures involving a foreign body implantation or for any surgical procedure where an ssi would be catastrophic (e.g., cardiac surgery or neurosurgical procedures). however, there is evidence that postoperative infections resulting from procedures not involving prosthetic elements are underreported; estimates show that more than 50% of all complications occur after the patient is discharged and are thus unrecognized by the surgical team. therefore antibiotic prophylaxis is also recommended for certain procedures, such as herniorrhaphy. 164, 165 the direct and indirect costs of these complications may not affect the hospital budget; however, they represent a substantial cost for the community at large. in the case of contaminated or dirty procedures, bacterial contamination or infection is established before the procedure begins. accordingly, the perioperative administration of antibiotics is a therapeutic, not a prophylactic, measure. the use of antibiotics in children has implications not only for the response to the current treatment but also to future treatments. thus all medical professionals are jointly responsible for the rational use of antibiotics. protocols, although effective, require continuous feedback on their acceptance and ssi results. 166 no surgical protocol can replace there are limited data supporting its use perioperatively. 151, 152 most recommendations for adults are the same for pediatric patients. dosing recommendations in pediatric patients are limited and have been extrapolated from adult data; therefore nearly all pediatric recommendations are based on expert opinion. pediatric efficacy data are few. fluoroquinolones should not be routinely used for surgical prophylaxis in pediatric patients because of the potential for toxicity in this population. the same principle of preoperative dosing within 60 minutes before incision has been applied to pediatric patients. additional intraoperative dosing may be needed if the duration of the procedure exceeds two half-lives of the antimicrobial agent or there is excessive blood loss during the procedure. as with adult patients, single-dose prophylaxis is usually sufficient. if antimicrobial prophylaxis is continued postoperatively, the duration should be less than 24 hours, regardless of the presence of intravascular catheters or indwelling drains. there are sufficient pharmacokinetic studies of most agents to recommend pediatric dosages that provide adequate systemic exposure and, presumably, efficacy comparable to that demonstrated in adults. therefore the pediatric doses recommended in guidelines are based largely on pharmacokinetic data and the extrapolation of adult efficacy data to pediatric patients. because few clinical trials have been conducted in pediatric surgical patients, strength of evidence criteria have not been applied to these recommendations. with few exceptions (e.g., aminoglycoside dosages), pediatric doses should not exceed the maximum adult recommended dosages. generally, if a dose is calculated on a milligram-per-kilogram basis for children weighing more than 40 kg, the calculated dosage will likely exceed the maximum recommended dose for adults; adult dosages should therefore be used for larger children. 153 the timing of antibiotic prophylaxis the 2013 revised policy paper on prophylactic antibiotics developed jointly by the american society of health-system pharmacists (ashp), the infectious disease society of america, the surgical infection society, and the society for healthcare epidemiology of america states: successful prophylaxis requires the delivery of the antimicrobial to the operative site before contamination occurs. thus, the antimicrobial agent should be administered at such a time to provide serum and tissue concentrations exceeding the minimum inhibitory concentration (mic) for the probable organisms associated with the procedure, at the time of incision, and for the duration of the procedure. 154 current evidence suggests that for most β-lactams, a bolus dose at 15 to 45 minutes before incision is ideal and provides maximum interstitial fluid concentrations at the time of initial bacterial seeding (see table 50 .12). because diffusion distances from capillary to pathogen are greater in obese patients, for this patient subset initiating antibiotic infusion 30 minutes or longer before incision is warranted on theoretical grounds. 155 the initial β-lactam bolus dose should be followed by additional doses at every 1 to 2 half-lives per the ashp guidelines. 154 the use of a ssi prevention bundle in pediatric patients improves compliance with preincision antibiotic administration and decreases the ssi infection rate. 156 allergy to β-lactams several studies have shown that the true incidence of allergy to antibiotics is less than that reflected in medical charts. 157 for surgical procedures where cephalosporins are the prophylaxis of the judgment of the medical professional; clinical reasoning must be tailored to the individual circumstances. finally, children with congenital heart disease and a subgroup of those with repaired congenital heart disease may require bacterial endocarditis prophylaxis (see also tables 16.2 and 16. 3). 167 preventing the transmission of pathogenic microbes during anesthesia infection control and anesthesia: lessons learned from the toronto sars outbreak fecal patina in the anesthesia work area intensive care unit environments and the fecal patina: a simple problem? transmission dynamics of gram-negative bacterial pathogens in the anesthesia work area serratia marcescens bacteremia traced to an infused narcotic postoperative infections traced to contamination of an intravenous anesthetic, propofol staphylococcus aureus bloodstream infections among patients undergoing electro-convulsive therapy traced to breaks in infection control and possible extrinsic contamination by propofol postsurgical candida albicans infections associated with an extrinsically contaminated intravenous anesthetic agent occupationally acquired infections in health care workers. part ii occupationally acquired infections in health care workers. part i transmission of hepatitis c virus by a cardiac surgeon transmission of infection by gastrointestinal endoscopy and bronchoscopy nosocomial transmission of multidrug-resistant mycobacterium tuberculosis. a risk to patients and health care workers disease transmission by inefficiently sanitized anesthetizing apparatus contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? pseudomonas aeruginosa respiratory tract infection acquired from a contaminated anesthesia machine pseudomonas aeruginosa cross-infection due to contaminated respiratory apparatus patient-to-patient transmission of hiv in private surgical consulting rooms hepatitis b virus transmission associated with a multiple-dose vial in a hemodialysis unit fine-particle humidifiers. source of pseudomonas aeruginosa infections in a respiratory-disease unit pseudomonas aeruginosa epidemic traced to delivery-room resuscitators an alternative strategy for infection control of anesthesia breathing circuits: a laboratory assessment of the pall hme filter nosocomial contamination of laryngoscope handles: challenging current guidelines leaving more than your fingerprint on the intravenous line: a prospective study references all boats rise with the tide bacterial reservoirs in the operating room transmission of pathogenic bacterial organisms in the anesthesia work area reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device anaesthetics and inhalers blood contamination of anesthesia equipment and monitoring equipment the routine wearing of gloves: impact on the frequency of needlestick and percutaneous injury and on surface contamination in the operating room infection control in the outpatient setting infection prevention in anesthesia practice: a tool to assess risk and compliance safe infection control practices for protection of prevention of airborne exposure during endotracheal intubation guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) blood contamination of anaesthetic and related staff update: human immunodeficiency virus infections in health-care workers exposed to blood of infected patients the eyes as a portal of entry for hepatitis and other infectious diseases molluscum contagiosum the epidemiology of molluscum contagiosum in children nosocomial outbreak of scabies in a hospital in spain an outbreak of scabies in a teaching hospital: lessons learned herpes simplex cross infection in the operating room herpetic whitlow infection in a general pediatrician-an occupational hazard herpetic whitlow: an infectious occupational hazard hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission reducing perioperative infection is as simple as washing your hands hand hygiene in the intensive care unit hygienic practices of consultant anaesthetists: a survey in the north-west region of the uk joint working party of the hospital infection society and the surgical infection study group workbook for designing, implementing and evaluating a sharps injury prevention program pep steps: a quick guide to postexposure prophylaxis in the health care setting. mountain plains aids education and training center the risk of needlestick injuries and needlesticktransmitted diseases in the practice of anesthesiology percutaneous injuries in anesthesia personnel sharp truth: health care workers remain at risk of bloodborne infection universal treatment success among healthcare workers diagnosed with occupationally acquired acute hepatitis c prevention of needle-stick injury. efficacy of a safeguarded intravenous cannula strategies for preventing sharps injuries in the operating room preventing transmission of blood-borne pathogens: a compelling argument for effective device-selection strategies accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at mayo clinic rochester don't get stuck with unsafe needles. instead, get involved in needle device selection update on needlestick and sharps injuries: the needle stick safety and prevention act of 2000 multicenter study of contaminated percutaneous injuries in anesthesia personnel needle injuries among pediatric housestaff physicians in new york city device-specific sharps injury and usage rates: an analysis by hospital department needlestick injuries among health care workers. a literature review sharps injuries among hospital support personnel prevalence of safer needle devices and factors associated with their adoption: results of a national hospital survey effect of implementing safety-engineered devices on percutaneous injury epidemiology a review of sharps injuries and preventative strategies preventing needlestick injuries among healthcare workers: a who-icn collaboration sharps disposal in the ed: simple techniques and equipment monografía-manual para el desarrollo de un programa de prevención de infecciones de sitio quirúrgico, escuela de salud pública prevención de infección de sitio quirúrgico y seguridad del paciente en pre, intra y postquirúrgico, instituto nacional de epidemiología documento de consenso on propofol anesthesia and implications of stopcock contamination recombinant factor viii for the treatment of previously untreated patients with hemophilia a. safety, efficacy, and development of inhibitors kogenate previously untreated patient study group a simple, cost-effective method of preventing laryngoscope handle contamination contamination and resterilization of the bain circuit glass particle contamination: influence of aspiration methods and ampule types glass particle contamination in single-dose ampules drug contamination from opening glass ampules a microbiological study of the contamination of the syringes used in anaesthesia practice anesthesiologists should not give iv medications with common syringe bacterial growth in ropivacaine hydrochloride ropivacaine 0.1% with sufentanil 1 microg/ml inhibits in vitro growth of pseudomonas aeruginosa and does not promote multiplication of staphylococcus aureus growth of staphylococcus aureus in four intravenous anesthetics propofol, but not thiopental, supports the growth of candida albicans growth of microorganisms in propofol, thiopental, and a 1 : 1 mixture of propofol and thiopental outbreak of severe sepsis due to contaminated propofol: lessons to learn infectious disease risk associated with contaminated propofol anesthesia bacterial contamination of needles used for spinal and epidural anaesthesia preventing perioperative transmission of infection: a survey of anesthesiology practice accidental needlesticks: do anesthesiologists practice proper infection control precautions? anesthesia practice-a vector of infection? letter: hepatitis-b antigen on environmental surfaces susceptibility of healthcare workers to measles, mumps rubella and varicella lessons learned: protection of healthcare workers from infectious disease risks guidelines for prevention of transmission of human immunodeficiency virus and hepatitis b virus to health-care and public-safety workers the dynamics of enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers hand hygiene knowledge and perceptions among anesthesia providers infection control-a problem for patient safety classic pages in obstetrics and gynecology. oliver wendell holmes. the contagiousness of puerperal fever the etiology, concept, and prophylaxis of childbed fever puerperal sepsis hand washing and hand disinfection: more than your mother taught you effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care quantification of hand hygiene compliance in anesthesia providers at a tertiary care center in northern india apic guideline for handwashing and hand antisepsis in health care settings compliance with handwashing in a teaching hospital improving compliance with hand hygiene in hospitals effectiveness of a hospital-wide programme to improve compliance with hand hygiene hand hygiene: improved standards and practice for hospital care improving adherence to hand hygiene practice: a multidisciplinary approach guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hipac/shea/apic/idsa hand hygiene task force preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects touch contamination levels during anaesthetic procedures and their relationship to hand hygiene procedures: a clinical audit guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee how-to guide: improving hand hygiene. a guide for improving practices among health care workers bacterial contamination of the hands of hospital staff during routine patient care anatomy of a defective barrier: sequential glove leak detection in a surgical and dental environment examination gloves as barriers to hand contamination in clinical practice prevention of central venous catheter-related bloodstream infections using non-technologic strategies benchmarking for prevention: the centers for disease control and prevention's national nosocomial infections surveillance (nnis) system experience public health service guidelines for the management of occupational exposures to hbv, hcv, and hiv and recommendations for postexposure prophylaxis varicella and paediatric staff: current practice and vaccine cost-effectiveness varicella serological status of healthcare workers as a guide to whom to test or immunize controlling varicella in the healthcare setting: the cost effectiveness of using varicella vaccine in healthcare workers varicella vaccination for healthcare workers at a university hospital: an analysis of costs and benefits a survey of policies at children's hospitals regarding immunity of healthcare workers: are physicians protected? prevention and control of varicella-zoster infections in healthcare facilities predicting transient particle transport in enclosed environments with the combined computational fluid dynamics and markov chain method room ventilation systems. operating room design manual occupational transmission of tuberculosis: implications for anesthesiologists occupational transmission of mycobacterium tuberculosis to health care workers in a university hospital in the bacterial and viral filtration performance of breathing system filters prevention of cross contamination, patient to anesthesia apparatus to patient, using filters heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. part 1-history, principles and efficiency heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. part 2-practical use, including problems, and their use with paediatric patients hidden hazards and dangers associated with the use of hme/filters in breathing circuits. their effect on toxic metabolite production, pulse oximetry and airway resistance who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care water-assisted liposuction for body contouring and lipoharvesting: safety and efficacy in 41 consecutive patients world health organization. practical guidelines for infection control in health care facilities. searo regional publication no. 41 hand hygiene among physicians: performance, beliefs, and perceptions multiple reservoirs contribute to intraoperative bacterial transmission retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population effects of controlled perioperative antimicrobial prophylaxis on infectious outcomes in pediatric cardiac surgery role of decolonization in a comprehensive strategy to reduce methicillin-resistant staphylococcus aureus infections in the neonatal intensive care unit: an observational cohort study immediate control of a methicillinresistant staphylococcus aureus outbreak in a neonatal intensive care unit clinical practice guidelines for antimicrobial prophylaxis in surgery clinical practice guidelines for antimicrobial prophylaxis in surgery administration of parenteral prophylactic beta-lactam antibiotics in 2014: a review reducing surgical site infections at a pediatric academic medical center drug allergies in the surgical population is there cross-reactivity between penicillins and cephalosporins? a review of evidence supporting the american academy of pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients practical aspects of choosing an antibiotic for patients with a reported allergy to an antibiotic hypersensitivity reactions to beta-lactam antibiotics anaphylactic shock due to cefuroxime in a patient taking penicillin prophylaxis antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery community surveillance of complications after hernia surgery quality in pediatric anesthesia prevention of bacterial endocarditis. recommendations by the american heart association key: cord-290524-2el9tx9v authors: weese, j. scott title: barrier precautions, isolation protocols, and personal hygiene in veterinary hospitals date: 2004-12-31 journal: veterinary clinics of north america: equine practice doi: 10.1016/j.cveq.2004.07.006 sha: doc_id: 290524 cord_uid: 2el9tx9v because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. written policies are required for practical and liability reasons and should be reviewed regularly. although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. regular reassessment of protocols based on ongoing research and clinical experiences is required. reduce the risk of infection of hospitalized animals with pathogens from the resident microflora of hospital personnel. in human medicine, prevention of transmission of bloodborne pathogens, such as hiv, hepatitis b virus, and hepatitis c virus, from patients to health care workers (hcws) is a major concern [1, 2] . the epidemic of hiv in the general population and hcws led to the development of universal precautions. based on universal precautions, infection control practices are applied to all patients, regardless of known or suspected infectious disease status, and emphasize the prevention of any contact with blood or certain body fluids [2] . in veterinary medicine, there currently are not the same concerns about transmission of bloodborne pathogens to veterinary personnel. indeed, the attitude toward blood contamination in veterinary medicine is somewhat cavalier. nevertheless, it is critical to remember that new diseases are emerging at all times and that many of these new diseases are zoonotic. just because there is minimal concern about bloodborne pathogens of horses at this point in time does not mean that there is no risk posed by exposure to equine blood now or in the future. it is prudent to ensure that adequate precautions be taken now rather than waiting for the infection of large numbers of veterinary personnel to stimulate change, as occurred in human medicine. although the initial focus of barrier precautions in human hospitals was prevention of disease in hcws, increasing attention has been paid to the role of hcws in dissemination of pathogens in human hospitals. the dissemination of multidrug-resistant (mdr) pathogens and the severe impact of mdr infections in human hospitals have led to changes in protocols to limit the spread of these organisms within hospitals. the use of barrier precautions has been an important part of these protocols; however, the efficacy and necessity of these protocols are unclear. in the united states, the occupational safety and health administration (osha) has mandated that hcws have access to appropriate personal protective equipment. the type of personal protective equipment required for each situation has been left to the discretion of the employee and employer; however, potentially contaminated body fluids are not to reach the employee's work clothes or street clothes, undergarments, skin, eyes, mouth, or other mucous membranes [3] . the level of barrier protection required would thus depend on the risk of contact with body fluids of concern, the potential for splashing or aerosol exposure, the volume of fluid that might be produced, and the duration of exposure [1] . these same points are relevant in the veterinary context. veterinary hospitals need to be aware of osha or equivalent rules to provide a safe workplace and avoid potential liability. thus, the development of appropriate infection control protocols, including barrier precautions, is required. in general, consideration must be given to the route of pathogen transmission: contact (direct or indirect), droplet, airborne, common vehicle (eg, equipment, medical devices), and vector borne. standard protective outerwear includes clean coveralls, laboratory coats, scrubs, or other dedicated clothing (eg, hospital uniforms). protective outerwear should be changed whenever it is visibly soiled or otherwise contaminated with body fluids perceived or known to pose a risk (eg, feces, blood, nasal exudates, urine or uterine fluid). additionally, outerwear should be changed frequently (at least daily), because gross contamination does not need to be present for pathogen contamination to have occurred. hospital personnel should change their hospital outerwear before leaving the building; coveralls, laboratory coats, surgical scrubs, and related items should not be worn out of the hospital setting. wearing protective outerwear home increases the risk of transmission of pathogens from the hospital to the household and from animals at home to hospitalized animals. all veterinary hospitals should provide laundry services so that outerwear does not leave the building. gloves are an important component of most, if not all, barrier protocols. the centers for disease control and prevention (cdc) recommend glove use by hcws to reduce the risk of transmission of infections from patients to personnel, to prevent hcw skin flora from being transmitted to patients, and to reduce transient contamination of the skin on hands of personnel by microorganisms that can be transmitted from one patient to another [2] . glove use has been shown to be an effective means of reducing pathogen transmission in human medicine. the use of gloves during peripheral venous catheter placement has been demonstrated to reduce the frequency of complications in human patients compared with regular handwashing [4] . glove use has been an important part of successful infection control programs in human hospitals [5] [6] [7] , although the relative effect of glove use versus concurrently applied measures is sometimes difficult to interpret. it has been suggested that universal glove use in human hospitals might be preferable for prevention of transmission of mdr bacteria, because as many as 5 to 10 patients may be colonized for every patient known to be infected [8] . to the author's knowledge, there are no published standards for glove use in veterinary hospitals apart from the use of sterile gloves during surgery. examination gloves that are clean but not sterile are often used when handling wounds, infected body sites, and animals known or likely to be shedding pathogens in body fluids from orifices or on their skin; however, widespread use of examination gloves and protocols regarding glove use are not common. at the ontario veterinary college veterinary teaching hospital (ovc-vth), a policy requiring glove use for any contact with equine patients was instituted in response to nosocomial and zoonotic transmission of methicillin-resistant staphylococcus aureus (mrsa). whether this has reduced the transmission of mrsa or other mdr bacteria at the ovc-vth is under investigation. objective data are not available to help develop glove use protocols for veterinary hospitals; however, it is reasonable to recommend that gloves be worn whenever there might be contact with nasal secretions; feces; or discharge from surgical incisions, draining abscesses, or wounds. education of hospital personnel is important so that glove use does not result in less emphasis on hand hygiene. gloves may have small inapparent defects or be torn during use, and hands may be contaminated while removing gloves. hand hygiene measures should be performed immediately after glove removal. if gloves are used to handle potentially contaminated items and not immediately discarded, they are not acting as an effective barrier in preventing the spread of nosocomial pathogens to surfaces or other patients, although they may still be protecting the wearer. care should be taken to remove gloves before handling items like pens, stethoscopes, thermometers, stall surfaces, medical records, pagers, telephones, and cabinet or door handles. gloves should be changed between all patient contacts. for more than a century, gowns have been used to prevent transmission of disease to hcws and patients [1] . gowns have most commonly been used in surgery; however, their use in hospital wards is increasing. the cdc has produced guidelines stating that ''gowns are worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments'' [2] . gowns should be worn whenever direct contact with the patient or indirect contact with the environment or patient care items may result in transmission of pathogens. a variety of types of gowns are available in terms of the degree of body coverage and the material the gown is made of. the ideal barrier gown would cover all areas of the body that might become contaminated, prevent penetration of liquids, be of adequate strength to resist tearing and puncture under normal activities, be comfortable to wear for long periods, be available in appropriate sizes for all personnel, be nonabrasive to skin, and be of acceptable cost [1] . neither the overall effectiveness of gowning nor the effectiveness of different gowns in veterinary situations has been adequately evaluated. all these factors must be considered when choosing a gown for use in a hospital (nonsurgical) situation. in particular, the ability to resist contamination during anticipated animal contacts, ease of use, and cost are important. the most likely problem in veterinary practice is poor resistance to liquids, especially under direct contact or pressure. in equine medicine, there is a greater likelihood of high-volume contact with fluids (ie, diarrheic horse) or direct contact with patient surfaces that would have moist secretions or excretions (ie, horse with nasal discharge rubbing against personnel). these types of high-risk situations must be considered when choosing an appropriate gown. additionally, prolonged contact with potentially infectious patients, such as with 24-hour nursing care of neonatal intensive care unit foals, creates additional problems. if gowns do not cover the entire body (eg, gowns that do not cover the lower extremities) and hospital personnel are in prolonged contact situations with foals, the likelihood of contamination is high. full body gowns may be more appropriate in these situations. there is more evidence supporting the effectiveness of gowns in preventing disease transmission to hcws compared with the prevention of spread of nosocomial disease [1] . some studies have failed to show any benefit of gowning in specific situations, such as newborn units and neonatal intensive care units [9] [10] [11] , whereas others have reported significant beneficial effects on nosocomial disease [12] [13] [14] . in particular, the use of gowns that offer little resistance to liquid penetration and those that leave the lower extremities exposed have been questioned. perhaps the main advantage of gowns in these situations is raising awareness of the potential infectious nature of the patient and encouraging the concurrent use of other appropriate infection control protocols. protective eyewear, including goggles and face shields, is used in human medicine during procedures in which sprays of blood, body fluids, and secretions may occur [2] , and the use of these items is mandated in some instances by the osha bloodborne pathogens final rule [3] . the use of eye protection in equine hospitals is extremely uncommon, perhaps justifiably so, considering the low prevalence of bloodborne zoonotic pathogens in horses. nevertheless, it would be prudent to consider the use of these items when spraying of potentially infected secretions may occur. normal surgical masks may be effective against the spread of large particle droplets that are transmitted by close contact and travel only short distances (up to 3 ft) from infected patients [2] . transmission of severe acute respiratory syndrome to hcws prompted re-evaluation of the effectiveness of normal surgical masks in the prevention of disease transmission. one study reported that wearing of surgical or n95 masks (but not paper masks) by staff was associated with protection [15] . other authors have questioned the overall effectiveness of surgical masks in hospital situations [16] . airborne transmission of zoonotic pathogens from horse to veterinary personnel is thought to be of minimal concern in most hospital settings, and mask use is uncommon in veterinary hospitals apart from surgical procedures. surgical masks might be useful for reducing transmission of mrsa. although mrsa is not considered to be spread via the airborne route, the main location of colonization of mrsa in hospital personnel is in the nasal passages, and hand-to-nose contact is frequent. thus, mask use prevents direct contact between the hand and nose, thereby decreasing hand contamination or decreasing the risk of inoculation of the nose after contamination of the hands during contact with a horse. the actual benefit of masks during short-term patient contact situations is unclear. basic barrier techniques must be used in all veterinary hospitals. clean protective outerwear must be worn by all hospital personnel. the use of other barrier techniques is much more variable and should be directed at control of specific diseases or syndromes. it is important that written protocols outlining the required level of barrier protection be available. gowns and overboots are the most commonly used items for additional barrier protection, but masks, caps, and eye protection may be required at times. in some facilities, overboots are not used but personnel are required to wear rubber boots that are easy to disinfect, and disinfection of boots is required after exiting potentially contaminated areas. determination of the required level of barrier precautions may be based on clinical findings (ie, diarrhea, fever of unknown origin, nasal discharge), farm history (eg, endemic disease, recent infectious diseases on farms), or the nature of the disease. at some hospitals, mainly those in regions where salmonellosis is of particular concern, all horses with colic are treated as if they may be shedding salmonella. common protocols for these equine patients include the use of gloves, gowns, and overboots; restriction of movement in the hospital; and provision of dedicated medical equipment (eg, thermometers, nasogastric tubes, buckets). an understanding of the incidence of pathogen shedding by certain groups within the equine population is required to define appropriate protocols. thus, ongoing active and passive surveillance of nosocomial infection rates plays a key role in determination of the appropriate barrier protocols. barrier precautions, as a whole, have been successful in controlling some outbreaks of nosocomial disease [17, 18] but not others [19] . the reasons why barrier precautions are variably effective is difficult to determine; however, nosocomial infection is a complex multifactorial process, and the individual effects of certain factors are difficult to discern. like most other infection control methods, barrier precautions are only effective if used appropriately, and poor compliance is an ever-present concern that can have a negative impact on the entire infection control program. failure of barrier techniques may involve inherent weaknesses in the items used, inappropriate selection of items, inappropriate use of items, inadequate training of personnel, or the inherent inability of barrier precautions to prevent pathogen transmission completely in all cases. it is important that barrier items do not create a false sense of security. barrier items are useful but by no means 100% effective at preventing transmission of pathogens. it is critical that veterinary personnel use all adjunctive infection control techniques (ie, hand hygiene) and not rely solely on barriers. the reported variability in the benefits of barrier precautions should not dissuade hospitals from implementing these protocols. the use of quarantine to prevent transmission of human or animal disease dates back to biblical times and was widespread in the middle ages [20] , predating understanding and acceptance of the ''germ theory.'' published recommendations for isolation protocols appeared as early as 1877 [21] . the early emphasis was on segregating certain patients in ''infectious disease hospitals,'' which continued to have high levels of nosocomial disease because of a lack of barrier precautions, asepsis, and separation of patients according to their disease [2] . these hospitals were closed over time as better infection control practices and hospital designs were developed [2] . isolation protocols are designed with two basic goals in mind: prevention of transmission of pathogens from infected animals to other animals, people, or the hospital environment and prevention of nosocomial infection to high-risk individuals. guidelines published by the cdc in 1970 and 1975 recommended that hospitals divide isolation precautions into a variety of categories: strict isolation, respiratory isolation, protective isolation, enteric precautions, wound and skin precautions, discharge precautions, and blood precautions [22, 23] . the protocols for each category were based on epidemiologic features of diseases in the given category. in 1983, guidelines were revised to allow for more decision making on the part of the users [24] . hospital infection control committees were given broader powers to develop their own protocols considering the circumstances and environment specific to the hospital. category-specific guidelines were modified and consisted of strict isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretion procedures, and blood and body fluid precautions [24] . further changes occurred later, largely in response to the hiv epidemic, and these earlier categories may be most relevant to veterinary hospitals at this point. in veterinary hospitals, there has been less attention paid to the development of standardized protocols for different diseases or categories. it is logical, however, that veterinary hospitals design appropriate guidelines to deal with diseases of concern in their area and hospital. most isolation protocols have been developed to limit transmission of salmonella. whether all these protocols are necessary for other pathogens, such as viral respiratory pathogens and mdr bacteria, needs consideration, as does whether extra precautions are required in some instances. at a minimum, strict isolation, respiratory isolation, contact isolation, enteric precautions, and drainage/ secretion isolation protocols based on cdc recommendations should be considered, and veterinary-specific guidelines for working with those classes should be developed. identification of the isolation status of patients is critical. this is particularly important when horses may be housed under isolation protocols implemented in the main hospital. appropriate signage should be used to make it clear to all personnel that the animal may be infectious and that additional protocols must be used. at the colorado state university veterinary teaching hospital, a color-coding system is used to indicate the infectious disease status of each patient (p. morley, dvm, phd, personal communication, 2003). under this system, adhesive dots are placed on the stall cards of all animals. red dots indicate animals with a known highly contagious disease. yellow dots indicate that the animal is suspected of having an infectious disease or is at increased risk of acquiring an infectious disease. green dots indicate that the animal is not suspected of carrying a relevant infectious agent and that it is not at an increased risk of acquiring an infectious agent compared with the general hospital population. this type of system is easy to apply and easy to understand and should be considered in all hospitals. additionally, more prominent signs can be used to indicate certain concerns (ie, salmonella, mrsa, rabies suspect) more clearly to all personnel. isolation units should be designed so that, apart from surgical procedures, horses rarely, if ever, have to leave the unit. stocks, examination areas, and weight scales should be available if possible. the isolation unit should be designed so that there is minimal movement of personnel and items between it and the main hospital. changing rooms with showers are ideally present in the unit. preferably, the isolation unit should be physically separated from the main hospital. in cold snowy climates, this may be problematic because of the difficulty in moving personnel, animals, and supplies. if the isolation unit is properly designed and largely self-sufficient in terms of supplies and staffing, these difficulties may be largely overcome, although there may be resistance from clinicians because of the additional effort required to evaluate animals in the isolation unit. much consideration should be given to the design of stalls in isolation units. in particular, the area of entry and means of manure disposal should be considered. anterooms containing routine supplies and medical records are commonly used. these rooms allow for containment of routine items used on the animal but can be a highly contaminated environment depending on the barrier methods used when in the stall, the method of removal of barrier items, and cleaning protocols for the stall and anteroom. if anterooms are stocked with routine items (ie, syringes, bottles of soap and disinfectant, medical records), consideration should be given to preventing contamination of these items and what to do with all items in the stall after an infectious animal is discharged. ideally, anterooms should be minimally stocked and all items disposed of when the animal leaves the hospital. any items returned to the hospital from an isolation stall should be cleaned and disinfected in the stall if possible, placed in a leak-proof bag, labeled as potentially infectious, and returned to the hospital to a designated area for further disinfection. contamination of the anteroom with manure should be avoided. ideally, there should be minimal contact of personnel with infectious animals and their stall environment. minimization of contact should not interfere with the delivery of appropriate veterinary care, however. sealed windows used as viewing sites allow for general inspection of patients without having to enter the stall or anteroom. closed-circuit televisions or web-cameras can be placed in stalls and projected to a central area for frequent remote monitoring. an added advantage of web-cameras is that remote password-controlled access from any computer can be established so that clinicians can evaluate the general appearance of the patient without even entering the isolation unit, let alone the stall. in some situations, a degree of increased barrier precautions or some physical distance from other patients when transferring a horse to the isolation unit is not indicated, practical, or desirable. examples of this would be when animals cannot be safely or effectively treated in isolation (eg, neonatal intensive care unit foals, horses with severe neurologic disease) or when the isolation unit is full. in these situations, some clinics use inhospital isolation or ''semi-isolation.'' in-hospital isolation protocols allow for an increased level of protection but are not a replacement for a proper isolation unit and should not be used solely for clinician convenience. it is critical that animals isolated within the main hospital be prominently identified, as discussed previously. protocols should be developed regarding the handling of animals, the stall, and the area around the stall. animals that are isolated in the hospital should not be walked outside their stall unless they are being moved for a required procedure. if they are moved, their feet should be picked out and scrubbed with an appropriate disinfectant (ie, 0.5% chlorhexidine) at the time they leave the stall. one person should follow behind the horse to collect and appropriately dispose of any feces, and any areas potentially contaminated by the horse or its body fluids should be sprayed with disinfectant. people handling these horses should wear protective barrier clothing, such as full waterproof coveralls or a full-length waterproof gown, gloves, and dedicated footwear or boot covers. care should be taken to avoid clutter of potentially contaminated items (ie, barrier items, buckets, nasogastric tubes) outside the stall. the area around the stall entrance should be considered potentially infectious and disinfected routinely (at least three to four times per day). attention should be paid to the pattern of water drainage from the stall and in the area. if water runs from the stall to the breezeway or runs down the breezeway past the stall, housing of potentially or known infectious animals in the stall may be inappropriate. horses should not be able to come into direct contact with neighboring animals. barriers may be required if solid walls are not present on all sides. horses potentially carrying respiratory pathogens that can be spread via the aerosol route should not be housed in general ward areas. specific protocols should be developed for cleaning inhospital isolation stalls. these stalls should be cleaned last, personnel cleaning stalls must wear protective gear, and items used to clean the stall must be disinfected immediately after use. one of the major problems with barrier precautions is obtaining compliance by hospital personnel. ''time factors'' and ''too cumbersome'' were the most commonly reported reasons for noncompliance with barrier precaution protocols by trauma professionals in a human hospital [25] . a similar study evaluated the use of barrier precautions during trauma resuscitations and reported that none of 104 hcws in the study were in complete compliance with protocols for the use of barrier precautions; however, 98% wore gloves [26] . the authors concluded that hcws are cavalier with respect to bloodborne diseases and that measures to encourage or force compliance are required. compliance is also of concern in isolation units in terms of admission of potentially infectious horses and the correct use of appropriate protocols. depending on the facility, there may be reluctance to admit certain moderate-risk patients to the isolation unit because of difficulties in case management, such as distance to the unit from the main hospital, time required to comply with all the isolation protocols, and the associated increased cost to the client. cost is another factor that may limit the use of barrier precautions. barrier precautions almost always involve the use of disposable items, and the cost of these items is not insignificant. at the ovc-vth, approximately us $42,000 is spent annually on disposable isolation gowns ($14,000), gloves ($18,000), and overboots ($10,000). although these figures are for the entire teaching hospital, most barrier items are used in caring for hospitalized equine patients. it is also important to note that glove use is required for any contact with horses in this institution, thereby explaining the use of more than 4200 boxes of examination gloves. in times of fiscal constraint, especially at veterinary teaching institutions, there may be reluctance to spend this amount of money without clearly demonstrated benefits. concerns about cost should be tempered with the consideration of the costs of nosocomial and zoonotic infections and costs of hospital closure and decontamination should major outbreaks occur. cost is also a concern with isolation facilities because they are expensive to build, maintain, and staff. isolation units should be designed so that enough stalls are present to allow contaminated stalls to be cleaned and disinfected, followed by a specific period when the stall remains empty between patients. ideally, isolation facilities should have dedicated personnel so that there is no cross-contact with the main hospital. this is not feasible in all situations, particularly in small hospitals, where the caseload does not justify full-time technical staffing. another area of concern that is difficult to quantify is the potential adverse effect of barrier precautions on patient care. if cumbersome protocols are required, particularly in busy hospitals, there may be a tendency to spend less time in direct contact with animals. in human medicine, it has been reported that certain infection control protocols may be a disincentive to enter patient rooms [27] . in some aspects, this might be desirable, because infection control protocols should reduce personnel traffic and limit the potential for spread of pathogens. although limiting unnecessary contact is desirable, the concern is that medically required contacts may be limited and that patient care may be compromised. a recent study in a human hospital confirmed this suspicion, reporting significantly lower contact times with isolated patients, despite the isolated patients being more severely ill [28] . results of this study clearly demonstrate that proper consideration be given to which patients to isolate and how to manage these patients to ensure proper care. of all the possible measures that can be taken to reduce nosocomial and zoonotic infection, hand hygiene is perhaps the most important, easiest to use, most cost-effective, and most underused measure [29] [30] [31] . an understanding of the beneficial effects of hand hygiene dates back to the middle 1800s and the astute observations of ignaz semmelweis [32] . his institution of a mandatory hand disinfection program for clinicians and students resulted in a tremendous decrease in puerperal fever, which was a common cause of postpartum disease in women during that period. independently, oliver wendell holmes concluded that the hands of hcws spread puerperal fever, and he described methods for limiting the spread of disease [33] . formal implementation of hand hygiene policies lagged tremendously, however, and it was well into the twentieth century before an emphasis began to be placed on hand hygiene. hands of hcws are thought to be the most common source of nosocomial infection; despite convincing data regarding the benefits of hand hygiene, particularly when compared with the overall dearth of other objective data regarding infection control measures, hand hygiene is still underused in the medical field. traditionally, handwashing with water and soap has been the standard for hand hygiene. the cleaning activity of soaps is from their detergent properties, which results in removal of debris from the hands [33] . plain soaps have little if any effect on pathogens residing on the hands, however. it has been demonstrated that handwashing with plain soap fails to remove pathogens from the hands of hospital personnel [34] . paradoxically, some studies have shown that handwashing with plain soap may increase bacterial counts on the skin [35, 36] . handwashing with plain soap before intravenous catheter placement was reported to be no more effective than no hand hygiene at reducing the incidence of catheter complications in human patients [4] . antimicrobial soaps are widely available in hospitals and have been demonstrated to be effective at reducing bacterial hand contamination. these may contain a variety of antimicrobial substances, including triclosan, hexachlorophene, povidone-iodine, and chlorhexidine [33] . unfortunately, compliance with handwashing is typically poor. studies evaluating handwashing frequency in hcws have yielded disappointing results, with handwashing only occurring after 12.9% to 75% of situations in which it was indicated [30, 37] . in particular, physicians tend to have poor compliance with hand hygiene protocols [27] . compliance with hand hygiene protocols is a major challenge for infection control programs. reasons given for poor compliance with hand hygiene include lack of time, poor access to proper handwashing facilities, and skin damage from repeated washing [33, 38] . skin damage from repeated handwashing is a definite concern in hospital situations. the frequency of dermatitis can be high in personnel who wash their hands frequently. one study reported that 25% of nurses evaluated had clinical signs of dermatitis and 85% had a history of skin problems [38] . damaged skin is of particular concern from an infectious control standpoint because it can harbor greater numbers of bacteria than normal skin. more recently, alcohol-based hand sanitizers have become popular. these products have many advantages over antimicrobial soaps, including their spectrum of antimicrobial activity, speed of activity, dermal tolerance, and ease of use. they also eliminate the chance for cross-contamination from water taps and paper towel dispensers [39] . increasingly, hand hygiene guidelines are recommending the use of these products when gross contamination of hands is not present [33] . most alcohol-based hand sanitizers contain 60% to 70% alcohol and may be in a gel or liquid form. recently, it has been suggested that an alcohol concentration of 80% or higher is desirable, and a product containing 85% alcohol is now available [40] . although there are potential advantages of alcohol-based products in terms of effectiveness against microorganisms, the main advantage is ease of use. additionally, alcohol-based hand sanitizers can easily be placed throughout the hospital at minimal cost. as well, individual use bottles can be dispensed to health care providers to keep on their person for ease of use even when wall dispensers are not in the immediate area. sinks, on the other hand, are difficult and costly to add in an established facility. the use and effectiveness of hand hygiene in veterinary situations have not been adequately explored. although much of the information obtained in human medicine can be applied to veterinary hospitals, care must be taken with direct extrapolation of human studies. it is logical to assume that horses would have a higher endogenous bacterial load on their skin because of their haired coat and typical housing methods. this would translate into the potential for greater contamination of the skin on hands of veterinary personnel who handle horses compared with human health care providers. veterinarians typically wear gloves less commonly than their counterparts in the medical field, and there is a somewhat cavalier attitude taken toward hand contamination in veterinary medicine as compared with human medicine. gross contamination of hands with feces, discharge, and pus is likely more common, and access to handwashing facilities may be limited. effectiveness of hand hygiene in veterinary situations has not been thoroughly evaluated. a recent study reported that use of an alcohol-based hand sanitizer was more effective at reducing hand contamination after physical examination of horses than a 15-second handwash with antibacterial soap (j.l. traub-dargatz, dvm, ms, personal communication, 2004). this finding is important because it countered concerns that debris on the hands from animal contact might inhibit the efficacy of alcohol-based products. many facilities are now placing alcohol-based hand disinfectant dispensers widely throughout the hospital. at the ovc-vth, approximately 80 dispensers have been placed. at some hospitals, individuals have been given small personal containers of hand disinfectant to carry around while on clinical duty. all hospitals should consider widespread placement of alcohol-based hand dispensers as part of the infection control program. the area under the fingernails tends to harbor large numbers of bacteria. hospital personnel with false fingernails have been shown to harbor more gram-negative bacterial pathogens under their fingernails before and after handwashing [41, 42] . naturally long (>0.25 in) fingernails may also affect the effectiveness of hand hygiene and harbor excessive bacteria [43] . additionally, chipped nail polish may support the growth of larger numbers of bacteria on the fingernails [33] . at the ovc-vth, people in animal contact positions are not allowed to wear false fingernails or nail polish and must keep their nails cut short. studies have indicated, not surprisingly, that skin underneath rings is more heavily colonized with bacteria compared with other areas on the fingers [44, 45] . this may relate to a more hospitable environment for bacterial growth (eg, warm, moist, protected) and decreased exposure during handwashing. whether the wearing of rings is linked to transmission of disease is unknown and requires further study [33] . in the interim, some facilities, including our institution, have restricted jewelry to wedding rings and wedding bands, although there has been little effort to evaluate and enforce compliance at this point. long neck chains and bracelets that could come into contact with animals are also of concern for safety (entanglement) and infection control reasons. although the risk of these items is unclear, it is reasonable to prohibit wearing of any jewelry items that could come into contact with animals. hospital personnel commonly carry cellular and wireless telephones, and these items have a high likelihood of becoming contaminated. frequently, personnel handle telephones if they are ringing regardless of the cleanliness of their hands or examination gloves. further, disinfection of telephones and pagers is rarely performed because of the possibility for damage to the telephone or pager. mrsa has been isolated from a wireless telephone in a veterinary clinic [46] . pagers have a similar potential to become contaminated [47] . the role of contaminated surfaces of telephones and pagers in pathogen transmission is unclear at this point but should be considered. unlike barrier materials, an additional concern about these items is that they frequently accompany personnel home and, if contaminated, could expose other individuals or animals at home. personnel training should emphasize that telephones and pagers should only be handled with clean hands. telephone covers that protect the telephone from contamination and can be routinely disinfected should be considered. personal medical items, particularly stethoscopes, have come under scrutiny as reservoirs of potential pathogens. stethoscopes have close and frequent contact with patient skin surfaces and can easily become contaminated. one study reported that 69% of doctors' stethoscopes had microorganisms on them, with most organisms being potential nosocomial pathogens [48] . regular cleaning of the stethoscope bell and diaphragm with alcohol has been shown to reduce bacterial contamination significantly [49] . stethoscopes should be cleaned at least once daily and after every contact with a potentially infectious horse. consideration should be given to providing dedicated stethoscopes for infectious cases and animals at greater risk of acquiring a nosocomial infection (ie, compromised neonatal foals). because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. written policies are required for practical and liability reasons and should be reviewed regularly. although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. regular reassessment of protocols based on ongoing research and clinical experiences is required. a review of single-use and reusable gowns and drapes in health care hospital infection control practices advisory committee. guideline for isolation precautions in hospitals department of labor occupational safety and health administration. occupational exposure to bloodborne pathogens; final rule the influence of hand hygiene protocols prior to insertion of peripheral venous catheters on the frequency of complications immediate control of a methicillin-resistant staphylococcus aureus outbreak in a neonatal intensive care unit the role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation prospective, controlled study of vinyl glove use to interrupt clostridium difficile nosocomial transmission controlling antimicrobial resistance in hospitals: infection control and use of antibiotics overgown use for infection control in nurseries and neonatal intensive care units a randomized controlled trial of a nursery ritual: wearing cover gowns to care for healthy newborns effects of discontinuing cover gowns on a postpartal ward upon cord colonization of the newborn prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions a prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit to gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) the effectiveness of surgical face masks: what the literature shows a cluster of vancomycin-resistant enterococcus faecium in an intensive care unit vancomycin-resistant enterococcus faecium in hospitalized children failure to eradicate vancomycin-resistant enterococci in a university hospital and the cost of barrier precautions the origin of quarantine communicable disease nursing us government printing office us government printing office cdc guideline for isolation precautions in hospitals barrier precautions in trauma: is knowledge enough? noncompliance of health care workers with universal precautions during trauma resuscitations adverse effects of contact isolation contact isolation in surgical patients: a barrier to care? a causal link between handwashing and risk of infection? examination of the evidence sensibly applying the science. compliance with handwashing and barrier precautions impact of handwashing on mortality in intensive care guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/ apic/idsa hand hygiene task force failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters physiologic and microbiologic changes in skin related to frequent handwashing skin intolerance and effectiveness of two hand decontamination procedures in everyday hospital use handwashing frequencies in an intensive care unit prevalence and correlates of skin damage on the hands of nurses bacterial transfer and cross-contamination potential associated with paper-towel dispensing spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent sterillium gel effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers bacterial carriage by artificial versus natural nails a prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? microorganisms isolated from skin under wedding rings worn by hospital personnel handwashing: ringwearing and number of microorganisms isolation of methicillinresistant staphylococcus aureus from the environment in a veterinary teaching hospital pathogenic bacteria on personal pagers bacterial colonization of stethoscopes and the effect of cleaning stethoscope: a potential source of infection key: cord-004580-wsd9g5z2 authors: nan title: händehygiene in einrichtungen des gesundheitswesens: empfehlung der kommission für krankenhaushygiene und infektionsprävention (krinko) beim robert koch-institut (rki) date: 2016-08-24 journal: bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz doi: 10.1007/s00103-016-2416-6 sha: doc_id: 4580 cord_uid: wsd9g5z2 nan kategorien in der richtlinie für krankenhaushygiene und infektionsprävention 1 einleitung 2 bezug zu anderen empfehlungen im vorliegenden dokument wird die empfehlung der krinko zur händehygiene aus dem jahr 2000 aktualisiert und erweitert. medizinische einrichtungen wie krankenhäuser, einrichtungen für ambulantes operieren, geburtshäuser/entbindungseinrichtungen, vorsorge-und rehabilitationseinrichtungen, vergleichbare behandlungs-und versorgungseinrichtungen sowie dialyseeinrichtungen und tageskliniken sind gemäß § 23 absatz 5 satz 1 infektionsschutzgesetz (ifsg) zur festlegung innerbetrieblicher verfahrensweisen zur infektionshygiene in hygieneplänen verpflichtet [2] . im hygieneplan der einrichtung sind die indikationen für die maßnahmen der händehygiene in abhängigkeit von den arbeitsaufgaben und den besonderheiten der zu betreuenden patienten einschließlich der rahmenbedingungen, die durchführung und die maßnahmen zur qualitätssicherung unter berücksichtigung der unterschiedlichen berufsgruppen (z. b. pflegedienst, op-team, physiotherapie, ergotherapie, logopädie, hebammen, reinigungsteam) im detail festzulegen und allen mitarbeitern zugänglich zu machen. es empfiehlt sich, an händedesinfektionsplätzen (z. b. im stationsdienstzimmer, in der op-funktionseinheit, in unreinen arbeitsräumen) einen händehygieneplan anzubringen, der aus dem desinfektionsplan als separate empfehlung herausgelöst werden kann, um auf die anliegen der händehygiene (erregerabhängige desinfektion, hautschutz, hautpflege, hygiene der spender) zu fokussieren. darin wird die durchführung der jeweiligen maßnahme (die sog. 5 w: wer, was, wann, womit, wie) festgelegt. diese sind in wischdesinfizierbaren schutzhüllen oder in laminierter form anzubringen. die einschlägigen bestimmungen der gesetzlichen unfallverhütungsvorschrift sind hier mit einzuarbeiten. jeder mitarbeiter ist aktenkundig in den hygieneplan einzuweisen. durch piktogramme kann die aufmerksamkeit auf dieses thema fokussiert werden. es ist zu empfehlen, patienten und besucher in die maßnahmen der händehygiene einzubeziehen. hierfür empfiehlt es sich, durch geeignete formen der aufklärung (z. b. flyer, plakat, patientenbroschüre) das interesse für dieses präventionsanliegen zu wecken und dadurch ein zusätzliches präventionspotential zu etablieren [3] . die nachfolgenden empfehlungen gelten für alle in stationären und ambulanten gesundheitseinrichtungen sowie in der ambulanten betreuung pflegebedürftiger menschen und der pflegerischen betreuung von heimbewohnern tätigen personen, sofern sie in direkten ärztlichen oder pflegerischen kontakt mit patienten oder bewohnern einschließlich der patientennahen umgebung treten, nach tätigkeiten mit erhöhtem kontaminationsrisiko (z. b. abfallentsorgung, wechsel der bettwäsche) oder vor reinen tätigkeiten (z. b. bereitstellung von arzneimitteln, wäsche u. ä.). zusätzlich zu den nachfolgenden empfehlungen sind die vorgaben des arbeitsschutzes, z. b. die trba 250 [4] und die empfehlungen der berufsgenossenschaft für gesundheitsdienst und wohlfahrtspflege zu beachten [5] . im folgenden werden 5 die indikationen der hygienischen und der chirurgischen händedesinfektion, 5 die indikationen für nicht sterile und sterile medizinische einmalhandschuhe, 5 indikationen und voraussetzungen für die händewaschung, 5 anforderungen an spender für hdm und handwaschpräparate, 5 erforderliche flankierende maßnahmen wie hautschutz und -pflege, 5 maßnahmen zur qualitätssicherung mit dem schwerpunkt der interventionsmöglichkeiten zur verbesserung der compliance der hygienischen händedesinfektion und 5 rechtliche aspekte beschrieben. die händehygiene ist als wichtigste maßnahme der basishygiene integraler bestandteil aller krinko-empfehlungen, wobei spezifische aufgabenstellungen der händehygiene einschließlich der bedeutung der hände als überträger von krankheitserregern vor allem in den empfehlungen zur infektionsprävention in pflege, diagnostik und therapie sowie zur betriebsorganisation in speziellen bereichen behandelt werden. bei der erarbeitung fach-bzw. einrichtungsspezifischer regelungen müssen daher zusätzlich auch diese entsprechenden dokumente berücksichtigt werden. gemäß deutschem arzneimittelrecht sind hdm mit medizinischer zweckbestimmung i. d. r. arzneimittel 1 im sinne des § 2 arzneimittelgesetz (amg) [6] und bedürfen gemäß § 21 amg einer zulassung durch die zuständige behörde. im rahmen des zulassungsverfahrens werden wirksamkeit, qualität, sicherheit und unbedenklichkeit geprüft. üblicherweise werden desinfektionsmittelspender mit einmalflaschen bestückt. rechtlich ist ein umfüllen nur unter bestimmten voraussetzungen möglich. in § 4 absatz 14 des amg [7] ist das umfüllen von arzneimitteln aus größeren gebinden in kleinere behältnisse als herstellen definiert, d. h. der umfüllende wird zum hersteller und benötigt gemäß § 13 absatz 1 amg eine herstellungserlaubnis. keiner erlaubnis bedürfen gemäß § 13 absatz 2 und 3 amg apotheken und krankenhausapotheken im rahmen des üblichen apothekenbetriebs, d. h. im rahmen ihres versorgungsauftrags. soweit das umfüllen nicht im rahmen des versorgungsauftrags erfolgt, d. h. als abgabe an kunden der apotheke, ist auch für die apotheke eine herstellungserlaubnis gemäß § 13 amg erforderlich. das umfüllen und kennzeichnen von desinfektionsmitteln in arztpraxen und krankenhäusern durch eigenes personal für die anwendung in der eigenen einrichtung ist zwar als herstellung gemäß § 4 absatz 14 amg anzusehen, unterliegt jedoch nicht dem erfordernis einer herstellungserlaubnis, da in diesen fällen weder gewerbs-noch berufsmäßig hergestellt wird. auch ein inverkehrbringen findet in dieser konstellation nicht statt, so dass die abgefüllten arzneimittel nicht der pflicht der zulassung gemäß § 21 amg unterliegen. allerdings muss das umfüllen nach § 67 absatz 2 amg der zuständigen aufsichtsbehörde angezeigt werden und qualitätsgesichert erfolgen. die 1 die europäische union hat in dem durchführungsbeschluss 2016/904 der kommission vom 8. juni 2016 festgelegt, dass 2-propanol-haltige hdm als biozidprodukte eingeordnet werden. derzeit wird diese einordnung aus fachlichen gründen kontrovers diskutiert. es ist daher unklar, ob sich diese auffassung europäisch durchsetzen wird [9] . qualitätssicherung umfasst u. a. die reinigung und sterilisation der desinfektionsmittel-behälter vor der neubefüllung, das umfüllen unter aseptischen bedingungen und die ordnungsgemäße kennzeichnung mit umfüll-und verfalldatum [8] . wegen des aufwands und der sicherheit ist einmalgebinden der vorzug zu geben. in jedem fall haftet der umfüllende für sein hergestelltes produkt [8] . anlass für ein vermeiden des umfüllens ist, dass bakteriensporen in alkohol basierten desinfektionsmitteln überleben und auf diesem weg z. b. in eine wunde gelangen können (risiko von gasbrand und tetanus) [10, 11] . das tatsächliche risiko ist jedoch minimal. so konnten in alkohol basierten händedesinfektionsmitteln nach längerem stehenlassen der geöffneten flasche in 18 % der proben bakteriensporen gefunden werden, jedoch weniger als eine spore pro 10 ml händedesinfektionsmittel. in keinem fall wurden sporen pathogener bakterienspezies identifiziert [12] . dagegen liegt über die in-use kontamination chlorhexidin-basierter handwaschpräparate ein umfangreiches schrifttum vor [13] . im fall einer infektion kann das umfüllen von hdm haftungsrechtlich relevant werden. so wurde in einer einrichtung umgefüllt und die hdm erwiesen sich in zwei überprüften umgefüllten flaschen als kontaminiert, was in verbindung mit weiteren hygienefehlern zu einem richterlichen urteil geführt hat [14] . in die jährlich aktualisierte desinfektionsmittelliste des vah [15] werden auf antrag des herstellers und nach bewertung durch die desinfektionsmittelkommission des vah präparate aufgenommen, sofern sie die prüfanforderungen des vah erfüllen [16] . diese berücksichtigen auch europäische normen [17] [18] [19] [20] [21] oder für den nachweis der viruzidie die anforderungen der dvv/rki-leitlinie [22] . hierbei ist die indikation auf die prophylaktische anwendung beschränkt. die liste der vom rki geprüften und anerkannten desinfektionsmittel und -verfahren [23] enthält nur präparate zur hygienischen und nicht zur chirurgischen händedesinfektion, weil die liste für behördlich angeordnete desinfektionsmaßnahmen gemäß § 18 ifsg vorgesehen ist [2] . zugleich ist es sinnvoll, im fall von massiver bzw. sichtbarer kontamination nach deren mechanischer entfernung eine zweimalige händedesinfektion durchzuführen. die hände des personals werden bei maßnahmen am patienten sowie bei kontakt mit der unmittelbaren patientenumgebung mit potentiell pathogenen erregern kontaminiert [24] [25] [26] [27] [28] [29] [30] und sind die wichtigsten überträger von krankheitserregern. die hygienische händedesinfektion gilt weltweit als die wirksamste einzelmaßnahme zur unterbrechung von infektionsketten in gesundheitseinrichtungen ebenso wie in pflegeeinrichtungen und damit zur prophylaxe von nosokomialen infektionen [31] [32] [33] [34] [35] [36] die bedeutung der händehygiene als eine der grundlegenden maßnahmen zur prävention von transmissionen und infektionen im rahmen der patientenversorgung ist mit hoher evidenz belegt. die who hat in ihrer richtlinie von 2009 einen umfassenden literaturreview zur effektivität der händehygiene bei der prävention von behandlungs-assoziierten infektionen erarbeitet [33] . bereits die erste publikation durch ignaz philipp semmelweis konnte die effektivität der händehygiene bei der prävention von behandlungs-assoziierten infektionen eindrucksvoll belegen [81, 82] . seitdem haben viele untersuchungen den infektionspräventiven einfluss einer gesteigerten händehygiene-compliance mit alkohol basierten desinfektionsmitteln in unterschiedlichen settings nachgewiesen [34, [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] . ebenso wurden durch die eindämmung der ausbreitung von mre die anzahl von mit mrsa, esbl-bildnern, acinetobacter baumannii kolonisierten patienten und von damit verbundenen infektionen reduziert [95] [96] [97] [98] [99] [100] [101] [102] . ebenso ist die effizienz der händedesinfektion bei der beherrschung von ausbrüchen nachgewiesen [103] [104] [105] [106] . auch wenn einige studien eine gewisse wirksamkeit antiseptischer handwaschpräparate zeigen konnten [107] [108] [109] [110] , wird nicht die wirksamkeit der alkohole erreicht. auf grund der schlechteren hautverträglichkeit und der längeren einwirkungszeit sind antiseptische handwaschpräparate daher keine alternative für alkoholische einreibepräparate. die voraussetzungen für eine effektive händedesinfektion sind nur z. t. untersucht und leiten sich überwiegend aus der hygienischen risikobewertung ab. klinik, praxis, pflegeeinrichtungen und andere medizinische arbeitsbereiche sind mit sichtbar sauberen händen und fingernägeln zu betreten. schmut-zige hände und fingernägel (z. b. nach gartenarbeit) sind bereits zuhause zu säubern. kommt es während der tätigkeit zur verschmutzung der hände, sind ein handwaschpräparat und zur schonung der haut nur bei notwendigkeit eine nagelbürste zu benutzen. kurzgeschnittene, mit den fingerkuppen abschließende fingernägel gewährleisten die reinigung der subungualen spatien und minimieren die gefahr der handschuhperforation an den fingerkuppen. nagellack ist abzulehnen, weil er die sichtbeurteilung der nägel behindert und mit steigender tragedauer die kolonisation auf den nägeln zunimmt. obwohl dieser einfluss bei frischem nagellack nicht nachweisbar war, ist die empfehlung, keinen nagellack im gesundheitswesen zu tragen, berechtigt, weil das alter des nagellacks und dessen güte (mikrorisse u. ä.) in praxi nicht beurteilbar sind [111] . die bakteriendichte ist auf künstlichen nägeln höher als auf natürlichen. zugleich beeinträchtigen künstliche nägel den erfolg der händehygiene und erhöhen die perforationsgefahr für einmalhandschuhe [112] [113] [114] [115] [116] . wiederholt konnten künstliche nägel als quelle für ni bei immunsupprimierten patienten und für ausbrüche postoperativer wundinfektionen identifiziert werden [117] [118] [119] [120] [121] [122] [123] . im fall dermatologisch begründbarer nagelbehandlungen sind die hiermit verbundenen risiken in absprache zwischen betriebsarzt bzw. dermatologen und krankenhaushygieniker abzuwägen. schmuckstücke an händen und unterarmen behindern die sachgerechte händehygiene und können dadurch zu einem erregerreservoir werden [124] . bei intensivpflegepersonal korrelierte die anzahl von gram-negativen erregern und s. aureus mit der anzahl getragener ringe [124] . beim tragen von ringen war auf den händen für enterobacteriaceae und nonfermenter eine erhöhte trägerrate, allerdings keine erhöhte transmissionsrate nachweisbar [125, 126] . aber auch wegen der verletzungsgefahr ist das tragen von ringen nicht zulässig [4] . schließlich führt das tragen von ringen zu erhöhter perforationshäufigkeit von medizinischen einmalhandschuhen (untersucht für op-handschuhe) [127] . bei vorliegen von hautläsionen an den händen ist es als ausreichend anzusehen, diese bei nichtchirurgischer tätigkeit erreger-und ggf. flüssigkeitsdicht abzudecken (flüssigkeitsdichtes pflaster) und darüber einen medizinischen einmalhandschuh anzulegen. voraussetzung ist, dass nach dem ablegen der handschuhe eine händedesinfektion toleriert wird. andernfalls sind die mitarbeiter für die dauer der hautläsion patientenfern einzusetzen. beim atopischem ekzem ist das risiko der besiedlung mit s. aureus einschließlich mrsa erhöht [128, 129] indikationen zur händedesinfektion sind situationen, in denen eine händedesinfektion die übertragung von potentiell pathogenen erregern auf patienten, personal sowie gegenstände und oberflächen unterbricht. beobachtungsstudien zur händehygiene-compliance zeigen immer wieder, dass es für die mitarbeiter bei hoher arbeitsbelastung mit häufigen unterbrechungen von arbeitsabläufen schwierig ist, eindeutig die indikationen zur händedesinfektion zu erkennen [132] . die who hat basierend auf den erkenntnissen zur erregertransmission über die hände die sich daraus ableitenden indikationen in 5 indikationsgruppen ("five moments") als grundlage für die schulung und das training der händedesinfektion zusammengefasst. da-tab. 1 vor-und nachteile einzelner händedesinfektionsmittel-spendertypen (adaptiert nach who guidelines on hand hygiene in health care [33] ). wand-oder bett-montierte spender die chirurgische händedesinfektion ist standard vor jedem operativen eingriff [146] , um präoperativ die transiente flora der hände zu eliminieren und die residente flora der hände für die dauer der op größtmöglich zu reduzieren. zusätzlich wird das kontaminationsrisiko durch das tragen steriler op-handschuhe reduziert. für aseptisches arbeiten an klinischen reinraumplätzen z. b. in einer hornhautbank, ist die chirurgische händedesinfektion mit nachfolgendem anlegen steriler handschuhe zu empfehlen [147] . die anforderungen an die wirksamkeit unterscheiden sich gemäß din en 12791 [18] nicht zwischen mikrobiziden handwaschpräparaten und alkoholischen einreibepräparaten; demzufolge war bei alternativer anwendung je eines vertreters beider präparatetypen kein unterschied auf die rate postoperativer wundinfek-tionen nachweisbar [148, 149] . dennoch ist der einsatz von handwaschpräparaten keine alternative für alkoholische einreibepräparate zur chirurgischen händedesinfektion, da die hautverträglichkeit alkoholischer einreibepräparate deutlich besser als von handwaschpräparaten ist [150, 151] . auch das kontaminationsrisiko beim waschvorgang durch die emission der siphonflora beim abspülen der hände spricht gegen den einsatz von handwaschpräparaten [152, 153] . für alkohol basierte präparate mit zusatz von chlorhexidin steht der nachweis der höheren wirksamkeit in bezug auf die prävention postoperativer wundinfektionen aus. auch wenn einige studien zeigen, dass durch den zusatz von chlorhexidin die remanente wirkung verbessert wird [154] [155] [156] , ist bei der ergebnisinterpretation zu berücksichtigen, dass keine neutralisierung von chlorhexidin in der ausknetflüssigkeit durchgeführt wurde. das es ist davon auszugehen, dass durch die chirurgische händedesinfektion das risiko postoperativer wundinfektionen gesenkt wird. diese schlussfolgerung lässt sich aus folgendem sachverhalt ableiten. op-handschuhe können in bis zu 40 % der eingriffe bemerkt oder unbemerkt perforieren [147] . experimentell wurde nachgewiesen, dass ausgehend von nicht desinfizierten händen bei einer handschuhperforation bis zu 10 3 -10 4 kolonie bildende einheiten (kbe) die wunde erreichen können [148] . im gegensatz dazu betrug die übertragene menge bei zuvor desinfizierten händen < 100 kbe [148, 149] . damit wäre zu erklären, dass bei im trageprozess perforierten op-handschuhen erst nach einer tragedauer von > 90 min ein bakterientransfer nachweisbar war [154, 155] . ein ausbruch postoperativer wundinfektionen wurde dadurch verursacht, dass anstelle eines jodhaltigen händedesinfektionsmittels eine nichtmedizinischen seife verwendet wurde [188] , d. h. auf grund der bei längeren chirurgischen operationen unvermeidbaren handschuhperforation wurde auf grund der fehlenden händedesinfektion ein ausbruch verursacht. der op-bereich ist mit sichtbar sauberen händen und fingernägeln zu betreten. schmutzige hände und fingernägel (z. b. nach gartenarbeit) sind bereits zuhause, spätestens aber im unreinen teil der personalschleuse vor dem anlegen der bereichskleidung zu säubern. kommt es während der tätigkeit zur verschmutzung der hände, sind ein handwaschpräparat und zur der schonung der haut nur im bedarfsfall eine nagelbürste zu benutzen. bezüglich fingernägeln und schmuckstücken an händen und unterarmen gelten die gleichen voraussetzungen wie für die hygienische händedesinfektion (s. 3.3) hände und unterarme sind wegen des risikos der wegbereitung von hautirritationen und der damit verbundenen höheren erregerabgabe nicht mit einer bürste zu behandeln [189, 190] . vor operativen eingriffen sollen keine nagelbettverletzung oder entzündliche prozesse an der hand vorliegen [190] . bei psoriasis mit kolonisation durch s. marcescens und bei schwerer onycholyse und onychomykose eines fingernagels mit gleichzeitigem subungualem nachweis von p. aeruginosa wurde ein ausbruch postoperativer wundinfektionen trotz tragens von op-handschuhen verursacht [114, 191] . unter sorgfältiger risikoabwägung erscheint es bei nichtentzündlichen veränderungen bzw. kleinen verletzungen im bereich der hand jedoch vertretbar, die operation mit zwei übereinander gezogenen paar handschuhen, ggf. nach vorheriger applikation eines wundantiseptikums mit remanenter wirksamkeit (z. b. auf basis von octenidin) im wundbereich durchzuführen [190] . alternativ könnten antimikrobiell imprägnierte op-handschuhe die schutzwirkung verbessern [192] . gegebenenfalls ist eine vorstellung beim betriebsarzt bzw. facharzt für dermatologie anzuraten. ringdosimeter können bei sachgerechter anwendung aus personalschutzgründen unter dem aspekt der risikoabwägung toleriert werden. getragene ringdosimeter sind unter berücksichtigung der herstellerangaben aufzubereiten, z. b. durch einlegen in ein alkoholisches hdm für die dauer von 10 min. danach kann der ring ohne klarspülen mit wasser nach lufttrocknung erneut auf die desinfizierte hand angelegt werden [193] . die chirurgische händedesinfektion ist vor dem direktem kontakt zum op-feld und zu sterilen mp oder materialien sowie vor sonstigen eingriffen mit gleichen anforderungen an die asepsis wie bei einer operation durchzuführen. im unterschied zur hygienischen händedesinfektion gibt es bei der akzeptanz der notwendigkeit einer chirurgischen händedesinfektion vor anlegen der sterilen handschuhe kein complianceproblem; letzteres kann nur die durchführung und die einhaltung der zeitdauer betreffen. um die sporenlast an den händen zu reduzieren, wird empfohlen, die hände vor der am op-tag erstmalig durchgeführten chirurgischen händedesinfektion möglichst mit einem abstand von 10 min vor der chirurgischen händedesinfektion zu waschen und sorgfältig abzutrocknen [194] . bei kürzerem abstand wird die wirksamkeit der alkohole durch den verdünnungseffekt der restfeuchte tendenziell oder signifikant reduziert [195] [196] [197] [198] [199] . eine wiederholung der händewaschung ist im weiteren tagesablauf nur bei sichtbarer verschmutzung erforderlich. zur waschung werden hände und unterarme bis zum ellenbogen mit nach oben gerichteten fingerspitzen und tief liegendem ellenbogen während etwa 30-60 s mit einem handwaschpräparat gewaschen. länger dauernde händewaschungen sind wegen potenzieller hautschädigung ab-empfehlungen zulehnen, zumal dadurch keine weitere verminderung der residenten flora erreicht wird [200] [201] [202] . zur desinfektion werden die hände und unterarme für die dauer der deklarierten einwirkungszeit durch eine eingeübte einreibetechnik benetzt. bei der händedesinfektion werden zunächst die hautareale der hand, dann des unterarms bis zum ellenbogen und nachfolgend wieder die hände benetzt. in dieser händedesinfektionsphase soll das hauptaugenmerk beim einreiben auf die fingerkuppen, nagelfalze und fingerzwischenräume gelegt und eine lückenlose benetzung erreicht werden. für die einwirkungszeit von 1,5 min [203] erwies sich folgendes vorgehen als effektiv: zunächst werden beide hände (10 s) und im 2. schritt beide unterarme benetzt (10 s). dem schließt sich die händedesinfektionsphase (70 s) mittels einreiben an [204] . dabei hat die anzahl der applizierten portionen keinen einfluss, solange die hände über die dauer der einwirkungszeit mit dem präparat benetzt gehalten werden [205] . es ist zu beachten, dass dieses vorgehen nur für produkte mit einer deklarierten einwirkzeit von 1,5 min untersucht wurde. die hände sollen trocken sein, bevor die op-handschuhe angelegt werden, weil dadurch die perforationsgefahr verringert [206] , das irritationsrisiko reduziert [207] und wirksamkeit der alkoholischen händedesinfektion bei 1 min lufttrocknung signifikant verbessert werden [208, 209]. ein hygienischer handwaschplatz muss mit zulauf für warmes und kaltes wasser ausgestattet sein [4] . bei einer neueinrichtung oder wesentlichen umgestaltung eines handwaschplatzes ist auf ein ausreichend groß dimensioniertes, tief ausgeformtes handwaschbecken ohne überlauf zu achten. der verzicht auf einen überlauf im waschbecken erscheint nicht nur hygienisch plausibel, sondern der kolonisierte überlauf konnte als ursache einer häufung von serratia liquefaciens infektionen identifiziert werden [210] . falls saubere arbeitsflächen an den waschplatz angrenzen, sind diese durch einen spritzschutz so abzuschirmen, dass es (insbesondere in bereichen der zubereitung von medikamenten) nicht zu einer kontamination der umgebung kommen kann [211] [212] [213] . der handwaschplatz muss abhängig von den räumlichen bedingungen mit wandmontierten spendern für händedesinfektionsmittel und handwaschpräparat und mit einmalhandtüchern ausgestattet sein [4] . der wasserstrahl darf nicht direkt auf den abfluss gerichtet sein, um die entstehung des erregerhaltigen aerosols aus dem siphon zu minimieren [194] . hautpflegemittel konventionelle heißlufttrockner sind für gesundheitseinrichtungen ungeeignet, weil die trocknungswirkung im vergleich zum handtuch geringer ist [221] [222] [223] . nur "jet air" händetrockner mit infrarot erwiesen sich bei 10 s anwendung dem papierhandtuch in der trocknungswirkung gleichwertig [224] . da nach händewaschung durch sorgfältige händetrocknung die translokation von bakterien von den händen auf kontaktflächen signifikant herabgesetzt wird [221, 225] , ist auch unter diesem gesichtspunkt die händetrocknung wichtig [226, 227] . allerdings war nach vorher durchgeführter händedesinfektion keine erhöhte translokation durch heißlufttrockner nachweisbar [228, 229] . nach händewaschung wird durch papier-oder textilhandtuch signifikant mehr restflora als durch heißlufttrockner entfernt [230] [231] [232] . schließlich ist bei der auswahl des trocknungssystems zu berücksichtigen, dass nutzer bezüglich komfort und nutzerfreundlichkeit einmalhandtücher gegenüber heißlufttrocknern bevorzugen [226] und die lärmbelastung bei "jet air" trocknern in 0,5 m entfernung 94 db erreicht [224] . für einen "air blade" trockner wurde ermittelt, dass die anzahl freigesetzter tröpfchen beim trocknungs-vorgang höher war und weiter reichte als bei benutzung eines papierhandtuchs. die autoren schließen nicht aus, dass bei vorhandensein von pathogenen auf den händen die umgebung mit ihnen kontaminiert werden könnte [233] . ein review kommt zu analoger schlussfolgerung, dass durch "jet air" und warmlufttrockner die ausbreitung kontaminierter aerosole begünstigt wird, so dass diese trockner in medizinischen einrichtungen und speziell in baderäumen ungeeignet sein könnten [234] . der waschbeckenablauf ist ein offenes erregerreservoir der fäkal-und oralflora des patienten [235] . beim einlaufen von wasser werden bakterien bis zu 1,85 m im umkreis aus dem im siphon stehenden abwasser emittiert [236] . da die ausbreitung von verschiedenen faktoren beeinflusst wird, sollte man aus sicherheitsgründen von 2 m ausgehen. bei siphonkontamination >10 5 kbe/ml ist die übertragung von bakterien auf die hände des pflegepersonals bei der händewaschung nachgewiesen [153] . mit p. aeruginosa kolonisierte siphons konnten als risikofaktor für die kolonisation von patienten identifiziert werden [237, 238] . beschrieben sind vom siphon ausgehend ausbrüche durch e. cloacae, p. aeruginosa, a. baumannii und serratia spp. [238] [239] [240] [241] . nach 3mal täglicher siphonreinigung und veränderung des siphons konnte ein sich über 5 jahre erstreckender ausbruch beendet werden [241] . bei einem multispeziesausbruch mit enterobakterien konnten die erreger u. a. auch im siphon nachgewiesen werden, wenn auch die sekundäre kontamination von lebensmitteln offenbar der entscheidende verbreitungsweg war [238] . wenn siphonstöpsel gewünscht sind, sollten sie leicht der desinfizierenden reinigung zu unterziehen sein, also nicht aus gummi oder kunststoff sein. günstig ist ein weit über die siphonöffnung übergreifender verschluss zur abschirmung des durch das einlaufende wasser entstehenden aerosols. automatische siphon-desinfektionsanlagen können in speziellen einheiten, z. b. bei mukoviszidosepatienten, zur prophylaxe von pseudomonas-infektionen indiziert sein [242] . silikonstöpsel sollen wegen der kontaminationsgefahr nicht auf dem waschbecken gelagert werden. [260] . bei ebenfalls nachgefüllten flaschen waren 1/5 bis 1/4 aller flüssigen handwaschpräparate in öffentlichen toiletten mit 15 verschiedenen spezies bis 10 7 kbe/ml kontaminiert [261, 262] . das nachfüllen wird auch in weiteren studien als kontaminationsursache verbunden mit ausbrüchen angesehen [260, [263] [264] [265] [266] . auch nosokomiale s. marcescens infektionen waren mit der kontamination eines flüssigen handwaschpräparats assoziiert [25, 267] . experimentell wurde nachgewiesen, dass durch waschen mit einem kontaminierten flüssigen handwaschpräparat die anzahl gram-negativer erreger auf den händen ansteigt und eine weiterverbreitung auch in gemeinschaftseinrichtungen möglich erscheint [263] . selbst wenn die spender mit einwegflaschen bestückt werden, ist bei nicht ordnungsgemäßer vollflächiger reinigung und desinfektion der spender einschließlich des steigrohrs eine kontamination des handwaschpräparats möglich [260, 268, 269] . als fazit ist die anwendung von handwaschprodukten in stückform in medizinischen und pflegerischen bereichen obsolet. zweck der händewaschung ist die reinigung der hände zur entfernung von schmutz und verunreinigungen sowie zur entfernung lose adhärierter krankheitserreger, sofern diese nicht durch händedesinfektion abgetötet werden können (z. b. bei kontamination mit bakteriensporen, helminthen, kryptosporidien, oozysten und protozoen). bei starker belastung der hände mit schweiß (z. b. nach langer op) empfiehlt es sich, die hände vor der händedesinfektion mit einem papierhandtuch zu trocknen. gegebenenfalls sollten abschließend eine händewaschung und die anwendung einer hautpflegenden lotion erfolgen [270] . nach toilettenbenutzung ist das standardverfahren die händewaschung. bei diarrhoe oder rhinitis kann eine händedesinfektion sinnvoll sein. bei der händewaschung sind besonders die subungualen räume zu berücksichtigen, da sie den größten teil der handflora enthalten [271] . stellt sich der wasserlauf nicht automatisch ab, wird er mit dem gebrauchten handtuch oder dem ellenbogen geschlossen [272] . ist sie müssen sowohl die allgemeinen anforderungen der en 420 [273] [196, 197] . beim anlegen der handschuhe ist zu beachten, dass diese am ärmelbündchen des kittels dicht abschließen. im op-bereich empfiehlt sich grundsätzlich der einsatz latexallergenarmer op-handschuhe, da bisher von keinem anderen material gleichwertige eigenschaften hinsichtlich tragekomfort, passgenauigkeit, griffigkeit und mechanischer belastbarkeit wie für naturlatex erreicht werden. der proteingehalt muss < 30 µg/ g handschuhmaterial betragen [274] . gepuderte latexhandschuhe sind wegen des allergisierungsrisikos untersagt [291] . bei patienten mit einem erhöhten risiko für die entwicklung einer latexallergie wird die naturlatexfreie versorgung empfohlen. das betrifft patienten, die von geburt an an spina bifida, urogenitalen fehlbildungen, ösophagusatresie und weiteren missbildungen leiden und die wiederholt operiert werden [303] [304] [305] [306] [307] [308] [309] . durch latexfreie op-handschuhe, latexfreie anästhesie und latexallergenvermeidung im alltag konnte die latexsensibilisierungsprävalenz signifikant gesenkt werden [310, 311] . talkum und ersatzprodukte bergen die gefahr der granulombildung im op-gebiet und sind nicht zu empfehlen [312] [313] [314] [315] [316] . für eine emulsion mit maisstärke ist das nicht untersucht; da aber kein einfluss auf die schweißmenge nachweisbar war [317] , ist sie entbehrlich. bei chirurgischen eingriffen mit erhöhtem perforationsrisiko und/oder chirurgischen eingriffen an patienten mit erhöhtem infektionsrisiko wird für das op-team das tragen von zwei paar übereinander gezogenen op-handschuhen (sog. double gloving) möglichst mit indikatorsystem empfohlen [127, 318] . da bekannt ist, dass die perforationsrate mit zunehmender dauer der op steigt, wird bei längeren ops diskutiert, ob bzw. wann ein routinemäßiger handschuhwechsel sinnvoll und begründet ist. die vorschläge reichen von 30 bis 180 min [319] . insgesamt sind die daten jedoch unzureichend, um eine allgemeine empfehlung geben zu können [26, 320] . bei tragen von nur einem paar handschuhen haben sich in der viszeralchi-rurgie über die op-dauer ansteigende perforationsraten für operateur und 1. assistenten gezeigt, woraus ein wechsel nach spätestens 90 min, für den 2. assistenten und die op-pflegekräfte nach 150 min abgeleitet wurde [319, 321] . für andere chirurgische fachdisziplinen kann sich das wechselintervall in abhängigkeit vom perforationsrisiko unterscheiden. folgende beispiele verdeutlichen die situation. für totale hüftendoprothesen wurde vorgeschlagen, den außenhandschuh nach der prothesenreduktion bzw. bei perforation zu wechseln. typische situationen einer perforation waren bei der inzision bzw. beim zementieren des hüftkopfs im femur. durch diese gezielten wechsel der außenhandschuhe konnte die rate von op-handschuhen, die intraoperativ an der außenseite steril sind, um 80 % erhöht werden [320] . der wechsel des äußeren handschuhpaars 1 h nach beginn der op hatte zur folge, dass die kontaminationsrate des äußeren handschuhs am op-ende 13 % anstatt 23 % betrug. deshalb empfehlen die autoren, vor dem einsetzen von implantaten die äußeren handschuhe zu wechseln [322] . bei sichtbarer intraoperativer handschuhbeschädigung müssen frische sterile op-handschuhe angelegt werden. hat sich die perforation zu op-ende ereignet, kann es ausreichend sein, einen frischen sterilen handschuh über den perforierten handschuh zu ziehen. ob vor dem anlegen des frischen op-handschuhs eine händedesinfektion erforderlich ist, ist eine ungeklärte frage. zweifellos findet während der op eine rekolonisation der haut im handschuh statt [323, 324] . andererseits wäre der handschuh ohne perforation nicht gewechselt worden. da nur im op-gebiet gearbeitet wurde, erscheint die händedesinfektion entbehrlich, zumal es bei der händedesinfektion zu einer kontamination des sterilen schutzkittels mit der hautflora kommen kann. auch handschuhe mit antibakterieller barriere bzw. antibakterieller imprägnierung können den erregertransfer durch perforationen [325] bzw. die erregermenge auf der hand [326] verringern, bergen jedoch in abhängigkeit vom verwendeten wirkstoff (z. b. chlorhexidin) eine allergiegefahr. durch unter dem op-handschuh angelegte sterile baumwollhandschuhe kann dem feuchtigkeitsstau entgegengewirkt werden. unmittelbar nach dem ablegen der op-handschuhe sollte eine händedesinfektion erfolgen, da perforationen nicht auszuschließen sind. der umfang erforderlicher händedesinfektionen kann durch konsequente planung von pflegerischen und ärztlichen medizinischen maßnahmen mit dem ziel der konsequenten trennung rein/unrein bzw. nicht kontaminiert/kontaminiert sowie durch realisierung der non-touch-technik z. b. im umgang mit devices und beim verbandwechsel reduziert werden. für den verzicht auf begrüßendes händeschütteln gibt es bei einhaltung der indikationen zur händedesinfektion weder eine epidemiologische evidenz, noch eine stichhaltige theoretische rationale. wenn die von der who empfohlenen 5 indikationsgruppen zur händedesinfektion konsequent eingehalten werden, ist der verzicht nicht begründbar. in anbetracht der schwierigkeit der erreichbarkeit einer indikationsumfassenden compliance der händedesinfektion kann zumindest in risikobereichen auf das begrüßende händeschütteln verzichtet werden, wodurch zugleich die notwendigkeit der händedesinfektion in den fokus gerückt wird. [334] noch verbesserungspotential besteht, insbesondere, wenn davon ausgegangen wird, dass sich durch direkte beobachtung die rate der händedesinfektionen deutlich erhöht (hawthorne-effekt) bzw. bei einer compliance von 51 % in der größenordnung von 180 % bewegen kann [335, 336] . auf grund des stellenwerts der händehygiene müssen alle möglichkeiten ausgeschöpft werden, eine maximale compliance in ihrer durchführung zu erreichen. dazu gehören die etablierung von messverfahren zur compliance sowie die analyse und optimierung von routinearbeitsabläufen. neben der verbesserung der compliance der händedesinfektion ist auch die korrekte durchführung ein weiterer wichtiger aspekt [337] . um einen effekt der händedesinfektion auf die raten von ni und mre zu erzielen, muss eine hohe compliance der händedesinfektion durch das personal erreicht werden [338] . die compliance der hygienischen händedesinfektion sowie die faktoren für nicht-compliance sind in den letzten jahren gut untersucht worden [337, 339, 340] [365] . die einstellungen und haltungen der mitarbeiter gegenüber dem thema händehygiene sind uneinheitlich und komplex. viele faktoren beeinflussen das letztendliche verhalten [366, 367] . in den letzten jahren hat eine vielzahl von studien die effizienz sogenannter multimodaler interventionsmodelle zur verbesserung der compliance gezeigt [34, 88, 92, [368] [369] [370] [371] . die who hat im rahmen ihrer weltweiten "clean care is safer care" kampagne ein multimodales interventionsprogramm entwickelt und in 58 pilothäusern weltweit erfolgreich getestet [33] . auf der grundlage dieser erkenntnisse sollte ein multimodales interventionsprogramm folgende grundlegende maßnahmen beinhalten: regelmäßige personalfortbildungen, messungen mit ergebnisrückmeldung, verbesserung der verfügbarkeit von hdm, nutzung von erinnerungs-und werbematerialien, sichtbare unterstützung durch die administrativen ebenen. zusätzlich haben sich zielvereinbarungen, anreizsysteme (incentives) und strategien zur förderung der übernahme von verantwortung (accountability) als effektiv erwiesen [372] . im rahmen eines solchen interventionsprogramms haben fortbildungen insbesondere in standardisierter form [373] und training [374] eine schlüsselfunktion, jedoch als alleinige interventionsmaßnahme nur einen geringen, kurz anhaltenden effekt [132, 370, 371, 375] . neben faktoren, die für überwindung der intentions-verhaltens-lücke relevant sind, hat auch die beteiligung von patienten z. b. durch ihre institutionelle einladung, hygienethemen anzusprechen (empowerment), im hinblick auf nachhaltige effekte ein großes potenzial [141, 376, 377] . zur nachhaltigen verbesserung der compliance nimmt die prozessoptimierung eine schlüsselfunktion ein, indem durch optimalen workflow die anzahl der indikationen zur händedesinfektion reduziert werden kann. selbst in be-empfehlungen reichen, die bereits jahrelang geschult wurden und teilnehmer von interventionskampagnen sind, können so ohne mehrarbeit erhebliche effekte erzielt werden [133, 378, 379] . daher sollten routinemaßnahmen kritisch in ihrem ablauf überprüft und standardisiert werden mit dem ziel, händedesinfektionen zu sparen [133, 342] . zugleich sollten interventionsprogramme auch auf den zeitdruck und die hohe arbeitsbelastung des personals zugeschnitten werden. dazu gehört auch die großzügige ausstattung mit hdm, um zusätzliche wege für das personal zu vermeiden. die kritische überprüfung der spenderausstattung unter berücksichtigung der arbeitsabläufe vor allem am patienten sowie ggf. die verbesserung der ausstattung können bereits zu einer verbesserung der compliance führen [34, [380] [381] [382] . die who empfiehlt die verfügbarkeit von hdm "at point of care", d. h. dort, wo die indikationen zur händedesinfektion entstehen: vor allem am patienten bzw. am patientenbett, an sauberen arbeitsplätzen, an behandlungsplätzen usw. [33] . in abhängigkeit von den räumlichen gegebenheiten sowie von der art der versorgten patienten können fest montierte oder mobile spendersysteme verwendet werden. die 2008 in deutschland gestartete nationale aktion saubere hände ist ein wichtiger beitrag zur umsetzung der von der who 2005 ins leben gerufenen kampagne "clean care is safer care". seit juni 2011 können krankenhäuser und rehabilitationskliniken, seit august 2015 auch einrichtungen der ambulanten medizin ein zertifikat über die teilnahme an der aktion saubere hände erwerben [http:// www.aktion-sauberehaende.de/ash/module/krankenhaeuser/zertifizierung/]. auch durch die teilnahme am internationalen tag der händehygiene wird der stellenwert der händehygiene unterstrichen. nach dem erreichen des goldzertifikats der aktion saubere hände ist es möglich, sich am wettbewerb "european hand hygiene excellence award" zu beteiligen und damit einen beitrag zur nachhaltigkeit der erreichten compliance zu leisten. als basismaßnahme zur gewährleistung der compliance der händehygiene ist mindestens jährlich und zusätzlich zeitnah bei hinweisen auf probleme in diesem bereich eine schulung aller mitarbeiter zu den indikationen der händedesinfektion in verbindung mit einem training und der evaluation der einreibetechnik z. b. mit fluoreszierendem farbstoff im hdm [383] zu gewährleisten. im rahmen dieser schulungen ist es zu empfehlen, dass die verbrauchsdaten für hdm innerhalb der organisationseinheiten bewertet werden. das setzt die übermittlung von auf die organisationseinheiten aufgeschlüsselten verbrauchsdaten pro patiententag (3 ml = eine händedesinfektionseinheit) voraus. die verbräuche sollten zusätzlich jährlich der ärztlichen und der pflegerischen leitung mitgeteilt und in der hygienekommission bewertet werden. hier kommt es vor allem darauf an, die situation in organisationseinheiten mit sehr niedrigem verbrauch pro patiententag kritisch zu hinterfragen und ggf. dort gezielt zu intervenieren. um defizite in der händedesinfektions-compliance bzw. deren veränderungen sichtbar zu machen, ist die etablierung von messsystemen unerlässlich [33, 34, 384] . als messinstrument für die hän-dedesinfektion stehen die direkte beobachtung der mitarbeiter zur bestimmung der compliance, elektronische systeme und als surrogatparameter die bestimmung des verbrauchs an hdm zur verfügung (. tab. die erhebung von daten zu unterschiedlichen zeitpunkten im rahmen einer intervention oder auch zur langzeiterfassung ist ein wichtiges instrument, um qualitative und quantitative aussagen zu ausgangssituationen sowie zu veränderungen treffen zu können. die drei methoden haben ihre vor-und nachteile und sollten idealerweise kombiniert angewandt werden [385, 386] . die messung des verbrauchs an hdm ist eine weniger ressourcenintensive möglichkeit der datenerhebung und als langzeitmesssystem geeignet, veränderungen im händedesinfektionsverhalten abzubilden. es ist zu beachten, dass der verbrauch nicht mit der compliance gleichzusetzen ist. verbrauchszahlen geben einen anhalt über die menge durchgeführter händedesinfektionen, die durchschnittlich an einem patienten in 24 h (also an einem patiententag) in einer organisationseinheit (z. b. pro station, pro klinik, pro einrichtung) durchgeführt worden sind. die qualität der daten hängt entscheidend davon ab, inwieweit die verbrauchszahlen der organisationseinheit sicher zugeordnet werden können. sinnvoll ist der vergleich nur mit verbrauchszahlen aus vergleichbaren organisationseinheiten, da im gegensatz zur compliance bisher keine verlässlichen sollwerte zur verfügung stehen. verbrauchsdaten lassen keine linearen rückschlüsse hinsichtlich compliance (fehlende nennerdaten, indikationsgerechte händedesinfektion, technik der händedesinfektion und sicherheit im erkennen der indikationen zur händedesinfektion im klinischen alltag) zu [347] . da die unterschiede in den einzelnen fachbereichen und zwischen intensiv-und nicht-intensivstationen erheblich sein können, ist eine stations-bzw. bereichsbezogene erfassung sinnvoll [371] . es wird empfohlen, die verbrauchsdaten auf organisationseinheiten aufgeschlüsselt in die qualitätsberichte der krankenhäuser aufzunehmen. die bestimmung der compliance für die händedesinfektion durch direkte beobachtung ist der goldstandard [33] . allerdings sind beobachtungsdaten aus der literatur für bestimmte bereiche oft nicht einfach auf individuelle settings übertragbar, da es große unterschiede in der methode der beobachtung sowie in der definition der indikationen zur händedesinfektion gibt. die who hat mit dem modell der 5 indikationen die grundlage für vergleichbare beobachtungen geschaffen [134] . voraussetzung dafür ist eine intensive schulung mit regelmäßiger validierung der beobachter. die beobachtung ist eine punktuelle messung. sie ermöglicht die einschätzung, in wieweit mitarbeiter die indikationen erkennen und welche maßnahmen für eine verbesserte compliance notwendig sind. sie sollte als fehleranalyse auch als grundlage für interventionen genutzt werden [387] . da die compliance einzelner mitarbeiter große unterschiede aufweisen kann, sollten möglichst viele mitarbeiter in eine beobachtung eingeschlossen werden, um eine aussage über die generelle compliance eines bereichs treffen zu können [33, 34] . der verbrauch an hdm kann durch elektronische erfassungsmöglichkeiten im zeitlichen verlauf am ort des verbrauchs erfasst werden, wodurch zeitnah einfluss auf die compliance und damit auf die ni-rate genommen werden kann [388] [389] [390] [391] . einem krankenhausweiten einsatz können allerdings die systemkosten entgegenstehen. neuere elektronische systeme erfassen händedesinfektionen zusätzlich auf individueller ebene, etwa mit mobilen "badges" oder erfassungsgeräten, ermöglichen ein individuelles feedback zur händehygiene oder können an fällige desinfektionen erinnern [376] , z. b. durch überwachung bestimmter zonen, deren betreten häufig mit der indikation für eine händedesinfektion verbunden ist. heutige systeme erlauben noch keine präzise erinnerung der mitarbeiter an alle indikationen zur händehygiene. auch wenn sie das verfügbare instrumentarium zur steigerung der compliance erweitern, konnte bisher nur ein geringer einfluss auf die verbesserung der compliance nachgewiesen werden [392] . evaluation und feed back sind wichtige komponenten einer umsetzungsstrategie zur steigerung der compliance [33, 132] . aspekte des datenschutzes, der akzeptanz und der notwendigen eigenmotivation der beschäftigten sind als randbedingungen zu beachten. aufklärung, trainingsprogramme mit regelmäßigen schulungen (mindestens jährlich) und die auswahl der hdm in desinfektionsplänen dienen in verbindung mit der festlegung des vorgehens in einrichtungsverbindlichen sops und mit gezielten kontrollmaßnahmen der qualitätssicherung der händehygiene. mikrobiologische untersuchungen, z. b. durch abdruckkulturen von den händen, können bei speziellen epidemiologischen fragestellungen durchgeführt werden, eignen sich aber nicht für eine routinemäßige überprüfung der wirksamkeit einer händedesinfektion. berufsbedingte hauterkrankungen stehen seit vielen jahren an der spitze der berufskrankheiten [393] . das liegt zum einen an falschen methoden der händehygiene, d. h. die hände werden zu viel gewaschen, anstatt alkoholische hdm zu benutzen, zum anderen am ungenügenden einsatz von hautschutz-und hautpflegemitteln [394, 395] . hautschutz und hautpflege dienen vorrangig dem arbeitsschutz, sind aber zugleich voraussetzung für eine effektive händedesinfektion [252] , da bereits kleinste risse bzw. mikrotraumen zu eintrittspforten für krankheitserreger und zum erregerreservoir werden können [395, 396] . beim einsatz von hautschutz-und -pflegemitteln ist das risiko der mikrobiellen kontamination zu beachten [397, 398] , d. h. keine entnahme aus salbentöpfchen und bei verwendung von tuben vermeiden eines rücksogs des ausgedrückten salbenstrangs. hautschutzpräparate schützen vor irritation [399] [400] [401] [402] [403] [404] [405] [406] [407] und werden vor und während der arbeit und ggf. zusätzlich in arbeitspausen aufgetragen [402, 408] . hautpflegepräparate unterstützen die regeneration der haut [409] . ihre anwendung wird am dienstende empfohlen [291] . zusätzlich können sie während der arbeit bei individuellem bedürfnis angewendet werden. bei sichtbarer verschmutzung der hände sollte vor dem auftragen von hautschutz-oder -pflegepräparaten die haut gereinigt werden, um dem eindringen von auf der haut verbliebenen substanzen mit hautreizenden eigenschaften entgegen zu wirken [410] . in ergänzung dazu empfiehlt es sich, auch im freizeitbereich hautschutz und hautpflege zu beachten. sowohl bei pflegepersonal als auch bei ärzten ergaben sich große wissensdefizite in bezug auf hautschutz und hautpflege [411] [412] [413] . deshalb ist die wissensvermittlung in verbindung mit der etablierung eines hautschutzplans wichtig und leistet einen beitrag zur verbesserung beruflich irritierter haut [414] [415] [416] . bei gefährdung der haut durch arbeiten im feuchten milieu -dazu gehört auch das tragen flüssigkeitsdichter handschuhe -hat der arbeitgeber zu prüfen, ob solche belastungen reduziert werden können. insbesondere sollen handschuhe nur so lange wie nötig getragen werden. der arbeitgeber hat geeignete hautschutz-und pflegemittel bereitzustellen, einen hautschutzplan zur auswahl von präparaten für die hautreinigung, den hautschutz und -pflege zu erstellen und die mitarbeiter in deren regelmäßige und richtige anwendung zu unterweisen [4] . für hautbelastende tätigkeiten (z. b. nass-und feuchtreinigung, desinfektion von flächen und gegenständen) muss der arbeitgeber psa bereitstellen, in einer betriebsanweisung die schutz-und verhaltensregeln festlegen und die arbeitsmedizinische vorsorge und überwachung gewährleisten [417] . bei beginnenden hautschäden sind unverzüglich der betriebsärztliche dienst oder ein hautarzt zu konsultieren. für die auswahl von hautschutz-und hautpflegepräparaten sind der wirksamkeitsnachweis (vorzugsweise durch in vivo verfahren) gemäß leitlinie berufliche hautmittel [393] bzw. ergebnisse von studien [418] sowie die sicherheitsbewertung empfehlungen [393] voraussetzung. wegen des risikos der sensibilisierung sollten produkte ohne duft-und ohne konservierungszusatz ausgewählt werden [393, 419] . bei hautschutzpräparaten sind wegen der penetrationsförderung präparate ohne harnstoff zur bevorzugen [408] . ob ein zeitlicher abstand zwischen der anwendung von hautschutz-und hautpflegepräparaten zur händedesinfektion eingehalten werden muss, ist nicht ausreichend untersucht. in praxisfremden modellen wurde eine wirkungsverminderung z. b. für alkoholische hdm durch pflegeprodukte [420] , für kationische antiseptika wie chlorhexidin durch anionische emulgatoren, feuchthaltesubstanzen und surfactants in pflegeprodukten [421, 422] sowie für chirurgische handwaschpräparate durch hautschutzprodukte nachgewiesen [401] . deshalb empfiehlt die association for professionals in infection control die kompatibilität von pflegeprodukt und hdm bereits bei der produktauswahl zu berücksichtigen, gibt jedoch keine hinweise zu einem verfahren der kompatibilitätsprüfung [423] . nach anwendung von hautschutz und hautpflege (je 3x/d) bei einem chirurgischen team wurde der hautzustand signifikant verbessert, ohne dass die wirksamkeit der händedesinfektion beeinträchtigt wurde [413] . da es hinweise gibt, dass einige hautpflegemittel die wirkung alkoholischer hdm beeinträchtigen können, ist deren anwendung -sofern ihr einfluss auf die wirksamkeit der händedesinfektion nicht untersucht istam günstigsten in arbeitspausen und zusätzlich nach arbeitsschluss vorzunehmen. zur unterlassung der händedesinfektion existieren zahlreiche gerichtsentscheidungen. so wurde in sieben fällen das unterlassen der hygienischen händedesinfektion als grober behandlungsfehler angesehen. auch das unterlassen der chirurgischen händedesinfektion oder die fehlende benutzung steriler handschuhe waren als grobe behandlungsfehler gegenstand von entscheidungen im arzthaftungsrecht [14] . aufgrund der tatsache, dass die durchführung der händedesinfektion und das tragen von handschuhen den kategorien ia bzw. ib entsprechen, sind diese maßnahmen unbedingt einzuhalten. patient-centered hand hygiene: the next step in infection prevention biologische arbeitsstoffe im gesundheitswesen und in der wohlfahrtspflege hrsg) (2013) hauptsache hautschutz. hände schützen, pflegen -gesund bleiben arzneimittelgesetz in der fassung der bekanntmachung vom 12. dezember 2005 (bgbl. i s. 3394), das zuletzt durch artikel 3 des gesetzes vom 10. dezember 2015 (bgbl. i s. 2210) geändert worden ist umfüllen von händedesinfektionsmitteln -hygienische und haftungsrechtliche aspekte durchführungsbeschluss (eu) 2016/904 der kommission vom 8 absatz 3 der verordnung (eu) nr. 528/2012 des europäischen parlaments und des rates über 2-propanol-haltige produkte für die händedesinfektion (abl. l verwendung von äthanol für desinfektionszwecke microbial contamination of antiseptics and disinfectants bacterial in-use contamination of an alcohol-based hand rub under accelerated test conditions in-vitro-und in-vivo-befunde zur resistenzsteigerung bei bakterien gegen antiseptika und desinfektionsmittel hygiene und recht. entscheidungssammlung-richtlinien. loseblattsammlung. mhp-verlag, wiesbaden 15. verbund für angewandte hygiene (vah) (hrsg) (2015) desinfektionsmittel-liste des vah. mhp-verlag anforderungen und methoden zur vah-zertifizierung chemischer desinfektionsverfahren hygienische händedesinfektion, prüfverfahren und anforderungen (phase 2/stufe 2) beuth verlag: berlin 19. din en 14476:2015-12 chemische desinfektionsmittel und antiseptika -quantitativer suspensionsversuch viruzidie für in der humanmedizin verwendete desinfektionsmittel und antiseptika -prüfverfahren und anforderungen (phase 2/stufe 1). beuth verlag: berlin 20. din en 13727:2015-12 chemische desinfektionsmittel und antiseptika -quantitativer suspensionsversuch zur bestimmung der bakteriziden wirkung im humanmedizinischen bereich -prüfverfahren und anforderungen leitlinie der deutschen vereinigung zur bekämpfung der viruskrankheiten (dvv) e. v. und des robert koch-instituts (rki) zur prüfung von chemischen desinfektionsmitteln auf wirksamkeit gegen viren in der humanmedizin. fassung vom 1. dezember liste der vom robert koch-institut geprüften und anerkannten desinfektionsmittel und -verfahren transmission of experimental rhinovirus infection by contaminated surfaces nosocomial serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap the survival and transfer of microbial contamination via cloths, hands and utensils an experimental model for study of candida survival and transmission in human volunteers prevention of surface-to-human transmission of rotaviruses by treatment with disinfectant spray comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, clostridium difficile, and acinetobacter species a causal link between handwashing and risk of infection? examination of the evidence hand contamination before and after different hand hygiene techniques: a randomized clinical trial the world health organization guidelines on hand empfehlungen hexidine gluconate for the removal of clostridium difficile from bare hands and gloved hands semmelweis ip (1861) die aetiologie, der begriff und die prophylaxis des kindbettfiebers semmelweis and the aetiology of puerperal sepsis 160 years on: an historical review hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in argentina decreasing hospital-associated rotavirus infection: a multidisciplinary hand hygiene campaign in a children's hospital dissemination of the cdc's hand hygiene guideline and impact on infection rates reduction in surgical site infections in neurosurgical patients associated with a bedside hand hygiene program in vietnam impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a russian neonatal intensive care unit skin hygiene and infection prevention: more of the same or different approaches? impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections hand hygiene: back to the basics of infection control back to basics: hand hygiene and isolation reduction in hospitalwide incidence of infection or colonization with methicillin-resistant staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub association between hand hygiene compliance and methicillin-resistant staphylococcus aureus prevalence in a french rehabilitation hospital multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance the impact of antimicrobial drug consumption and alcohol-based hand rub use on the emergence and spread of extended-spectrum beta-lactamase-producing strains: a time-series analysis systematic patients' hand disinfection: impact on meticillin-resistant staphylococcus aureus infection rates in a community hospital performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by mrsa and antibiotic costs changes in healthcare-associated staphylococcus aureus bloodstream infections after the introduction of a national hand hygiene initiative how often do you wash your hands? a review of studies of hand-washing practices in the community during and after the sars outbreak in 2003 outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial outbreaks norovirus infections in preterm infants: wide variety of clinical courses infection control and prevention measures to reduce the spread of vancomycin-resistant enterococci in hospitalized patients: a systematic review and meta-analysis gentamicin-resistant klebsiella aerogenes in a urological ward elimination of methicillin-resistant staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan use of 0.3% triclosan (bacti-stat) to eradicate an outbreak of methicillin-resistant staphylococcus aureus in a neonatal nursery the use of antiseptics for handwashing by medical personnel einfluß von nagellack auf die effektivität der händedesinfektion bacterial carriage by artificial versus natural nails pathogenic organisms associated with artificial fingernails worn by healthcare workers effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers banning artificial nails from health care settings artificial nails: are they putting patients at risk? a review of the research candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use postoperative serratia marcescens wound infections traced to an out-of-hospital source endemic pseudomonas aeruginosa infection in a neonatal intensive care unit a prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? artificial nails... very real risks outbreak of extended-spectrum beta-lactamase-producing klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails a cluster of hemodialysis-related bacteremia linked to artificial fingernails impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital impact of a single plain finger ring on the bacterial load on the hands of healthcare workers impact of finger rings on transmission of bacteria during hand contact increased awareness of glove perforation in major joint replacement. a prospective, randomised study of regent biogel reveal gloves methicillin-resistant staphylococcus aureus colonization in children with atopic dermatitis recent insights into atopic dermatitis and implications for management of infectious complications availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit how "user friendly" is the hospital for practicing hand hygiene? an ergonomic evaluation increasing icu staff handwashing: effects of education and group feedback improving hand hygiene compliance rates in the haemodialysis setting: more than just more hand rubs my five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene widespread environmental contamination associated with patients with diarrhea and methicillin-resistant staphylococcus aureus colonization of the gastrointestinal tract risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients' environment the role played by contaminated surfaces in the transmission of nosocomial pathogens the role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens the role of the surface environment in healthcare-associated infections microbial air quality and bacterial surface contamination in ambulances during patient services hrsg) krankenhaus-und praxishygiene: hygienemanagement und infektionsprävention in medizinischen und sozialen einrichtungen less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection introducing alcohol based hand rub for hand hygiene: the critical need for training an evaluation of handwashing techniques-1 surgical hand hygiene: scrub or rub? adka-leitlinie: aseptische herstellung und prüfung applikationsfertiger parenteralia. version vom 12.12 hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates an inuse microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing irgasan dp300 in a deodorant contact sensitivity to irgasan dp 300 emission von bakterien aus geruchsverschlüssen generation of pseudomonas aeruginosa aerosols during handwashing from contaminated sink drains, transmission to hands of hospital personnel, and its prevention by use of a new heating device evaluation of a waterless, scrubless chlorhexidine gluconate/ethanol surgical scrub for antimicrobial efficacy prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis population kinetics of the skin flora on gloved hands following surgical hand disinfection with 3 propanol-based hand rubs: a prospective, randomized, double-blind trial anaphylaxis to chlorhexidine. case report. implication of immunoglobulin e antibodies and identification of an allergenic determinant immediate hypersensitivity to chlorhexidine is increasingly recognised in the united kingdom ige-mediated allergy to chlorhexidine occupational hand dermatitis in hospital environments untersuchungen zur hautverträglichkeit von alkoholischen händedesinfektionsmitteln resistenzentwicklung von staph. aureus, pseud. aeruginosa und enterobacteriaceae gegen antiseptika development of resistance to chlorhexidine diacetate in pseudomonas aeruginosa and the effect of a "residual" concentration in vitro study of chlorhexidine resistance in subgingival bacteria effect of r-plasmid rp1 and nutrient depletion on the resistance of escherichia coli to cetrimide, chlorhexidine and phenol genetische grundlagen der resistenzentwicklung von mikroorganismen gegenüber antiseptika bzw. desinfektionsmitteln. in: handbuch der antiseptik, bd. i/2, grundlagen der antiseptik antiseptic and antibiotic resistance plasmid in staphylococcus aureus that possesses ability to confer chlorhexidine and acrinol resistance plasmids and bacterial resistance to biocides development of resistance to chlorhexidine diacetate and cetylpyridinium chloride in pseudomonas stutzeri and changes in antibiotic susceptibility outer membrane changes in pseudomonas stutzeri resistant to chlorhexidine diacetate and cetylpyridinium chloride chlorhexidine resistance in proteus mirabilis chlorhexidine resistance and the lipids of providencia stuartii chlorhexidine resistance in escherichia coli isolated from clinical lesions resistance of providencia stuartii to chlorhexidine: a consideration of the role of the inner membrane chlorhexidine resistance among bacteria isolated from urine of catheterized patients a hospital outbreak caused by a chlorhexidine and antibiotic-resistant proteus mirabilis serratia marcescens outbreak in a paediatric oncology unit traced to contaminated chlorhexidine the relationships and susceptibilities of some industrial, laboratory and clinical isolates of pseudomonas aeruginosa to some antibiotics and biocides antiseptic susceptibility and distribution of antiseptic-resistance genes in methicillin-resistant staphylococcus aureus distribution of antiseptic resistance genes qaca, qacb, and smr in methicillin-resistant staphylococcus aureus isolated in toronto contact dermatitis to triclosan contact dermatitis from triclosan (irgasan dp 300) benzalkoniumchlorid: relevantes kontaktallergen oder irritans? ergebnisse einer multicenter-studie der deutschen kontaktallergiegruppe allergic contact dermatitis from triclosan in antibacterial handwashes triclosan, ein dermatologisches lokaltherapeutikum oberflächenaktive verbindungen an outbreak of handscrubbing-related surgical site infections in vascular surgical procedures irritancy of scrubbing up for surgery with or without a brush kommission für krankenhaushygiene und infektionsprävention (krinko) (2007) prävention postoperativer infektionen im operationsgebiet outbreak of serratia marcescens colonization and infection traced to a healthcare worker with long-term carriage on the hands antibacterial activity of a sterile antimicrobial polyisoprene surgical glove against transient flora following a 2-hours simulated use hygienische und dermatologische aspekte der händedesinfektion und der prophylaktischen hautantiseptik improving adherence to surgical hand preparation einfluss der seifenwaschung auf die keimabgabe durch die haut hygienic hand disinfection verbessern händewaschen und verwendung der handbürste das ergebnis der chirurgischen händedesinfektion effekt der sequentiellen anwendung von chlorhexidinseife und einer alkoholischen chx-präparation versus flüssigseife und einer solchen präparation bei der chirurgischen händedesinfektion does a preceding hand wash and drying time after surgical hand disinfection influence the efficacy of a propanol-based hand rub? einfluss einiger variablen auf die ergebnisse von prüfungen hygienischer händedesinfektionsverfahren wirksamkeitsvergleich von desinfektionsverfahren zur chirurgischen händedesinfektion unter experimentellen und klinischen bedingungen alcohol for surgical scrubbing? surgical hand disinfection with a propanol-based hand rub: equivalence of shorter application times determination of antiseptic efficacy of rubs on the forearm and consequences for surgical hand disinfection efficacy of alcohol-based gels compared with simple hand wash and hygienic hand disinfection the integrity of latex gloves in clinical dental practice effect of a 1 min hand wash on the bactericidal efficacy of consecutive surgical hand disinfection with standard alcohols and on skin hydration experimental study on disinfection effect of different dose of rapid hand disinfectant severe serratia liquefaciens sepsis following vitamin c infusion treatment by a naturopathic practitioner kommission für krankenhaushygiene und infektionsprävention (krinko) (2011) anforderungen an die hygiene bei punktionen und injektionen contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? outbreak of multidrug-resistant pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design non-touch fittings in hospitals: a possible source of pseudomonas aeruginosa and legionella spp non-touch fittings in hospitals: a procedure to eradicate pseudomonas aeruginosa contamination pseudomonas aeruginosa infections due to electronic faucets in a neonatal intensive care unit should electronic faucets be recommended in hospitals? bacterial contamination associated with electronic faucets: a new risk for healthcare facilities should electronic faucets be used in intensive care and hematology units? residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing hand drying: studies of the hygiene and efficiency of different hand drying methods efficiency of hand drying for removing bacteria from washed hands: comparison of paper towel drying with warm air drying a comparative study of three different hand drying methods: paper towel, warm air dryer, jet air dryer touch contamination levels during anaesthetic procedures and their relationship to hand hygiene procedures: a clinical audit the hygienic efficacy of different hand-drying methods: a review of the evidence dispersal of bacteria by an electric air hand dryer hot air electric hand driers compared with paper towels for potential spread of airborne bacteria hot-air hand driers a comparison of hand drying methods a comparison of the cleaning efficiency of three common hand drying methods comparative evaluation of the hygienic efficacy of an ultra-rapid hand dryer vs conventional warm air hand dryers assessment of the environmental microbiological cross contamination following hand drying with paper hand towels or an air blade dryer microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander sink flora in a long-stay hospital is determined by the patients' oral and rectal flora reservoirs of pseudomonas in an intensive care unit for newborn infants: mechanisms of control prospective study of nosocomial colonization and infection due to pseudomonas aeruginosa in mechanically ventilated patients microbial agents associated with waterborne diseases prevention and control of health care-associated waterborne infections in health care facilities outbreak of multidrug-resistant pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design outbreak of extended-spectrum β-lactamase-producing klebsiella oxytoca infections associated with contaminated handwashing sinks erprobung eines chemischen waschbeckendesinfektionssystems an der medizinischen hochschule hannover hrsg) (2012) the sccs's notes of guidance for the testing of cosmetic substances and their safety evaluation desinfektion der hände physiologic and microbiologic changes in skin related to frequent handwashing effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a bangladesh village an outbreak of salmonellosis among children attending a reptile exhibit at a zoo epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit how irritant is alcohol? gesunde haut als voraussetzung für eine effektive händedesinfektion mikrobiologische und dermatologische anforderungen an antiseptische seifen contamination of bar soaps under "in-use" conditions microbial contamination of "in use" bar soap in dental clinics isolation of some microorganisms from bar soaps and liquid soaps in hospital environments microbial flora of in-use soap products bacterial colonization of bar soaps and liquid soaps in hospital environments washing with contaminated bar soap is unlikely to transfer bacteria outbreak of serratia marcescens in a neonatal intensive care unit: contaminated unmedicated liquid soap and risk factors occurrence of heterotrophic and coliform bacteria in liquid hand soaps from bulk refillable dispensers in public facilities evaluation and remediation of bulk soap dispensers for biofilm bacterial hand contamination and transfer after use of contaminated bulk-soap-refillable dispensers outbreaks associated with contaminated antiseptics and disinfectants serratia marcescens contamination of antiseptic soap containing triclosan: implications for nosocomial infection serratia marcescens outbreak associated with extrinsic contamination of 1% chloroxylenol soap serratia marcescens outbreak associated with extrinsic contamination of 1% chlorxylenol soap mikrobielle kontamination von flüssigseifen-wandspendern mit einwegflaschensystem reinigungs-und desinfektionsleistung eines aufbereitungsprogramms für die routinemäßige reinigung von dosierspendern im krankenhaus regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing composition and density of microflora in the subungual space of the hand skin cleansing. in: prevention and control of nosocomial infections, 2. aufl single-use medical examination gloves -part 2: specification for gloves made from poly(vinyl chloride) bacterial contamination of unused, disposable non-sterile gloves on a hospital orthopaedic ward indications and the requirements for single use medical gloves empfehlung des umweltbundesamtes nach anhörung der trinkwasserkommission des bundesministeriums für gesundheit. hygienisch-mikrobiologische untersuchung im kaltwasser von wasserversorgungsanlagen nach § 3 nr. 2 buchstabe c trinkwv 2001, aus denen wasser für die öffentlichkeit im sinne des § 18 abs. 1 trinkwv 2001 bereit gestellt wird removal of nosocomial pathogens from the contaminated glove. implications for glove reuse and handwashing prospective, controlled study of vinyl glove use to interrupt clostridium difficile nosocomial transmission effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care intra-laboratory reproducibility of the hand hygiene reference procedures of en 1499 (hygienic handwash) and en 1500 (hygienic hand disinfection) effectiveness of hand-cleansing agents for removing methicillin-resistant staphylococcus aureus from contaminated hands examination gloves as barriers to hand contamination in clinical practice integrity of vinyl and latex procedure gloves letzte änderung vom: 30 richtlinie 89/686/ewg des rates vom 21.12. 1989 zur angleichung der rechtsvorschriften der mitgliedstaaten für persönliche schutzausrüstungen untersuchungen zur wiederholten desinfizierbarkeit von einweghandschuhen während des tragens bestimmung des widerstandes gegen degradation durch chemikalien the durability of examination gloves used on intensive care units din en 374-2:2015-03 schutzhandschuhe gegen gefährliche chemikalien und mikroorganismen -teil 2: bestimmung des widerstandes gegen penetration. beuth verlag: berlin 298. din en iso 374-5:2015-05 schutzhandschuhe gegen chemikalien und mikroorganismen -teil 5: terminologie und leistungsanforderungen für risiken durch mikroorganismen standard test method for resistance of materials used in protective clothing to penetration by blood-borne pathogens using phi-x174 bacteriophage penetration as a test system standard practice for assessment of resistance of medical gloves to permeation by chemotherapy drugs einsatz wiederaufbereitbarer textiler unterziehhandschuhe für medizinische tätigkeiten: eine machbarkeitsstudie schutzhandschuhe gegen mechanische risiken gemeinsame leitlinie von dgai und äda. soforttyp-allergie gegen naturlatex spina bifida as an independent risk factor for sensitization to latex natural rubber latex sensitisation and allergy in patients with spina bifida, urogenital disorders and oesophageal atresia compared with a normal paediatric population prevalence of latex allergy in spina bifida: genetic and environmental risk factors empfehlungen der interdisziplinären arbeitsgruppe "naturlatex -allergie". ergebnisse eines treffens am 18. dezember 1995 im berufsgenossenschaftlichen forschungsinstitut für arbeitsmedizin in bochum latex allergy in spina bifida: at the turning point? reduction of latex sensitisation in spina bifida patients by a primary prophylaxis programme effects of latex avoidance on latex sensitization, atopy and allergic diseases in patients with spina bifida surgical gloves: current problems retrograde migration of glove powder in the human female genital tract evolution of the surgical glove peritonitis granulomatosa por el almidón en guantes quirúrgicos; granulomatous peritonitis due to the starch used in surgical gloves dangers of cornstarch powder on medical gloves: seeking a solution einfluss von biosorb auf die langzeitwirkung der chirurgischen händedesinfektion und die schweißproduktion der hand. dissertation intraoperative glove perforation-single versus double gloving in protection against skin contamination wann sollte in operationsräumen ein wechsel chirurgischer handschuhe erfolgen? surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed incidence of microperforation for surgical gloves depends on duration of wear glove and gown effects on intraoperative bacterial contamination bacterial population kinetics on hands during 2 consecutive surgical hand disinfection procedures a 1-minute hand wash does not impair the efficacy of a propanol-based hand rub in two consecutive surgical hand disinfection procedures evaluation of an innovative antimicrobial surgical glove technology to reduce the risk of microbial passage following intraoperative perforation suppression of surgeons' bacterial hand flora during surgical procedures with a new antimicrobial surgical glove ausstattung des handwaschplatzes in arztpraxen hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems recommendations and requirements for soap and hand rub dispensers in healthcare facilities untersuchung der mikrobiellen kontamination von waschlotionsspendern aus unterschiedlichen risikobereichen serratia marcescens outbreak associated with extrinsic contamination of 1% chloroxylenol soap molecular epidemiology of a pseudomonas aeruginosa hospital outbreak driven by a contaminated disinfectant-soap dispenser nosocomial serratia marcescens outbreak in compliance with hand hygiene: reference data from the national hand hygiene campaign in germany quantification of the hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study quantifying the hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring hand hygiene among physicians: performance, beliefs, and perceptions impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series a multicenter study using positive deviance for improving hand hygiene compliance the impact of the international nosocomial infection control consortium (inicc) multicenter, multidimensional hand hygiene approach in two cities of india compliance of healthcare workers with hand hygiene practices in neonatal and pediatric intensive care units: overt observation how can compliance with hand hygiene be improved in specialized areas of a university hospital? compliance der händedesinfektion auf intensivstationen compliance with antiseptic hand rub use in intensive care units: the hawthorne effect differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/ apic/idsa hand hygiene task force compliance with hand hygiene on surgical, medical, and neurologic intensive care units: direct observation versus calculated disinfectant usage hand hygiene after touching a patient's surroundings: the opportunities most commonly missed three years of national hand hygiene campaign in germany: what are the key conclusions for clinical practice? hygienische händedesinfektion-leitlinien-compliance auf intensivstationen eines universitätsklinikums mit chirurgischem schwerpunkt quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene utilizing improvement science methods to improve physician compliance with proper hand hygiene reduction of health care associated infection risk in neonates by successful hand hygiene promotion attitudes and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates intensive care physicians' and nurses' perception that hand hygiene prevents pathogen transmission: belief strength and associations with other cognitive factors psychosocial determinants of self-reported hand hygiene behaviour: a survey comparing physicians and nurses in intensive care units outbreak of enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices no time for handwashing!? handwashing versus alcoholic rub: can we afford 100% compliance? handwashing and skin. physiologic and bacteriologic aspects meine hände sind sauber hand hygiene and patient care: pursuing the semmelweis legacy organizational culture and its implications for infection prevention and control in healthcare institutions behavioural considerations for hand hygiene practices: the basic building blocks implizite einstellung zur händehygiene als relevanter prädiktor von händehygieneverhalten dgkh test-und lernprogramm "klinische händehygiene compliance with handwashing a multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance global implementation of who's multimodal strategy for improvement of hand hygiene: a quasi-experimental study interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial hand hygiene compliance rates after an educational intervention in a neonatal intensive care unit establishment of a national surveillance system for alcohol-based hand rub consumption and change in consumption over 4 years comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis investigating the prevention of hospital-acquired infection through standardized teaching ward rounds in clinical nursing hand hygiene in preventing nosocomial infections: a nursing research interventions to improve hand hygiene compliance in patient care patient empowerment and hand hygiene systematic review of the effectiveness of strategies to encourage patients to remind healthcare professionals about their hand hygiene long-term sustainability of hand hygiene improvements in the hemodialysis setting improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit a systematic approach for the location of hand sanitizer dispensers in hospitals alcohol-based handrub: evaluation of technique and microbio-empfehlungen logical efficacy with international infection control professionals the world health organization hand hygiene observation method measuring hand hygiene compliance in a hematology-oncology unit: a comparative study of methodologies measurement of compliance with hand hygiene establishing evidence-based criteria for directly observed hand hygiene compliance monitoring programs: a prospective, multicenter cohort study electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit electronic surveillance of wall-mounted soap and alcohol gel dispensers in an intensive care unit evaluation of an electronic device for real-time measurement of alcohol-based hand rub use measuring hand hygiene compliance: a new frontier for improving hand hygiene präoperative hautantiseptik und hautschutz arbeitsgemeinschaft der wissenschaftlichen medizinischen fachgesellschaften (awmf), arbeitsgemeinschaft für berufs-und umweltdermatologie (abd) in der deutschen dermatologischen gesellschaft (ddg)(hrsg) berufliche hautmittel: hautschutz -hautpflege -hautreinigung wahrnehmung von handhygienemaßnahmen durch pflegepersonal: alkoholische händedesinfektion versus hygienische händewaschung -eine multicenterfragebogenstudie mit anschließender epikutantestung. dissertation hand dermatitis in intensive care units zur prüfung der händedesinfektion type of closure prevents microbial contamination of cosmetics during consumer use creams used by hand eczema patients are often contaminated with staphylococcus aureus the repetitive irritation test (rit) with a set of 4 standard irritants glycerol accelerates recovery of barrier function in vivo effects of a protective foam on scrubbing and gloving vergleich einer hautschutzcreme und ihrer grundlage bezüglich wirksamkeit gegen das berufsbedingte irritative handekzem bei krankenschwestern prevention of work-related skin problems in student auxiliary nurses: an intervention study prevention of work related skin problems: an intervention study in wet work employees das stratum corneum in vitro -ein modell zur entwicklung von hautschutzpräparaten mit entquellenden eigenschaften auf die hornschicht skin care education and individual counselling versus treatment as usual in healthcare workers with hand eczema: randomised clinical trial prospektive studie zum dermatologischen nutzen von hautschutz und hautpflege bei einem chirurgischen team integrated skin protection from workplace irritants: a new model for efficacy assessment skin protection in the healthcare setting occupational skin-protection products -a review practices of skin care among nurses in medical and surgical intensive care units: results of a self-administered questionnaire ergebnisse einer fragebogenerhebung des bdc zum stellenwert von hautschutz und hautpflege bei chirurgischem personal/handschutz und practice of skin protection and skin care among german surgeons and influence on the efficacy of surgical hand disinfection and surgical glove perforation skin changes in geriatric nurses prior to training heralding a particular risk of hand dermatitis hautschutzseminare zur sekundären individualprävention bei beschäftigten in gesundheitsberufen: erste ergebnisse nach über 2jähriger durchführung der dreistufige hautschutzplan technische regeln für gefahrstoffe -gefährdung der haut durch arbeiten im feuchten milieu (feuchtarbeit). gmbl acne therapy: neutrogena hand cream as an aid to topical treatment inhaltsstoffe von hautschutz-und-pflegemitteln aus allergologischer sicht. analyse von ivdk-daten und literaturübersicht zur kompatibilität von hautpflege-cremes mit hautdesinfektions-präparaten the effect of handcream on the antibacterial activity of chlorhexidine gluconate the effects of surfactant systems and moisturizing products on the residual activity of a chlorhexidine gluconate handwash using a pigskin substrate apic guidelines for handwashing and hand antisepsis in health care settings key: cord-021571-7kbq0v9w authors: heath, joan a.; zerr, danielle m. title: infections acquired in the nursery: epidemiology and control date: 2009-05-19 journal: infectious diseases of the fetus and newborn infant doi: 10.1016/b0-72-160537-0/50037-2 sha: doc_id: 21571 cord_uid: 7kbq0v9w nan neonates, especially premature neonates, requiring intensive care support constitute a highly vulnerable population at extreme risk for nosocomial or health care-associated infections. it has been estimated that as many as 6% to 22% of infants who survive 48 or more hours in a high-risk nursery or neonatal intensive care unit (nicu) acquire a nosocomial infection."* although nosocomial infections have long been recognized in nicus, only recently have data on rates been documented in the literature. as technology and treatments have advanced to significantly diminish mortality and morbidity among critically ill neonates, especially infants of very low birth weight (less than 1500 g), this vulnerability has only increased, as a result of both more profound immune system immaturity and more frequent use of invasive interventions that bypass skin and mucous membrane barriers. ' nosocomial infections in neonates carry high attendant morbidity and mortality and health care costs. prevention and control of these infections, although highly desirable, present a formidable challenge to health care professionals. because control over birth weight-the most significant predictor of nosocomial infection risk-is limited, proper nicu customs, environment, and procedures (e.g., hand hygiene, antimicrobial usage, catheter-related practices, skin and cord care, visitation policies, unit design, and staffing) can reduce the risk for infection in the nicu. understanding the epidemiology of nosocomial infections in neonates and methods for their prevention and control is critical to minimizing poor outcomes. this chapter describes the epidemiology, etiology, and clinical characteristics of neonatal nosocomial infections as well as the methods required for effective infection prevention and control. it is well recognized that the immune system of the newborn infant, especially the premature infant, is functionally inferior to that of older infants, children, and adults (see chapter 4). the lineages of the cells that will develop into the immune system are present at the beginning of the second trimester. the major components of the neonatal immune system, including t cells, neutrophils, monocytes, and the complement pathways, are functionally impaired, however, when compared with those in older infants and adults. for example, neonatal neutrophils show decreased chemotaxis, diminished adherence to the endothelium, and impaired phagocyto~is~~~; neonatal complement levels and opsonic capacity also are reduced, particularly in the premature ne0nate.4'~ in addition, neonatal t cell lymphokine production, cytotoxicity, delayed-type hypersensitivity, and help for b cell differentiation all are inferior when measured against those in adults! antigenic naivete may account for many of these differences; however, inherent immaturity also appears to account for certain inequities. for example, neonatal t cells are delayed in their ability to generate antigen-specific memory function after hsv infection, even in comparison with naive adult t cells. ' passively acquired maternal immunoglobulin g (igg) is the sole source of neonatal igg. soon after birth, maternal igg levels begin to fall; weeks later, production of immunoglobulins by the neonate commences. neonatal igg levels reach about 60% of adult levels by 1 year of age.6 unfortunately, because much of the maternal igg is not transferred to the infant until the last 8 to10 weeks' gestation, premature infants start with significantly lower levels of serum igg than in their term counterparts, which persist throughout most of the first months of life. other issues specific to the premature neonate also affect the functional immune system. for instance, the immature gastrointestinal tract (lack of acidity worsened by use of histamine h2 blockers and continuous feedings) and easily damaged skin constitute open potential portals of entry for pathogens or commensals. in addition, like other intensive care unit populations, the nicu population frequently experiences extrinsic breeches of the immune system through use of intravascular catheters as well as other invasive equipment and procedures used to care for critically ill patients. it is generally accepted that colonization with "normal flora" prevents, to some degree, colonization by pathogenic organisms. the neonate begins life essentially sterile. in the healthy term neonate, colonization occurs within the first few days of life. the organisms involved by site are a-hemolytic streptococci in the upper respiratory tract, staphylococcus epidermidis and other coagulase-negative staphylococci (cons) on the skin, and gram-negative bacilli and anaerobes in the gastrointestinal tract. this process of colonization with normal flora is disrupted in infants cared for in an nicu in part because of exposure to the nicu environment, the hands of health care workers (hcws), antimicrobial agents, and invasive procedures. as a result, the microflora of infants in the nicu can be markedly different from that of healthy term infantses9 multiple antimicrobial agent-resistant cons, klebsiella, enterobacter, and citrobacter species colonize the skin and the respiratory and gastrointestinal tracts of a high proportion of nicu neonates by the second week of hospitali~ation.'~-'~ in addition, neonates in the nicu become colonized not only with candida albicans but also with non-albicans candida species and malasse~ia.'~-' ' because colonization of the neonate with pathogenic organisms is a prelude to invasive infection from the same pathogens? measures to prevent such colonization need to be considered. first, as a result of abnormal colonization, infants in the nicu themselves serve as an important reservoir of potential pathogens. second, contamination of the hands of hcws during routine patient care has been well documented.'* thus, careful attention to hand hygiene before and after contact with patients and their environment, as well as decontamination of potential fomites, are crucial measures in preventing spread of colonization and infection. nosocomial infections in healthy term infants are uncommon unless other conditions require that they be cared for in the nicu for several days to weeks. on the other hand, these other conditions are frequent in neonates of very low birth weight (less than 1500 g), who require prolonged nicu care. understanding the epidemiology of nosocomial infections in nicus can be challenging, because reported rates vary dramatically by institution. this variation probably results from use of nonstandard definitions of nosocomial infection and from differences in patient populations, such as mean gestational age, birth weight, and severity of underlying illness, which significantly affect the incidence of nosocomial infection." the national nosocomial infections surveillance (nnis) system is a national surveillance system of the centers for disease control and prevention (cdc) that uses standardized surveillance protocols and the involvement of multiple medical centers to provide benchmark data for the epidemiology of nosocomial nicu infections. using standardized definitions, "is reported in 1996 that 13,179 nosocomial infections occurred between 1986 and 1994 in 10,296 neonates in 99 nicus.~' in this study, rates of intravascular catheterassociated bloodstream infection, the most frequent nosocomial infection, ranged from fewer than 5 infections per 1000 umbilical or central catheter days in infants with a birth weight greater than 1500 g to almost 15 infections per 1000 catheter days in the lowest-birth-weight group (less than another national, multicenter surveillance study, the pediatric prevention network's (ppn) point prevalence survey, was undertaken in 1999 to determine the point prevalence of nosocomial infections in nicus and to define risk factors associated with development of these infections." this study included 827 infants from 29 nicus. of the 827 infants, 94 (1 1.4%) had an active nosocomial infection on the day of the survey. bacteremia accounted for 53% of infections; lower respiratory tract infections, ear-nose-throat infections, and urinary tract infections accounted for 13%, 9%, and 9%, respectively (table 35-1) . in contrast with the nicu setting, the frequency of nosocomial infection in well-baby nurseries has been estimated to be between 0.3% and 1.7%?2-24 in general, non-lifethreatening infections such as conjunctivitis account for a majority of infections in the well-baby population. the remainder of this chapter focuses almost entirely on nosocomial infections in and control measures for the nicu setting. 1000 g). 2/26 (7.7) 2/2 (100) 0 2/5 (40) 115 for purposes of surveillance and tracking, all infections occurring in hospitalized newborns could be considered nosocomial. infections that are manifested in the first few days of life, however, usually are caused by pathogens transmitted vertically from the maternal genital tract. unfortunately, no precise time point perfectly distinguishes maternally acquired neonatal infections from those transmitted within the nicu. nnis has attempted to address this issue by stratifying infections according to whether they are likely to be maternally acquired.20 in 89% of neonates who had an infection thought to be maternally acquired, onset occurred within 48 hours of birth. use of a cutoff period of 48 hours or less to designate maternally acquired infections allowed 15.3% of bacteremias and 14.5% of pneumonias to be considered as originating from a maternal source. maternally acquired bloodstream infections were more likely to be caused by group b streptococci, other streptococci, and escherichia coli, whereas those not maternally acquired usually were caused by coagulase-negative staphylococci.20 in general, nonmaternal routes of transmission of microorganisms to neonates are divided into three categories: contact (from either direct or indirect contact from an infected person or a contaminated source), droplet (from large respiratory droplets that fall out of the air at a maximum distance of 3 feet), and airborne (from droplet nuclei, which can remain suspended in air for long periods and as a result travel longer distances). specific microorganisms can be spread by more than one mechanism; in most instances, however, a single mode of spread predominates. the cdc has developed a system of precautions for the control of nosocomial infections that is based on these modes of transmi~sion.~~ contact transmission of bacteria, viruses, and fungi on the hands of hcws is arguably the most important yet seemingly preventable means of transmission of nosocomial infection. spread of infection by this means can occur either by transmission of the hcw's own colonizing or infecting pathogens or, more often, by transmission of pathogens from one patient to another. that the hands of hcws become contaminated even in touching intact skin of patients has been well demonstrated.'* poor compliance with hand hygiene is another means by which the hands of hcws can spread organisms from one patient to another.26227 furthermore, hands of hcws have been implicated in multiple outbreaks with a variety of different organisms; through experimental studies, a causal link between hand hygiene and nosocomial infection has been established.28 contact transmission by means of fomites also can occur and has been described as a potential mechanism of spread of pathogens in multiple nicu outbreaks. as described later in this chapter, implicated items have included linens, medical devices, soap dispensers, and breast pumps, to name a few. these observations highlight the need for careful attention to disinfecting items shared between infants. spread through large respiratory droplets is an important mode of transmission for pertussis and infections due to neisseria meningitidis, group a streptococci, and certain respiratory viruses, whereas airborne transmission by means of droplet nuclei is relevant for measles, varicella, and pulmonary tuberculosis. for large droplet or droplet nuclei transmission, usually an ill adult, either an hcw or a parent, is the source of infection in an nicu setting. in general, these organisms are rare sources of outbreaks. infusates, medications, and feeding powders or solutions can be intrinsically or extrinsically contaminated and have been reported as the source of outbreaks due to a variety of different pathogens. it is important when possible to mix infusates in a controlled environment (usually the pharmacy), to avoid multiuse sources of medication, and to use bottled or sterilized feeding solutions when breast milk is not available. of course, nosocomial infection also can arise from endogenous sources within the neonate. the "abnormal flora" of the neonate residing in the nicu, however, is determined at least in part by the nicu environment and hcws' hands. with use of molecular techniques, even organisms typically considered to originate solely from normal flora (e.g., cons) have been shown to have clonal spread in the hospital setting, suggesting transmission by means of the hands of hcws.~~,~' as discussed earlier, infants in nicus have intrinsic factors predisposing them to infection, such as an immature immune system and compromised skin or mucous membrane barriers. in addition, multiple extrinsic factors play important roles in the development of infection, such as presence of indwelling catheters, performance of invasive procedures, and administration of certain medications, such as steroids and antimicrobial agents. birth weight is one of the strongest predictors of risk for nosocomial infection. for instance, "is data demonstrate that compared with larger infants, low-birth-weight infants are at higher risk of developing bloodstream infections and ventilator-associated pneumonia, even after correction for central intravascular catheter and ventilator use." similarly, in the ppn's point prevalence survey, infants weighing 1500 g or less at birth were 2.69 (95% confidence interval [ci] 1.75% to 4.14%; p < .001) times more likely to have an infection than those weighing more than 1500g.2' the relationship between birth weight and nosocomial infection is complicated by multiple other factors that accompany low birth weight and also increase risk for nosocomial infection. low birth weight, however, has been shown to be an independent predictor for nosocomial infection, after adjustment for use of vascular catheters, parented alimentation, and mechanical ~entilation.~~ it is likely that birth weight also is a surrogate marker for other unmeasured factors, such as immune system immaturity. central venous catheters (cvcs) increase the risk for development of nosocomial bloodstream infections. in a study by chien and colleagues 19,507 infants admitted to 17 nicus in canada, nosocomial bloodstream infections were found to occur at a rate of 3.1 to 7.2 infections per 1000 catheter days, depending on the type of catheter, versus 2.9 infections per 1000 noncatheter days. other studies have demonstrated that the association between cvcs and bloodstream infection is independent of birth weight.2' mechanisms for cvc-related nosocomial bloodstream infections probably involve colonization of the catheter by means of the catheter hub, colonization of the skin at the insertion site?3 or hematogenous spread of pathogens from distant sites of infection or colonization. bloodstream infections also can result from contaminated intravenous fluids, which have the potential for intrinsic or, especially with use of multiuse vials, extrinsic contamination. factors related to the management of cvcs influence the risk of infection. disconnection of the cvc and the frequency of blood sampling through the catheter increase the frequency of catheter-related infection^.^^ by contrast, administration of a solution with heparin and exit-site antisepsis decreased infection. lower frequency of cvc tubing changes (every 72 hours versus every 24 hours) was associated with increased catheter contamination, suggesting a potential for increased risk of infecti0n.3~ cvc management techniques, including use of antiseptic-impregnated dressings, antimicrobialcoated catheters, and avoidance of scheduled replacement of cvcs, are discussed in the most recent cdc recommendations, summarized in "guidelines for the prevention of intravascular catheter-related infection," published in 2002 and prepared by the hospital infection control practice advisory c~m m i t t e e .~~ it has been suggested that use of peripherally inserted central catheters (piccs) may be associated with a lower rate of infection than for other cvcs. studies based in nicus have yielded conflicting results. in a study by chien and colleagues?' the relative risk of bloodstream infection, after adjustment for differences in infant characteristics and admission illness severity, was 2.5 per 1000 catheter days for umbilical venous catheters, 4.6 for piccs, and 4.3 for broviac catheters, compared with no catheter ( p < .05). another study also documented similar rates of infection for broviac catheters and for piccs.~~ by contrast, a higher rate of infection with broviac catheters than with piccs was suggested by brodie and co-w~rkers.~~ further study of different cvcs in nicu infants is needed to delineate infection risks for individual catheter types. parented alimentation and intralipids have been shown to increase risk of bloodstream infection in premature infants even after adjustment for other covariables such as birth weight and cvc use.38 etiologic agents often associated are cons, candida species, and malassezia species. the pathogenesis of this association remains unclear. potential hypotheses are many. intralipids, for example, could have a direct effect on the immune system, perhaps through inhibition of interleukin-2.39 alternatively, as with any intravenous fluids, parented alimentation has the potential for intrinsic and extrinsic contamination, and intralipids especially may serve as a growth medium for certain bacteria and fungi. finally, total parented alimentation and intralipids delay the normal development of gastrointestinal mucosa because of lack of enteral feeding, encouraging translocation of pathogens across the gastrointestinal mucosa. it is well accepted that mechanical ventilation is an important risk factor for nosocomial lower respiratory tract infection. a large multicenter study of 8263 neonates found that mechanical ventilation was a risk factor for bloodstream infection as well, even after adjustment for a number of covariables such as birth weight, parented nutrition, and umbilical catheterization:' clinically obvious respiratory infection appeared to precede some but not all cases of bloodstream infection associated with mechanical ventilation. the study authors suggested that the increased risk of mechanical ventilation could be attributed to colonization of humidified air, as well as to physical trauma from the endotracheal tube and its suctioning. a number of medications critical to the survival of infants in the nicu increase risk of infection. broad-spectrum antimicrobial agents, especially with prolonged use, are important in the development of colonization with pathogenic micro-organism~.~ the widespread use of broad-spectrum antimicrobial agents has been associated with increased colonization with resistant organisms in many settings, including nicus." in addition to colonization, antimicrobial agents also have been shown to increase risk of infection with resistant bacteria4' and with fungal pathogens!' other medications also appear to play a role in nosocomial infection. for instance, infants who receive corticosteroids after delivery are at approximately 1.3 to 1.6 times higher risk for nosocomial bacteremia in the subsequent 2 to 6 weeks than that observed for infants who do not receive this in addition, colonization and infection with bacterial and fungal pathogens have been shown to increase with the use of h, blocker^.'^"' measures of illness severity have been developed, in part, in an effort to account for variations in birth weight-adjusted mortality scores between nicus. the score for neonatal acute physiology (snap) was developed and validated by richardson and ass0ciates,4~ and the clinical risk index for babies (crib) was developed by the international neonatal network.% these scores are highly predictive of neonatal mortality even within narrow birth weight strata and are predictive of nosocomial infection. thus, in investigating potential risk factors for nosocomial infection, it is important to consider adjusting for illness severity using such measures, in addition to adjusting for other potential confounders. other risk factors related to infection include poor hand hygiene and environmental issues, such as understaffing and overcrowding.47b48 these and related issues are discussed later in this chapter under "prevention and control." nosocomial infections can affect any body site or organ system and manifest in a multitude of different ways. "is and ppn data demonstrated that bloodstream infections are the most common manifestation of nosocomial infection and account for 32% to 53% of infections (table 35-2; see also table 35 -1).20,'' respiratory infections and eye, ear, nose, or throat infections are second and third in frequency, whereas gastrointestinal infections, urinary tract infections, surgical site infections, meningitis, cellulitis, omphalitis, septic arthritis, and osteomyelitis are reported less frequently."*" bloodstream infections are the most common and one of the most potentially serious nosocomial infections that occur in nicu patients. factors discussed earlier, including birth weight, intravascular catheters, mechanical ventilation, use of parented alimentation, and steroids, all have been shown to be associated with an increased risk of bloodstream infection. the most common pathogen associated with nosocomial bloodstream infections is cons (see table 35 -2). staphylococcus aureus, enterococcus, candida species, e. coli, enterobacter species, klebsiella pneurnoniae, and pseudomonas aeruginosa also play important roles and are associated with higher morbidity and mortality rates than those associated with cons?^,^" in one study, the frequency of fulminant sepsis (fatal within 48 hours) was estimated to be 56% (95% ci 38% to 72%) when the bloodstream infection was caused by pseudomonas species, whereas it was only 1% (95% ci 0% to 4%) when infection was caused by cons.^" the difficulty of assigning an etiologic role to cons on the basis of one blood culture that could be contaminated probably accounts for some distortion of the incidence and mortality data related to this organism, and this problem is discussed in detail in chapter 6. pneumonia accounts for 12% to 18% of nicu nosocomial infections" and has been associated with prolonged hospital stay and increased mortality.51 organisms most commonly associated with nosocomial pneumonia include cons, s. aureus, and i? aeruginosa (see table 35 -2). mechanical ventilation and birth weight are important risk factors for nosocomial respiratory infection^.^^ diagnosis of nosocomial respiratory infections requires correlation of microbiologic results with clinical findings and can be challenging in lowbirth-weight infants because of the mostly nonspecific associated signs of illness and often misleading results of radiologic ~tudies.~' eye, ear, nose, and throat infections account for approximately 8% to 21% of infections, depending on birth weight." common etiologic organisms include cons and s. aureus, although gram-negative organisms, such as e. coli, e! aeruginosa, and k. pneumoniae, also can be isolated from these sites (see table 35 -2). conjunctivitis appears to be the most common of these infections, accounting for 54% to 76%, depending on birth weight?' risk factors for neonatal conjunctivitis identified in a study from nigeria included vaginal delivery, asphyxia, and prolonged rupture of membranes.53 in the nnis review, gastrointestinal infections were estimated to account for 5% to 11% of nosocomial infections, depending on birth weight. necrotizing enterocolitis (nec) was the most common presentation.'" nec carries high morbidity and mortality rates. a review of 17 nec epidemics estimated that surgery was required for a mean of 16% (range, 0% to 67%) of infants, and death occurred in a mean of 6% (range, 0% to 8 8 y 0 ) .~~ in controlled studies, identified risk factors for nec have included young chronologic age, low gestational age, low birth weight, and young age at first feeding.54 implication of specific pathogens is complex, requiring careful selection of an appropriate control population and attention to how and where specimens are collected. pathogens associated with nec outbreaks have included pseudornonas species, salmonella species, e. coli, k. pneumoniae, enterobacter cloacae, s. epidermidis, clostridium species, coronavirus, and r~t a v i r u s .~~'~~ the importance of infection control methods such as strict attention to hand hygiene and cohorting patients in the nicu is suggested by the observation that their implementation has been followed by resolution of the outbreak.55 a detailed discussion of the cause of nosocomial sepsis and meningitis is found in the chapter on bacterial sepsis (chapter 6) and chapters describing specific etiologic agents. s. aureus is a colonizing agent in neonates and has been a cause of nosocomial infection and outbreaks in well-baby nurseries and nicus. methicillin-resistant s. aureus (mrsa) has become a serious nosocomial pathogen, and outbreaks have been reported in many areas of hospitals, including n~rseries.~~-~' in addition to the usual manifestations of neonatal nosocomial infection (conjunctivitis, bloodstream infections, and pneumonia), nosocomial s. aureus infections can manifest as skin infection^?^ bone and joint infections,@' parotitis:' staphylococcal scalded skin syndr0me,6~*~~ toxic shock syndrome?6 and disseminated sepsis. the role of the hands of hcws in transmitting and spreading pathogenic organisms among infants was demonstrated with s. aureus in the 1960~."*~~ currently, in a majority of instances, s. aureus transmission is thought to occur by direct contact. thus, it is not surprising that understaffing and overcrowding have been associated with s. aureus outbreaks in n i c u s .~~.~ the potential for airborne transmission, however, has been suggested by the occurrence of "cloud babies? described by eichenwald and colleagues67 in 1960. "cloud" hcws also have been described; in such cases, the point source of an outbreak was determined to be a colonized hcw with a viral respiratory infe~tion.~~'~' in one of these studies, dispersion of s. aureus from the implicated hcw was found to be much higher after experimental infection with rhinovirus.68 more recently, molecular techniques not only have defined outbreaks57 but also have demonstrated that transmission to infants probably occurs from colonized hcws,6* and sometimes from colonized parents. 69 nasal mupirocin ointment has been used to control outbreaks of both methidin-susceptible s. aureus and mrsa.62,70 the pharynx, rather than the anterior nares, however, may be a more common site of colonization in neonates and infants," and eradication of the causative organisms with nasal mupirocin may be more difficult in this site.72 since the early 1980s, cons has been the most common cause of nosocomial infection in the nicu. ' this finding suggests that a portion of cons infections may be preventable by strict adherence to infection control practices. the fact that a hand hygiene campaign was associated with increased hand hygiene compliance and a lower rate of cons-positive cultures supports this ~ontention.'~ enterococcus has been shown to account for 10% of total nosocomial infections in neonates, 6% to 15% of bloodstream infections, 0% to 5% of cases of pneumonia, 17% of urinary tract infections, and 9% of surgical site sepsis and meningitis are common manifestations of enterococcal infection during nicu outbreak^'^,^^; however, polymicrobial bacteremia and nec frequently accompany enterococcal sepsis.77 identified risk factors for enterococcal sepsis, after adjustment for birth weight, include use of a nonumbilical cvc, prolonged presence of a cvc, and bowel resection?' because enterococcus colonizes the gastrointestinal tract and can survive for long periods of time on inanimate surfaces, the patient's environment may become contaminated and, along with the infant, serve as a reservoir for ongoing spread of the organism. the emergence of vancomycin-resistant enterococci (vre) is a concern in all hospital settings, and vre have been the cause of at least one outbreak in the nicu setting7' in the neonate, resistant strains appear to cause clinical syndromes indistinguishable from those due to susceptible enteroco~ci.'~ the conditions promoting vre infection, such as severe underlying disease and use of broad-spectrum antimicrobial agents, especially vancomycin, can be difficult to alter in many nicu settings. guidelines for the prevention and control of vre infection have been published; these focus on infection control tools such as rapid identification of a vrecolonized or vre-infected patient, cohorting, isolation, and barrier precautions. 80 historically, before the recognized importance of hand hygiene and the availability of antimicrobial agents, group a streptococci (gas) were a major cause of puerperal sepsis and fatal neonatal sepsis. although less common now, gas continue to be a cause of well-baby and nicu outbreak^.'^-'^ gas-associated clinical manifestations include severe sepsis and soft tissue infections. one report described a high frequency of "indolent omphalitis"; in this outbreak, the umbilical stump appeared to be an important site of gas colonization and an ongoing reservoir of the organism." routine cord care included daily alcohol application. after multiple attempts, the outbreak finally was interrupted after a 15-day interval during which bacitracin ointment was applied to the umbilical stump in all infants, and affected infants received intramuscular penicillin. molecular techniques have enhanced the ability to define outbreaks, and use of these techniques has suggested that transmission can occur between mother and infant, between hcw and infant, and between infantsprobably indirectly on the hands of hcws.",~~ in one recurring outbreak, inadequate laundry practices appeared to be a contributing factor. 85 nnis data have shown that group b streptococci (gbs) infections account for less than 2% of non-maternally acquired nosocomial bloodstream and pneumonia infections." a number of studies from the 1970s and 1980s demonstrated nosocomial colonization of infants born to gbs-negative ~o m e n .~~-~o these studies suggested a rate of transmission to babies born to seronegative mothers as high as 12% to 270/0.8~,~' a recent case-control study evaluating risk factors for lateonset gbs infection demonstrated that premature birth was a strong predictor?' in that study, 50% of the infants with late-onset gbs infection were born at less than 37 weeks of gestation (compared with 15% of controls), and only 38% of the mothers of these infants were colonized with gbs, suggesting possible nosocomial transmission of gbs during the nicu stay. the hands of hcws are assumed to account for the transmission of most cases of nosocomial gbs infection. breast milk also has been implicated as a potential mode of acquisition, however. in one report, gbs probably was transmitted from breast milk to one set of premature triplets between days 12 and 63 of life.92 two maternal vaginal swabs taken before delivery did not grow gbs, but repeated cultures of the mother's breast milk yielded a pure growth of gbs (greater than 10' colony-forming units [ cfu] /ml) despite no evidence of mastitis. in this report, antimicrobial therapy administered to the mother appeared to eradicate the organism. the enterobacteriaciae family has long been recognized as an important cause of nosocomial infection. neonatal infection can be manifested as sepsis, pneumonia, urinary tract infections, and soft tissue infections; morbidity and mortality rates frequently are enterobacter species, k. pneumoniae, e. coli, and serratia marcescens are the members of the family enterobacteriaciae most commonly encountered in the nicu. enterobacter species have been estimated to account for 3% of bloodstream infections, 8% of cases of pneumonia, and 8% of surgical site infections in the nicu setting (see table 35 -2). outbreaks due to enterobacter species in nicus have been associated with thermometer^?^ a multidose vial of d e x t r o~e~~ intravenous fluids,% and powdered formula?7 as well as with understaffing, overcrowding, and poor hand hygiene practice^.'^ in one outbreak in which contaminated saline was linked to the initial cases, subsequent ongoing transmission was documented, presumably by means of the hands of hcws and the environment." in that study, early gestational age, low birth weight, exposure to personnel with contaminated hands, and e. cloacae colonization of the stool were associated with e. cloacae bacteremia, whereas use of cvcs and mechanical ventilation was not. k. pneumoniae has been estimated to account for a similar proportion of infections in the nicu setting to that identified for enterobacter species. investigations in outbreaks involving klebsiella species have implicated contaminated breast milk,1oo infusion therapy practices,"' intravenous dextrose,io2 cockroaches, 134 di~infectant,"~ incubator humidifier^,'^' thermometers, oxygen saturation probes,io6 and ultrasonography coupling ge1.io8 in a surveillance study of 383 nicu infants in brazil, 50% became colonized with kleb~iella.'~ in this study, colonization was associated with use of a cephalosporin and aminoglycoside combination therapy, as well as with longer duration of the nicu stay. e. coli has been estimated to cause 4% of bloodstream, 14% of gastrointestinal, and 12% of surgical site infections. e. coli also has been responsible for outbreaks of pyelonephritis,io8 ga~troenteritis,'~'*"o and nec. s. marcescens is an opportunistic pathogen that survives in relatively harsh environments. disease due to s. marcescens often is manifested as meningitis, bacteremia, and pneumonia.'" s. marcescens infections have a high potential for morbidity and mortality."2,'13 s. marcescens outbreaks have been associated with, but not limited to, contaminated soap,114 multiuse bottles of theophylline,"5 formula,"' enteral feeding additives,l16 breast pumps,' ",'i8 and transducers from internal monitors.ii6 although point source environmental contamination is important in serratia outbreaks, in many of these outbreaks and in reports in which no point source was identified,"' patient-to-patient spread of the organism by means of the hands of hcws appeared to be an important mechanism of spread.i13 extended-spectrum p-lactamases (esbls) are plasmidmediated resistance factors produced by members of the enterobacteriaceae family. esbls inactivate third-generation cephalosporins and aztreonam. they most commonly occur in k. pneumoniae and e. coli but have increasingly been found in other gram-negative bacilli. colonization with esblproducing organisms has been associated with administration of certain antimicrobials and longer duration of hospitalization, whereas infection has been associated with prior colonization and use of cvcs.i3 that the esbl-containing plasmids can be transmitted to other enterobacteriaceae organisms has been demonstrated in nicu outbreaks in which the implicated plasmid spread from klebsiella species to e. coli, e. cloacae, and citrobacter fieundii.'20s'zl the gastrointestinal tract in neonates and the hands of hcws serve as reservoirs for members of the enterobacteriaceae family. thus, in general, measures aimed at controlling spread of organisms in this family have focused on attention on hand hygiene, cohorting of patient and staff, and observation of isolation precautions.'21"22 i? aeruginosa, an opportunistic pathogen that persists in relatively harsh environments, frequently has been associated with nosocomial infections and outbreaks in the nicu setting. nosocomial i! aeruginosa infections vary in their clinical presentation, but the most common manifestations are respiratory, ear, nose, or throat and bloodstream infections.*' from the ppn data it has been estimated that j? aeruginosa species account for 6.8% of total pathogens, 5% of bloodstream infections, and 15% of respiratory infections.21 l ? aeruginosa infections, particularly bloodstream infections, have been associated with a very high mortality rate.'23 feeding intolerance, prolonged parented alimentation, and long-term intravenous antimicrobial therapy have been identified as risk factors for pseudomonas infe~ti0n.l~~ outbreaks due to i! aeruginosa have been linked with contaminated hand lotion,'24 respiratory therapy solution, 12' a water bath used to thaw fkesh-frozen plasma,'26 a blood gas analy~er,'~' and bathing sources. in one case, neonatal pseudomonas sepsis and meningitis were shown by pulsed-field gel electrophoresis to be associated with shower tubing from a tub used by the infant's mother during labor.i2' of importance, hcws and their contaminated hands also have been linked with pseudomonas infections in the nicu setting. in a study of a new york outbreak, recovery of pseudomonas from the hands of hcws was associated with older age and history of use of artificial nails.12' this and other studies suggest that the risk of transmission of pseudomonas to patients is higher among hcws with onychmycosis or those who wear long artificial or long natural nail^.'^^,'^^ as a result of these and other findings, the cdc revised its 2002 hand hygiene recommendations to include a recommendation against the presence of hcws with artificial fingernails in intensive care units.'31 bordetella pertussis is a rare cause of nosocomial infection in neonates. when b. pertussis infection occurs, parents and hcws typically are the source. a parent was the source of an outbreak involving three neonates and one nurse in a special care nursery in a~stralia.'~' in 1999 in knoxville, tennessee, an outbreak involving six neonates probably was due to transmission of infection by an hcw."' as a result of the tennessee outbreak, 166 infants received erythromycin prophylaxis. subsequently, an increase in infantile hypertrophic pyloric stenosis was noted by local pediatric surgeons. results of a cdc investigation suggested a causal role of erythromycin in the cases of hypertrophic pyloric steno~is.'~~~~" erythromycin remains the recommended agent of choice for prophylaxis after pertussis exposure, but parents should be informed of the risk and signs of hypertrophic pyloric stenosis, and cases associated with erythromycin use should be reported to medwat~h.'~~ newborn infants are particularly prone to infection and disease following exposure to mycobacteriurn tuberculosis. a cluster of multidrug-resistant m. tuberculosis infections was noted in three infants born during a 2-week period in one new york h0spita1.l~~ investigation implicated an hcw who visited the nursery several times during that period. pulmonary and extrapulmonary disease occurred in three infants 4 to15 months after exposure, highlighting the vulnerability of the newborn p~pulation.'~~ tuberculosis screening of hcws, ultraviolet lighting, and a high number of air exchanges appear to be effective methods in preventing nosocomial tuberculosis infe~ti0n.i~' the cdc's "guidelines for preventing the transmission of mycobacteriurn tuberculosis in health-care settings" emphasizes (1) use of engineering controls and personal protective equipment, (2) risk assessments for the development of institutional tuberculosis control plans, (3) early identification and management of individuals with tuberculosis infection and disease, (4) tuberculosis screening programs for hcws, (5) hcw education and training, and (6) evaluation of tuberculosis control prograrns.l3* candida species are an increasingly important cause of nosocomial infection in nicu patients and have been estimated to account for 6.9% of bloodstream infections and 42% of urinary tract infection^.^^^"^ prospective studies have estimated colonization rates with candida to be 12% to 54% in low-birth-weight neonate^,'^"^^-'^' and colonization has been associated with subsequent invasive disease.14' the mortality rate can be high in invasive candidiasis. in one study of 34 patients with fungemia due to candida species, a case-fatality rate of 41% was r e~0 r t e d . i~~ risk factors for fungal infections in neonates are similar to risk factors for bacterial infections; low birth weight and gestational age are important predictors. in addition, a prospective, multicenter study of 2157 infants found that use of a third-generation cephalosporin, presence of a cvc, intravenously administered lipids, and hz blocker therapy were associated with candida colonization after adjusting for length of stay, birth weight of 1000 g or less, and gestational age less than 32 weeksl4 candida parapsilosis appears to be the most frequent species associated with nosocomial candida infection in nicu infants. both cross-contamination and maternal reservoirs are sources of nosocomial candida albicans infection, as demonstrated in studies using molecular typing method^.'^-'^^ malassezia species, lipophilic yeasts, frequently colonize nicu patients. in one french study, 30 of 54 preterm neonates (56%) became colonized with malassezia fit+r.147 malassezia pachydermatis, a zoonotic organism present on the skin and in the ear canals of healthy dogs and cats, also has been associated with nosocomial outbreaks in the nicu setting. 147, 148 in one report, the outbreak appeared to be linked to colonization of hcws' pet dogs.i4' pichia anornala, or hansenula anornala, a yeast found in soil and pigeon droppings, and on plants and fruits, also can colonize the human throat and gastrointestinal tract. in general, it is an unusual cause of nosocomial infection in neonates, but it was the cause of two reported outbreaks in this ~e t t i n g . '~~, '~~ in both reports, carriage on the hands of hcws appeared to be a factor. invasive mold infections are a rare cause of nosocomial infection in neonates, but when they occur, they are associated with high mortality rate. aspergillus infections may manifest as pulmonary, central nervous system, gastrointestinal, or disseminated disease. a cutaneous presentation, with or without subsequent dissemination, appears to be the most common presentation for hospitalized premature infants without underlying immune defi~iency.'~'.'~~ often, skin maceration is the presumed portal of entry. in a series of four patients who died of disseminated aspergillus infection that started cutaneously, a contaminated device used to collect urine from the male infants was impli~ated.'~' similarly, contaminated wooden tongue depressors, used as splints for intravenous and arterial cannulation sites, were associated with cutaneous infection due to rhizopus microsporus in four premature infants.'53 in addition to preterm birth, use of broad-spectrum antimicrobial agents, steroid therapy, and hyperglycemia are thought to be risk factors for mold infection. even zoophilic dermatophytes have been described as a source of nosocomial infection in neonates. in one report, five neonatal cases in one unit were traced to an infected nurse and her cat.154 prolonged therapy for both the nurse and her cat was necessary to clear their infections. although many pathogens can cause nosocomial gastroenteritis, rotavirus is responsible for 95% or more of viral infections in high-risk nurseries, including the nicu." in one longitudinal study, rotavirus infection developed during hospitalization in 95 of 194 neonates (49?40).'~~ in this study, rotavirus was manifested as frequent and watery stools in term infants and as abdominal distention and bloody, mucoid stools in the preterm neonates. a high titer of virus is excreted in stool of infected persons, and the organism is viable on hands and in the environment for relatively prolonged periods of time.'56"57 attention to hand hygiene and disinfection of potential fomites are crucial in preventing spread of infection. this concept is illustrated by the results of one study in which rotavirus infection was associated with ungloved nasogastric tube feeding.157 respiratory viruses including influenza a virus, parainfl uenza virus, coronavirus, respiratory syncytial virus, and aden )virus have been reported to cause nosocomial infections in qicu patient^.'^^-'^' associated clinical findings include rhino rrhea, tachypnea, retractions, nasal flaring, rales, and wheezir g, but illness also can be manifested as apnea, sepsis-like i lness, and gastrointestinal symptoms. 16',16* identified risk f ictors for acquisition vary from study to study but have includl id low birth weight, low gestational age, twin pregnancy, mech anical ventilation, and high crib s~o r e . '~~-'~* contact and d :oplet transmission are the most common modes of sprcad of infection, again highlighting the importance of scrul (dous hand hygiene in delivery of patient care for this popul, tion. numerous nursery and nicu outbreaks of enterovii a1 infection have been r e p~r t e d . '~~"~ in the neonate with e iteroviral infection, clinical manifestations can range fron mild gastroenteritis to a severe and fulminant sepsis-like sync home or meningitis/encephalitis. the latter presentation c m be associated with a high mortality rate.lw in index cas :s, the patient may have acquired disease vertically, with subst quent horizontal spread leading to outbreak^'^^'^^; with othe r viral pathogens, virus can be shed into the stool for prolnged periods, enabling patient-to-patient transmission by the hands of hcws when hand hygiene procedures are impr iperly performed. congenitally acquired cytomegalovirus (cmv) infecti )n is a cause of morbidity and occasionally death, whereas postnatally acquired cmv infection follows a benign col rse in virtually all healthy term infants. postnatal cmv infi ction, however, can cause considerable morbidity and death i n premature infants. 166 hepatitis, neutropenia, thrombocyto penia, sepsis-like syndrome, pneumonitis, and developmi nt of chronic lung disease each have been associated with postnatal acquisition of cmv in premature infant^.'^^''^^ w th the routine use of cmv-seronegative blood products in these neonates, a majority of postnatal cmv infections ap1 ear to be acquired through breast milk.'69 it has been estinated that transmission by this mode occurs in approximate1 y 37% of breast-fed infants of mothers with cmv detec ed in breast milk. '70 in one study, approximately 50% of these infants had clinical features of infection, and 12% pre iented with a sepsis-like syndrome. nosocomial person-to-] ierson transmission has been d o~u m e n t e d , '~'~'~~ but the exl ent to which this occurs is contr~versial.'~~ at present, no p :oven, highly effective method is available for removing cml ' from breast milk without destroying its beneficial compc nents. some data, however, suggest that freezing the breas: milk before use may decrease the cmv titer, thereby liniting subsequent transmission."* in a majority of cases, neonatal herpes simplex virus hsv) infection is acquired vertically from the mother. nursery transmission of hsv infection is rare but has been describe( . [175] [176] [177] in each of these cases, hsv-1 was involved. in one infa it, the source of virus was thought to be a patient's father, wl 10 had active herpes labiali~.'~~ subsequent spread of virus from this first infant to a second infant was thought to have occurred by means of the hands of an hcw. in another report, the source of hsv for the index case, an infant who died of respiratory distress in whom evidence of hsv infection was found at postmortem examination of the brain, was unthe hands of hcws were implicated in the spread of hsv to three subsequent cases, however. in another report, direct spread from an hcw was thought to be responsible for transmission of hsv to three infants over a period of approximately 3 years.'77 studies of adults with herpes labialis suggest a high frequency of recovery of virus from the mouth and the hands (78% and 67%, re~pectively).'~~ in this same study, hsv was shown to survive for 2 to 4 hours on skin, cloth, and plastic. implementing contact precautions for infants with hsv and instructing hcws with active herpes labialis regarding control measures, such as covering the lesion, not touching the lesion, and using strict hand hygiene, are reasonable means to prevent nosocomial transmission of hsv. if there are concerns that an hcw would be unable to comply with control measures or if the hcw has a herpetic whitlow, such persons should be restricted from patient contact. nosocomial transmission of varicella in the nicu setting, although unusual, has been de~cribed.'~~ large-scale outbreaks in nurseries and nicus are rare, most probably because of the high rate of varicella-zoster virus (vzv) immunity in hcws and pregnant women. premature infants born at less than 28 weeks of gestation are unlikely to have received protective levels of vzv igg from their mothers, so their potential risk is significant if an exposure occurs. transmission is most likely to occur from an adult with early, unrecognized symptoms of varicella. in such instances, the potential risk for vzv-seronegative exposed infants and hcws is substantial, especially if the patient in the index case is an hcw.'" for this reason, it is recommended that hcws be screened for prior varicella infection by history, with subsequent immunization as indicated. hepatitis a is a rare cause of nosocomial infection in nicus, but a number of outbreaks in this setting have been r e p~r t e d . '~' . '~~ in most instances, disease in neonates is clinically silent. neonatal cases often are detected only through recognition of the symptomatic secondary adult cases. in one report, disease was acquired by patients in the index cases through blood transfusion from a donor with acute hepatitis of note, the virus subsequently spread to another 11 infants, 22 nurses, and 8 other hcws. overall, hepatitis a affected 20% of the patients and 24% of the nurses. lapses in infection control practices and the prolonged shedding of the virus in infants stool probably contributed to the rapid spread and high attack rate documented in the outbreak. outbreaks such as this one are unlikely because of current blood product practices to eliminate transmissible agents from donor blood. an effective infection control program that focuses on reducing risk on a prospective basis can decrease the incidence of nosocomial infection^.'^"^^ the principal function of such a program is to protect the infant and the hcw from risk of hospital-acquired infection in a manner that is cost-effective. activities crucial to achieving and maintaining this goal include collection and management of critical data relating to surveillance for nosocomial infection, and direct intervention to interrupt the transmission of infectious diseases.22 reducing the incidence of nosocomial infection for neonates must begin with surveillance for these events. surveillance has been defined as "a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the health care team to assist in improving those outcomes."'86 essential elements of a surveillance program include the following: defining the population and data elements as concisely collecting relevant data using systematic methods consolidating and tabulating data to facilitate evaluation analyzing and interpreting data reporting data to those who can bring about changeia7 surveillance systems necessarily vary, depending on the population; accordingly, a written plan, based on sound epidemiologic principles,ls7 should be in place to track rates of infection over time. because new risks can emerge, such as new interventional technology or drugs, changing patient demographics, and new pathogens and resistance patterns, the plan should be reviewed and updated the joint commission on accreditation of healthcare organizations (jcaho) recommends that hospitals have a written infection control plan that includes a description of prioritized risks; a statement of the goals of the infection control program; a description of the hospital's strategies to minimize, reduce, or eliminate the prioritized risks; and a description of how the strategies will be evaluated. the jcaho further recommends that hospitals identify risks for transmission and acquisition of infectious agents (table 35system provides high-risk nursery-specific data collection methods as well as denominator data and allows external benchmarking of infection rates for this populati~n.'~~,'~' the nnis system defines a nosocomial infection as a localized or systemic process that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and that was not present or incubating at the time of admission to the hospital. nnis also recognizes as special situations, and defines as nosocomial, some infections in neonates that result from passage through the birth canal but do not become clinically apparent until several or more days after birth. it does not, however, consider infections that are known or proved to have been acquired transplacentally to be noso-~omial.'~' distinction between maternal and hospital sources of infection is important, although difficult at times, because control measures designed to prevent acquisition from hospital sources will be ineffective in preventing perinatal acquisition of pathogen^.'^' surveillance for infections in healthy newborns also is challenging because of the typically short length of stay. infections can develop after discharge, and these are more difficult for infection control practitioners (icps) to capture. methods for postdischarge surveillance have been developed, but because most neonatal infections that occur following discharge are noninva~ive,'~~ such surveillance has not been widely implemented, because of concerns about the cost-effectiveness of these labor-intensive processes. the ultimate goal of surveillance is to achieve outcome objectives (e.g., decreases in infection rates, morbidity, mortality, or cost).is7 baseline infection rates for an inpatient unit must be established so that the endemic rate of infection can be understood and addressed. in the nicu, concurrent surveillance (initiated while the infant is in the hospital) should be conducted by persons trained to collect and interpret clinical information. typically, such persons are icps working closely with hcws and using various data sources (table 35-4) . using nnis or other accepted definitions, the icp should collect data regarding cases of nosocomial infection in the nicu population as well as population-specific denominator data. denominators must be carefully chosen to represent the population at risk. attempts to stratify risk should take into account both underlying infant-specific risks and those resulting from therapeutic or diagnostic interventions.'86 risk stratification techniques that attempt to control for distribution of risk have included severity of illness score, intensity of care required, and birth weight.74 because the risk for developing nosocomial infection is greater for lower-birthweight infants:' the nnis system breaks down data collection and analysis into birth weight categories (tables 35-5 and 35-6).'912' 94 the use of invasive devices, however, also is an important factor to consider. the appropriate denominator for an infection related to the use of a medical device, such as a cvc-related primary bloodstream infection, according to nnis, would be total device days for the population during the surveillance period. the formula generally used for calculating nosocomial infection rates is (x/y)k, where x equals the number of events (infections) over a specific time period, y equals the population at risk for development of the outcome, and k is a constant and a multiple of 10. rates can be expressed as a percentage (k = loo), although device-related infections usually are expressed as events per 1000 device days (k = 1000). a value should be selected for k that results in a rate greater than because use of invasive devices is such a significant risk factor both for bloodstream infection and ventilatorassociated pneumonia, assessing nicu practices with device use may be warranted. "is provides a benchmark for nicu device utilization broken down into birth weight categories. an nicu device utilization ratio can be calculated using the following formula: in those units with device utilization ratios above the nnis 90th percentile, investigation into the practices surrounding use of invasive devices may be ~a r r a n t e d . '~~ calculating monthly and annual rates to employ as benchmarks can assist in identification of a potential problem in device-related procedures. surveillance data must be arranged and presented in a way that facilitates interpretation, comparison both directed internally and with comparable external benchmarks, and dissemination within the organization. quality improvement tools (e.g., control and run charts) can be useful for these purposes. statistical tools should be used to determine the significance of findings, although statistical significance should always be balanced with the evaluation of clinical ~ignificance."~ external benchmarking through interhospital comparison is a valuable tool for improving quality of are'^,'^^ but should be performed only when surveillance methodologies (e.g., case definitions, case finding, data collection methods, intensity of ~urveillance)'~~ can reasonably be assumed to be consistent between facilities. few overall infection rates in nicus are available, but a small study done in 17 children's hospitals performing nicu nosocomial infection surveillance reported a median nosocomial infection rate of 8.9 infections per 1000 patient days (range, 4.6 to 18.1).19' nnis does not provide a benchmark for overall infection rates within nicus. instead, nnis provides birth weight-stratified device-associated infection rates for umbilical and central intravascular line-associated bloodstream infections. the most recent rates for catheterrelated bloodstream infections (137 to 143 nicus reporting) and ventilator-associated pneumonias (78 to 96 nicus reporting) are summarized in table 3 e~6 . l~~ once arranged and interpreted, nosocomial infection data must be shared with personnel who can effect change and implement infection control interventions. written reports summarizing the data and appropriate control charts should be provided to the facility's infection control committee, unit leaders, and members of the hospital administration on an ongoing basis. the interval between reports is determined by the needs of the institution. in addition to formal written reports, face-to-face reports are appropriate in the event of identification of a serious problem or an outbreak. icps can serve as consultants to assist nicu or neonatology service leaders in addressing infection rate increases or outbreak management. surveillance activities typically identify endemic nosocomial infections (i.e., those infections that represent the usual level of disease within the nursery or nlcu).'99 although the rate can fluctuate over time, in the absence of interventions that successfully reduce risk of infection, the difference rarely is statistically significant. establishing an nicu's endemic infection rate and expected variation around that rate allows the icp to rapidly identify unusual increases in rates that may indicate on outbreak (epidemic) of a particular infection. using baseline surveillance data along with aggregate data from sources such as the "is system allows the icp to develop meaningful threshold rates for initiating outbreak investigation.is8 alternatively, hcws can be the first to sense an increase in infections, which then can be confirmed or refuted by surveillance data?00 even a single case of infection due to an unusual and potentially dangerous pathogen (e.g., salmonella) can constitute the index case for a subsequent outbreak and thus merits rapid and comprehensive investigation. outbreaks may need to be reported to health authorities, depending on local and state requirements as well as the organism involved. numerous studies have described nursery and nicu epidemics caused by a variety of pathogens (table 35-7) , and most such epidemics have required the coordinated efforts of icps, nicu leadership, staff, and hospital administration outbreak investigation and intervention should be approached systematically, applying sound epidemiologic principles. in general, the process should include the follo~ing'~~~~''": for resolution.79, 106,115,136, i 57j6 i, 162,zo 1 -2 12 confirming that an outbreak exists, by comparing the outbreak infection rate with baseline data (or with rates reported in the literature if baseline data are not available), and communicating concerns to stakeholders within the institution (and to those in other agencies if notification of health authorities is necessary) assembling the appropriate personnel to assist in developing a case definition and in planning immediate measures to prevent new cases performing active surveillance using the case definition to search for additional infections and collecting critical data and specimens characterizing cases of infection by person, place, and time, including plotting of an epidemic curve (to facilitate identification of shared risk factors among involved patients, such as invasive devices, proximity to other infected patients or temporal association with infection in such patients, common underlying diagnoses, shared medical or nursing staff, surgery, and medications, including antimicrobial agents) formulating a working hypothesis and testing this hypothesis (if the severity of the problem warrants this level of study, and provided that the institution has and can commit the necessary resources), with use of analytic approaches, including case-control and cohort studies, as appropriate to determine the likely cause of the outbreak instituting and evaluating control measures, which can be implemented anywhere in the foregoing process (more directed measures become possible as more is learned about the outbreak, and efficacy of control measures can be judged on whether the outbreak resolves, as indicated by return of number of cases to endemic levels or by cessation of occurrence of infections) reporting findings to appropriate personnel, including unit staff, hospital administration, and public health authorities (if involved in management of the outbreak), in comprehensive written reports, including summaries of how the outbreak was first recognized, study and analysis methods used, interventions implemented to resolve the epidemic, results, and a discussion of any other important outcomes or surveillance and control measures identified interventions used to control and limit outbreaks usually have consisted of isolation and cohorting of infected or colonized infants to prevent transmission of organisms. transmission-based precautions, a system developed by the cdc, can be used to determine the most effective barrier precautions to use with affected patients. cohorting, or placing infants infected or colonized with the outbreak organism together in geographically segregated areas and assigning dedicated staff and equipment to their care, also has been used successfully to halt outbreaks in nurseries and nicus. in extreme cases, closure of an nicu to admissions has been necessary to bring an outbreak under ~o n t r o l .~~~'~~, '~~ every attempt should be made to identify the source of a nursery outbreak, although this is not always possible. sources implicated in nicu outbreaks have included medications, equipment, and enteral feeding solutions; person-to-person transmission and environmental reservoirs also have been efforts to identify the source may include culturing of specimens from hcws, equipment, and the environment, although careful consideration should be given to the potential benefits before initiating these measures. culture of samples from the environment and equipment, in view of the vast number of objects that could be contaminated, usually is not helpful in identifying the source of an outbreak unless specific case characteristics or microbiologic data strongly suggest the location. culture of specimens obtained from hcws when person-to-person transmission is suspected may be more likely to identify the source of an outbreak, but it must be remembered that an hcw whose culture specimen yields the outbreak organism may have been transiently colonized while working with an affected infant, rather than constituting the source of the infection. management of culture-positive hcws (possible furlough, treatment, and return to work criteria) should be planned in advance of widespread culture surveillance and should involve supervisors of affected employees and occupational health services.'" reported. 102, 106, 157, 201, 202, 213 the most widely accepted guideline for preventing the transmission of infections in hospitals was developed by the cdc. most recently revised in 1996, the system contains two tiers of precautions. the first and most important, standard precautions, was designed for the management of all hospitalized patients regardless of their diagnosis or presumed infection status. the second, transmission-based precautions, is intended for patients documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions to interrupt transmission are needed.25 standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are to be followed for the care of all patients, including neonates. they apply to blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes. components of standard precautions include hand hygiene and wearing gloves, gowns, and masks and other forms of eye protection. hand hygiene plays a key role for caregivers in the reduction of nosocomial infection for patient^'^.^'^ and in prevention of nosocomial or health cart+associated infections. hand hygiene should be performed before and after all patient contacts; before donning sterile gloves to perform an invasive procedure; after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, and wound dressings; in moving from a contaminated body site to a clean body site during patient care (ie., from changing a diaper to performing mouth care); after contact with inanimate objects in the immediate vicinity of the patient; after removing gloves; and before eating and after using the re~troom.'~~ when hands are visibly soiled or contaminated with proteinaceous materials, blood, or body fluids, and after using the restroom, hands should be washed with antimicrobial soap and water. soaps containing 2% to 4% chlorhexidine gluconate or 0.3% t r i~l o s a n '~~ are recommended for hand washing in n~rseries.'~~ when hands are not visibly soiled, alcohol-based hand rubs, foams, or gels are an important tool for hand hygiene. compared with washing with soap and water, use of the alcohol-based products is at least as effective against a variety of pathogens and requires less time, and these agents are less damaging to skin. the cdc "guideline for hand hygiene in the health care setting" calls for use of alcohol hand rubs, foams, or gels as the primary method to clean hands, except when hands are visibly soiled.i3l programs that have been successful in improving hand hygiene and decreasing nosocomial infection have used multidisciplinary teams to develop interventions focusing on use of the alcohol rubs in the settin of institutional commitment and support for the initiativetj7~15 hcws should wash hands and forearms to the elbows on arrival in the nursery. a 3-minute scrub has been suggested?l6 but consensus on optimal duration of initial hand hygiene is lacking. at a minimum, the initial wash should be long enough to ensure thorough washing and rinsing of all parts of the hands and forearms. routine hand washing throughout care delivery should consist of wetting the hands, applying product, rubbing all surfaces of the hands and fingers vigorously for at least 15 seconds, rinsing, and patting dry with disposable t0we1s.l~~ wearing hand jewelry has been associated with increased microbial load on hands. whether this results in increased transmission of pathogens is not known. many experts, however, recommend that hand and wrist jewelry not be worn in the in addition, the cdc guideline states that staff who have direct contact with infants in nicus should not wear artificial fingernails or nail extenders."' only natural nails kept less than y.. inch long should be allowed. clean, nonsterile gloves are to be worn whenever contact with blood, body fluids, secretions, excretions, and contaminated items is anticipated. the hcw should change gloves when moving from dirty to clean tasks performed on the same patient, such as after changing a diaper and before suctioning a patient, and whenever they become soiled. because hands can become contaminated during removal of gloves, and because gloves may have tiny, unnoticeable defects, wearing gloves is not a substitute for hand hygiene. hand hygiene must be performed immediately after glove removal. 25 personnel in nurseries including the nicu historically have worn cover gowns for all routine patient contact. the practice has not been found to reduce infection or colonization in neonates and is u n n e c e~s a r y ? '~~~~~ instead, cdc guidelines recommend nonsterile, fluid-resistant gowns to be worn as barrier protection when soiling of clothing is anticipated and in performing procedures likely to result in splashing or spraying of body substance^.^^ possible examples of such procedures in the nicu are placing an arterial line and irrigating a wound. the perinatal guidelines of the american academy of pediatrics and the american college of obstetricians and gynecologists recommend that a longsleeved gown be worn over clothing when a neonate is held outside the bassinette by nursery personnel.'" nonsterile masks, face shields, goggles, and other eye protectors are worn in various combinations to provide barrier protection and should be used during procedures and patient care activities that are likely to generate splashes or sprays of body substances and fl~ids.'~ standard precautions also require that reusable patient care equipment be cleaned and appropriately reprocessed between patients; that soiled linen be handled carefully to prevent contamination of skin, clothing, or the environment; that sharps (i.e., needles, scalpels) be handled carefully to prevent exposure to blood-borne pathogens; and that mouthpieces and other resuscitation devices be used, rather than mouth-to-mouth methods of re~uscitation.'~ in addition to standard precautions, which must be used for every patient, the cdc recommends transmission-based precautions when the patient is known or suspected to be infected or colonized with epidemiologically important or highly transmissible organisms. always used in addition to standard precautions, transmission-based precautions comprise three categories: contact precautions, droplet precautions, and airborne precautions. contact precautions involve the use of barriers to prevent transmission of organisms by direct or indirect contact with the patient or contaminated objects in the patient's immediate e n~i r o n m e n t .~~ sources of indirect contact transmission in nurseries can include patient care equipment such as monitor leads, thermometers, isolettes, breast pumps,le6 toys, and instruments and contaminated hands. 222 the patient requiring contact precautions should be placed in a private room whenever possible but, after consultation with an infection control practitioner, can be cohorted with a patient infected with the same microorganism but no other infection.25 many nurseries, however, have few if any isolation rooms. the american academy of pediatrics states that infected neonates requiring contact precautions can be safely cared for without an isolation room if staffing is adequate to allow appropriate hand hygiene, a 4-to 6-footwide space can be provided between care stations, adequate hand hygiene facilities are available, and staff members are well trained regarding infection transmission modes.'" hcws should wear clean, nonsterile gloves when entering the room or space of a patient requiring contact precautions and should wear a cover gown when their clothing will have contact with the infant, environmental surfaces, or items in the infant's area. a cover gown also should be worn when the infant has excretions or secretions that are not well contained, such as diarrhea or wound drainage, which may escape the diaper or dressing. infant care equipment should be dedicated to the patient if possible so that it is not shared with 0thers.2~ examples of conditions in the neonate that require contact precautions include neonatal mucocutaneous herpes simplex virus infection, respiratory syncytial virus infection, varicella (also see airborne precautions), infection or colonization with a resistant organism such as mrsa or a multiple drug-resistant gram-negative bacillus, and congenital rubella syndrome. droplet precautions are intended to reduce the risk of transmission of infectious agents in large-particle droplets from an infected person. such transmission usually occurs when the infected person generates droplets during coughmg, sneezing, or talking, or during procedures such as suctioning. these relatively large droplets travel only short distances and do not remain suspended in the air, but can be deposited on the conjunctiva, nasal mucosa, andfor mouth of persons working within 3 feet of the infected patient.25 patients requiring droplet precautions should be placed in private rooms (see earlier discussion of isolation rooms in nurseries in the paragraph on contact precautions), and staff should wear masks when working within 3 feet of the patient.25 examples of conditions in the neonate that necessitate droplet precautions are pertussis and invasive n. meningitidis infection. airborne precautions are designed to reduce the risk of airborne transmission of infectious agents.25 because of their small size, airborne droplet nuclei and dust particles containing infectious agents or spores can be widely spread on air currents or through ventilation systems and inhaled by or deposited on susceptible hosts. special air-handling systems and ventilation are required to prevent transmission. patients requiring airborne precautions should be placed in private rooms in negative air-pressure ventilation with 6 to 12 air changes per hour. air should be externally exhausted or subjected to high-efficiency particulate air (hepa) filtration if it is recirculated. 222 examples of conditions in the neonate for which airborne precautions are required are varicella-zoster virus infections and measles. susceptible hcws should not enter the rooms of patients with these viral infections. if assignment cannot be avoided, susceptible staff members should wear masks to deliver care. if immunity has been documented, staff members need not wear masks.222 airborne precautions also are required for active pulmonary tuberculosis, and although neonates are rarely contagious, the cdc recommends isolating patients while they are being e~aluated.~'~ a more important consideration is the need to isolate the family of a suspected tuberculosis patient until an evaluation for pulmonary tuberculosis has been completed, because the source of infection frequently is a member of the child's before the 1990s, well-baby nurseries and many nicus were constructed as large, brightly lit open wards with rows of incubators surrounded by equipment. sinks could be provided in such rooms only around the periphery, limiting access to hand hygiene facilities for staff and families. in these nicus, parents' time with their infant was severely restricted, and the units were designed for the convenience and function of the hcw.225 more recently, perinatal care professionals have come to understand that neonates (and especially preterm infants) can benefit from a quiet, soothing atmosphere and protection from unnecessary light, noise, handling, uncomfortable positioning, and sleep disruptions?26 if infants are kept in a central nursery rather than roomingin with mothers, at least 30 square feet of floor space should family.223,z24 be provided per neonate, and bassinets should be at least 3 feet apart.216 teams designing units delivering higher levels of perinatal care, including nicus, should plan individual bed areas large enough for families to stay at the bedside for extended periods of time without interfering with the staffs ability to care for the child. if individual rooms cannot be provided, at least 150 square feet of floor space should be allowed for each neonate in an nicu, incubators or overhead warmers should be separated by at least 6 to 8 feet, and aisles should be at least 8 feet a scrub sink with foot, knee, or touchless (electronic sensor) controls should be provided at the entrance to every nursery and should be large and deep enough to control splashing. sinks in patient care areas should be provided at a minimum ratio of 1 sink for at least every 6 to 8 stations in the well-baby nursery and 1 sink for every 3 or 4 stations in higher-level nurseries, including the nicu.'i6 every bed position should be within 20 feet of a hand-washing sink and accessible for children and persons in wheelchairs.227 for nicus composed of individual rooms, a hand-washing sink should be located in each room near the door to facilitate hand hygiene on entering and leaving the room. environmental surfaces should be designed so that they are easy to clean and do not harbor microorganisms. sink taps and drains, for instance, have been implicated in outbreaks of infection.2283z29 installing sinks with seamless construction may minimize this risk by decreasing areas where water can pool and microorganisms proliferate. faucet aerators have been implicated in outbreaks of infection and should be avoided in the intensive care unit.230 although carpeting can reduce noise levels in a busy nicu, the cdc "guidelines for environmental infection control in health-care facilities" recommend against use of carpeting in areas where spills are likely, including intensive care units. the guidelines further recommend against upholstered furniture in nicus.~~' if, for reasons of noise reduction and developmentally appropriate care, porous surfaces such as carpeting and cloth upholstery are selected for the nicu, cleaning must be performed carefully. carpet should be vacuumed regularly with equipment fitted with hepa filters, and upholstered furniture should be removed from inpatient areas to be cleaned. attention also should be paid to air-handling systems. according to the perinatal guidelines, minimal standards for inpatient perinatal care areas include six air changes per hour, and a minimum of two changes should consist entirely of outside air. air delivered to the nicu should be filtered with at least 90% efficiency. in addition, nurseries should include at least one isolation room capable of providing negative pressure vented to the outside, observation windows with blinds for privacy, and the capability for remote m~n i t o r i n g .~~~'~~~ floors and other horizontal surfaces should be cleaned daily by trained personnel using environmental protection agency (epa)-registered hospital disinfectantddetergents. these products (including phenolics and other chemical surface disinfectants) must be prepared in accordance with manufacturers' recommendations and used carefully to avoid exposing neonates to these products. phenolics should not be used on surfaces that come in direct contact with neo-nates' skin.231 high-touch areas, such as counter tops, work surfaces, doorknobs, and light switches, may need to be cleaned more frequently because they can be heavily contaminated during the process of delivering care. hard, nonporous surfaces should be "wet dusted" rather than dry dusted, to avoid dispersing particulates into the air, and then disinfected using standard hospital disinfectant^.'^^ sinks should be scrubbed daily with a disinfectant detergent. walls, windows, and curtains should be cleaned regularly to prevent dust accumulation, but daily cleaning is not necessary unless they are visibly soiled. bassinets and incubators should be cleaned and disinfected between infants, but care must be taken to rinse cleaning products from surfaces with water before use. care units should not be cleaned with phenolics or other chemical germicides during an infant's stay. instead, infants who remain in the nursery for long periods of time should periodically be moved to freshly cleaned and disinfected units.23' patient care equipment must be cleaned, disinfected, and, when appropriate, sterilized between patients. sterilization (required for devices that enter the vascular system, tissue, or sterile body cavities) and higher levels of disinfection (required for equipment that comes in contact with mucous membranes or that has prolonged or intimate contact with the newborn's skin) must be performed under controlled conditions in the central processing department of the hospital. examples of patient care equipment that require these levels of processing are endotracheal tubes, resuscitation bags, and face masks.216,232,233 low-level disinfection is required for less critical equipment, such as stethoscopes or blood pressure cuffs, and usually can be performed at point of use (e.g., the bedside), although this type of equipment should be dedicated to individual patients whenever possible. requirements for linen handling and management for neonates do not vary appreciably from those for other hospitalized patients. although soiled linen can contain large numbers of organisms capable of causing infections, transmission to patients appears to be rare. studies suggesting linen as a source of infection often have failed to confirm it as the source of infection.234 at least one report, however, has implicated linen in the transmission of group a streptoco~ci.~~ investigation of this outbreak revealed that clothing worn by the neonates was being washed in the local hospital "mini laundry," rather than being processed under the usual laundry contract. investigation of the dryers revealed extensive contamination with the outbreak organism. this case illustrates the importance of having standard hospital laundry protocols and ensuring that appropriate water and dryer temperatures are maintained. when such protocols are followed, the mechanical actions of washing and rinsing, combined with hot water and/or the addition of chemicals such as chlorine bleach, and a final commercial dryer and/or ironing step significantly reduce bacterial few hospitals in the united states use cloth diapers, but regardless of type used, soiled diapers should be carefully bagged in plastic and removed from the unit every 8 hours.216 hcws caring for neonates have the potential both to transmit infections to infants and to acquire infections from vaccine should be considered for all hcws, including those born before 1957, who have no proof of immunity (receipt of 2 doses of live vaccine on or after first birthday, physician-diagnosed measles, or serologic evidence of immunity). hcws believed t o be susceptible can be vaccinated; adults born before 1957 can be considered immune. hcws, both male and female, who lack documentation of receipt of vaccine on or after first birthday or serologic evidence of immunity should be vaccinated; adults born before 1957 can be considered immune, except women of childbearing age. hcws without a reliable history of varicella or serologic evidence of varicella immunity should be vaccinated. patients. educating hcws about infection control principles is crucial to preventing such transmission. hospitals should provide education about infection control policies, procedures, and guidelines to staff in all job categories during new employee orientation and on a regular basis throughout employment. the content of this education should include hand hygiene, principles of infection control, the importance of individual responsibility for infection control, and the importance of collaborating with the infection control department in monitoring and investigating potentially harmful infectious exposures and outbreaks. transmission of infectious organisms between patients and hcws has been well documented. several studies have indicated that a high proportion of hcws acquire rsv (34% to 56%) when working with infected children, and these workers appear to be important in the spread of the illness within hospital^.^^'.^^^ although 82% of the infected hcws in one of these rsv studies were asymptomatic, staff should be aware of the importance of self-screening for communicable disease. they should be encouraged to report personal infectious illnesses to supervisors, who in turn should report them to occupational health services and infection control. in general, hcws with respiratory, cutaneous, mucocutaneous, or gastrointestinal infections should not deliver direct patient care to neonates.2i6 in addition, seronegative staff members exposed to illnesses, such as varicella and measles, should not work during the contagious portion of the incubation period. 232 staff members with hsv infection rarely have been implicated in transmission of the virus to infants and thus do not need to be routinely excluded from direct patient care. those with herpes labialis or cold sores should be instructed to cover the lesions and not to touch their lesions, and to comply with hand hygiene policies. persons with genital lesions also are unlikely t o transmit hsv so long as hand hygiene policies are followed. however, hcws who are unlikely or unable to comply with the infection control measures and those with herpetic whitlow should not deliver direct patient care to neonates until lesions have healed. 240 acquisition of cmv often is a concern of pregnant hcws because of the potential effect on the fetus. approximately 1% of newborn infants in most nurseries and a higher percentage of older children (up to 70% of children 1 to 3 years of age in child-care centers) excrete cmv without clinical manifestation^.'^^ the risk of acquiring cmv infection has not been shown to be higher for hcws than for the general for this reason, pregnant caregivers need not be excluded from the care of neonates suspected to be shedding cmv. they should be advised of the importance of standard precautions. hcws in well-baby nurseries and nicus should be as free from transmissible infectious diseases as possible?16 and ensuring that they are immune to vaccine-preventable diseases is an essential part of a personnel health program. the cdc recommends several immunizations for health care personnel (table 35-8) . staffing levels in a patient care setting also can affect patient outcomes. a number of studies suggest that as patient-tonurse ratios in intensive care units increase, so do nosocomial infections and mortality rate^.^^,'^^,'^ although optimal staffing ratios have not been established for nicus and will vary according to characteristics of individual units, one study demonstrated that the incidence of clustered s. aureus infections was 16 times higher after periods when the infantto-nurse ratio exceeded 7: 1. decreased compliance with hand hygiene during a period of understaffing frequently is cited as contributing to nosocomial infection rate increases." further study is necessary to determine best practice surrounding staffing levels in nicus. the first nicus in the late 1960s grouped infants together in large, brightly lit rooms with incubators placed in rows. parents were allowed very little time with their babies and even less physical contact. in the decades since, it has been recognized that "the parent is the most important caregiver and constant influence in an infant's life"225 and that hcws working in nicus should encourage parents to become involved in the nonmedical aspects of their child's care. principles of family-centered care also include liberal nicu visitation for relatives, siblings, and family friends and the involvement of parents in the development of nursery policies and programs that promote parenting skills.226 care must be taken, however, to minimize risk of infection for the neonate. mothers can transmit infections to neonates both during delivery and post partum, although separation of mother and newborn rarely is indicated. in the absence of certain specific infections, mothers, including those with postpartum fever not attributed to a specific infection, should be allowed to handle their infants if the following conditions are met: 0 they feel well enough. they wash their hands well under supervision. a clean gown is worn. contact of the neonate with contaminated dressings, a mother with a transmissible illness not requiring separation from her infant should be carefully educated about the mode of transmission and precautions necessary to protect her infant. personal protective equipment, such as cover gowns, gloves, and masks, and hand hygiene facilities should be readily available to her, and she should perform hand hygiene and don a long-sleeved cover gown before handling her infant. if wounds or abscesses are present, drainage should be contained within a dressing. if drainage cannot be completely contained, separation from the infant may be necessary. care should be taken to prevent the infant from coming in contact with soiled linens, clothing, dressings, or other potentially contaminated items. the mother with active genital hsv lesions need not be separated from her infant if the foregoing precautions are taken. those with herpes labialis should not kiss or nuzzle their infants until lesions have cleared; lesions should be covered and a surgical mask may be worn until the lesions are crusted and dry, and careful hand hygiene should be stressed. mothers with viral respiratory infections should be made aware that many of these illnesses are transmitted by contact with infected secretions as well as by droplet spread, that soiled tissues should be disposed of carefully, and that hand hygiene is critical to transmission prevention. masks can be worn to reduce the risk of droplet t r a n s m i s s i~n .~~~'~~~ as previously mentioned, although very few infections require separation of mother and infant, women with untreated active pulmonary tuberculosis should be separated from their infants until they no longer are contagious. mothers with group a streptococcal infections, especially when involving draining wounds, also should be isolated from their infants until they no longer are contagious. less certain is the necessity of separating mothers with peripartum varicella (onset of infection within 5 days before or 2 days after delivery) from their uninfected infants. the perinatal guidelines recommend that such infants remain with their mothers after receiving varicella-zoster immune globulin (vzig) but caution that infant and mother must be carefully managed in airborne and contact precautions245 to prevent transmission within the nursery. some experts recommend separating these mothers from their infants until all lesions are dried and crusted.246 numerous studies support the value of human milk for infants (see chapter 5). besides providing optimal nutritional content for infants, it has been shown to be associated with a lower incidence of infections and sepsis in the first year of linen, clothing, or pads is avoided.245 although contraindications to breast-feeding are few, mothers who have active untreated tuberculosis, human immunodeficiency virus (hiv) infection, breast abscesses (as opposed to simple mastitis that is being treated with antimicrobial therapy), or hsv lesions around the nipples should not breast-feed. mothers who are hepatitis b surface antigen positive may breast-feed, because ingestion of an infected mother's milk has not been shown to increase the risk of transmission to her child, but the infant must receive hepatitis b virus immune globulin (hbig) and vaccine immediately after birth. 248 because systemic disease may develop in preterm infants with low concentrations of transplacentally acquired antibodies to cmv following ingestion of milk of cmv-seropositive mothers, decisions regarding breast-feeding should consider the benefits of human milk versus the risk of cmv transmission. freezing breast milk has been shown to decrease viral titers but does not eliminate cmv; pasteurization of human milk can inactivate cmv. either method may be considered in attempts to decrease risk of transmission for breast-feeding nicu neonates. 249 neonates in the nicu frequently are incapable of breastfeeding because of maternal separation, unstable respiratory status, and immaturity of the sucking reflex. for these reasons, mothers of such infants must use a breast pump to couect milk for administration through a feeding tube. pumping, collection, and storage of breast milk create opportunities for contamination of the milk, and for cross-infection if equipment is shared between mothers. several studies have demonstrated contamination of breast pumps, contamination of expressed milk that had been frozen and thawed, and higher levels of stool colonization with aerobic bacteria in infants fed precollected breast milk. 16,250 *251 consensus is lacking on the safe level of microbiologic contamination of breast milk, and most expressed breast milk contains normal skin flora. although breast milk containing greater than 100 cfu/ml of gram-negative bacteria has been reported to cause feeding intolerance and to be associated with suspected sepsis, routine bacterial culturing of expressed breast milk is not recommended.249v250 instead, efforts to ensure safety of expressed milk should focus on optimal collection, storage, and administration techniques. cleaning and disinfection of breast pumps should be included in educational material provided to nursing mothers (table 35-9 ). in addition, mothers should be instructed to perform hand hygiene and cleanse nipples with cotton and plain water before expressing milk in sterile containers. 1923249 expressed breast milk can be refrigerated for up to 48 hours and can be safely frozen (-20" c f 2â°c [-4" f f 3.6" f]) for up to 6 months.192 it can be thawed quickly under warm running water (avoiding contamination with tap water) or gradually in a refrigerator. exposure to high temperatures, as may be experienced in a microwave, can destroy valuable components of the milk. thawed breast milk can be stored in the refrigerator for up to 24 hours before it must be discarded. to avoid proliferation of microorganisms, milk administered through a feeding tube by continuous infusion should hang no longer than 4 to 6 hours before replacement of the milk, container, and for mothers who choose not to breast-feed, commercial infant formula is available. most hospitals now use sterile, ready-to-feed formulas provided by the manufacturer in bottles, with sterile nipples to attach just before use. nipples each mother is supplied with a personal pumping kit. nursing staff instruct mothers in techniques of milk expression and appropriate procedures for cleaning breast pump parts: wipe all horizontal surfaces at the pumping station with hospital disinfectant before and after pumping. wash hands with soapy water before and after pumping. wash all parts of the breast pump kit that have been in contact with milk in hot water and dish detergent or in a dishwasher. expressed milk is collected in sterile, single-use plastic (polycarbonate or polypropylene) containers. breast milk containers are labeled with infant's name and the date and time of collection. administration containers (bottle or syringe) are similarly labeled when breast milk is transferred from collection containers. all hcws wear gloves when handling and administering breast milk. two persons check t h e labeled administration container against the infant's hospital identification band before administering breast milk (may be two hcws or one hcw and a family member). hcw. health care worker. from infection control policy, children's hospital and regional medical center, seattle, 2003 are best attached at the bedside just before feeding, and the unit should be used immediately and discarded within 4 hours after the bottle is ~ncapped.'~' specialty and less commonly used formulas may not be available as a ready-to-feed product, and breast milk supplements do not come in liquid form. after a recent report of a case of fatal enterobacter sakazakii meningitis in a neonate fed contaminated powdered infant formula:7 concerns have risen about the safety of these products. although powdered formulas are not sterile, preparation and storage practices can decrease the possibility of proliferation of microorganisms after preparation. the cdc, the food and drug administration, and the american dietetic association offered updated recommendations on the safe preparation and administration of commercial formula after the recall of the product linked to the e. sakazakii case. these recommendations instruct the care provider as follows: use alternatives (ready-to-feed or concentrated formulas) to powdered infant formula whenever possible. prepare formula using aseptic technique in a designated formula preparation room. refrigerate prepared formula so that a temperature of 2" to 3" c is reached by 4 hours after preparation, and discard any reconstituted formula stored longer than 24 hours. limit ambient-temperature hang time of continuously infused formula to no longer than 4 hours. use hygienic handling techniques at feeding time, and avoid open delivery systems. have written guidelines for managing a manufacturer's recall of contaminated formula.252 the fda also recommended that boiling water be used to prepare powdered formulas, but concerns about this recommendation include potential damage to formula components from the high temperature of the water, a lack of evidence that using this method would lull potential pathogens in the formula, and risk of injury to persons preparing the f0rmula.2~' the concept of co-bedding, or the bunlung of twin infants (or other multiples) in a single isolette or crib, is being explored in nicus for the potential benefits offered to the babies. co-bedding as a component of developmentally supportive care is based on the premise that extrauterine adaptation of twin neonates is enhanced by continued physical contact with the other twin.253 potential benefits need further study but may include increased bonding, decreased need for temperature support, and easier transition to home. it is certainly possible, however, for one of a set of multiples to be infected while the others are not, and for parents to be implicated as vectors in infection transmission. it also is possible for invasive devices and intravascular catheters to be dislodged by close contact with an active sibling. therefore, exclusion criteria for co-bedding infants should include clinical findings suggesting infection that could be transmitted to a sibling (e.g., draining wound) and the need for drains and central venous or arterial line^.*^^-'^^ the principles of family-centered care encourage liberal visitation policies, both in the well-baby nursery (or roomingin scenario) and in the nicu. parents, including fathers, should be allowed unlimited visitation to their newborns, and siblings also should be allowed liberal visitation. expanding the number of visitors to neonates may, however, increase the risk of disease exposure if education and screening for symptoms of infection are not implemented. written policies should be in place to guide sibling visits, and parents should be encouraged to share the responsibility of protecting their newborn from contagious illnesses. the perinatal guidelines regarding persons who visit newborns are listed in table 35-10. adult visitors to neonates, including parents, have been implicated in outbreaks of infections including p aeruginosa infection, pertussis, and salmonella i n f e c t i~n . '~'~~~~~~~~ ac cordingly, the principles for sibling visitation should be applied to adult visitors as well. they should be screened for symptoms of contagious illness, instructed to perform hand hygiene before entering the nicu and before and after touching the neonate, and should interact only with the family member they came to the hospital to visit. families of neonates who have lengthy nicu stays may come to know each other well and serve as sources of emotional support to one another. nevertheless, they should be educated about the potential of transmitting microorganisms and infections between families if standard precautions and physical separation are not maintained, even though they may be sharing an inpatient space. sibling visits should be encouraged for healthy and ill newborns. parents should be interviewed at a site outside the nursery to establish that the siblings are not ill before allowing them to visit. children with fever or other symptoms of an acute illness such as upper respiratory infection or gastroenteritis, or those recently visiting children should visit only their sibling. children should be prepared in advance for their visit. visitors should be adequately observed and monitored by hospital staff. children should carefully wash their hands before patient contact. throughout t h e visit, siblings should be supervised by parents or another responsible adult. exposed to a known communicable disease such as chickenpox, should not be allowed to visit. bathing the newborn is standard practice in nurseries, but very little standardization in frequency or cleansing product exists. if not performed carefully, bathing actually can be detrimental to the infant, resulting in hypothermia, increased crying with resulting increases in oxygen consumption, respiratory distress, and instability of vital signs.257 although the initial bath or cleansing should be delayed until the neonate's temperature has been stable for several hours, removing blood and drying the skin immediately after delivery may remove potentially infectious microorganisms such as hepatitis b virus, hsv, and hiv, minimizing risk to the neonate from maternal infection.249 when the newborn requires an intramuscular injection in the delivery room, infection sites should be cleansed with alcohol to prevent transmission of organisms that may be present in maternal blood and body for routine bathing in the first few weeks of life, plain warm water should be used. this is especially important for preterm infants, as well as full-term infants with barrier compromise such as abrasions or dermatitis. if a soap is necessary for heavily soiled areas, a mild ph-neutral product without additives should be used, and duration of soaping should be restricted to less than 5 minutes no more than three times per week. 257 few randomized studies comparing cord care regimens and infection rates have been performed, and consensus has not been reached on best practice regarding care of the umbilical cord stump. a review published in 2003 described care regimens used for more than 2 decades, including combinations of triple dye, chlorhexidine, 70% alcohol, bacitracin, hexachlorophene, povidone-iodine, and "dry care" (soap and water cleansing of soiled periumbilical skin) and found variable impact on colonization of the stump.258 the study authors suggested that dry cord care alone may be insufficient and that chlorhexidine seemed to be a favorable antiseptic choice for cord care because of its activity against gram-positive and gram-negative bacteria. they went on to stress, however, that large, well-designed studies were required before firm conclusions could be drawn. the current perinatal guidelines do not recommend a specific regimen but warn that use of alcohol alone is not an effective method of preventing umbilical cord colonization and ~mphalitis.'~~ the perinatal guidelines further recommend that diapers be folded away from and below the stump and that emollients not be applied to the although blindness resulting from neonatal conjunctivitis is rare in the united states, with a reported incidence of 1.6% or less, the rate among the 80 million infants born annually throughout the world is as high as 23%. 259 chlamydia trachornatis has been the most common etiologic agent in the united states, but other organisms such as neisseria gonorrhoeae, s. aureus, and e. coli also can cause ophthalmia neonatorum.260 use of 1% silver nitrate drops, at one time the agent of choice, is no longer recommended because of concerns about associated chemical irritation. agents thought to be equally efficacious and now recommended include 1% tetracycline and 0.5% erythromycin ophthalmic ointments, administered from sterile single-use tubes or vials. 156~245 povidone-iodine (2.5%) ophthalmic solution also can be used and in one study was shown to be more effective than silver nitrate or erythromycin in the prevention of ophthalmia neonatorum. bacterial resistance has not been seen with this agent, it causes less toxicity than either silver nitrate or erythromycin, and it is less expensivea definite consideration in developing countries.259 whatever the agent selected, it should reach all parts of the conjunctival sac, and the eyes should not be irrigated after application. ophthalmic agents will not necessarily prevent ocular or disseminated gonorrhea in infants born to mothers with active infection at time of delivery. these infants should be given parenteral antimicrobial therapy as well as ocular p r o p h y l a~i s . '~~,~~~ some experts also advise giving infants born to mothers with untreated genital chlamydia1 infections a course of oral erythromycin beginning on the second or third day of life.261 primary bloodstream infections (defined by the cdc nnis system as being due to a pathogen cultured from one or more blood specimens not related to an infection at another site) account for a large proportion of infections in nicu infants:' and most are related to the use of an intravascular catheter.36 peripheral intravenous catheters (pivs) are the most frequently used devices for the neonate for intravenous therapy of short duration. when longer access is necessary, nontunneled cvcs such as umbilical catheters and piccs most commonly are the most recent data available conduct surveillance in nlcus to determine catheter-related bloodstream infection rates, monitor trends, and identify infection control lapses. investigate events leading to unexpected life-threatening or fatal outcomes. select the catheter, insertion technique, and insertion site with the lowest risk for complications for the anticipated type and duration of intravenous therapy. use a cvc with the minimal number of ports essential f o r management of t h e patient. designate one port for hyperalimentation if a multilumen catheter is used. educate hcws who insert and maintain catheters, and assess their knowledge and competence periodically. use aseptic technique and maximal sterile barriers during insertion of cvcs (cap, mask, sterile gown, sterile gloves, and a large sterile barrier). do not routinely replace cvcs, piccs, or pulmonary artery catheters to prevent catheter-related infections. do not remove on the basis of fever alone. in pediatric patients, leave peripheral venous catheters in place until intravenous therapy is completed unless a complication (e.g., phlebitis, infiltration) occurs. remove intravascular catheters promptly when no longer essential. observe proper hand hygiene procedures either by washing with antiseptic-containing soap and water or use of waterless alcohol-based products before and after working with intravascular lines. disinfect skin with an appropriate antiseptic before catheter insertion and during dressing changes. a 2% chlorhexidine-based preparation is preferred. do not use topical antibiotic ointment or creams on insertion sites, except when using dialysis catheters. use either sterile gauze or sterile, transparent, semipermeable dressing to cover t h e catheter site. replace gauze dressings on short-term cvc sites every 2 days and transparent dressings at least weekly, except in pediatric patients, in whom the risk of dislodging the catheter outweighs the benefit of changing the dressing. change if damp, loosened, or visibly soiled. replace dressings on tunneled or implanted cvc sites no more than once per week until the insertion site has healed. chlorhexidine sponge dressings are contraindicated in neonates younger than 7 days or those born at a gestational age of less than 26 weeks. clean injection ports with 70% alcohol or an iodophor before accessing the system. use disposable transducer assemblies with peripheral arterial catheters and pressure monitoring devices. keep all components of such systems sterile, and do not administer dextrose-containing solutions or parenteral nutrition fluids through them. from nnis (august 2003) revealed that the mean umbilical catheter-and cvc-associated bloodstream infection rates for nicus ranged from 10.6 per 1000 catheter days for infants whose birth weight was less than 1000 g to 3.7 per 1000 catheter days in infants whose birth weight was 2500 g or more.'94 the cdc recommends implementing strategies to reduce the incidence of such infections that strike a balance between patient safety and cost-effectiveness. few large studies of risks related to intravascular devices have been performed in nicu patients. as a result, intravascular device recommendations for neonates are based on those developed for adults and older pediatric patients (table 35-1 1) . several differences in their management should be considered. although the cdc recommends, in certain circumstances, using antimicrobialor antiseptic-impregnated cvcs in adults whose catheters are expected to remain in place more than 5 days,36 these catheters are not available in sizes small enough for neonates. of more importance, studies to evaluate their safety in neonates, especially premature neonates of very low birth weight, have not been performed. in addition, although the cdc recommends changing the insertion site of pivs at least every 72 to 96 hours in adults, data suggest that leaving pivs in place in pediatric patients does not increase the risk of complications. 262 the 2002 cdc guidelines recommend that pivs be left in place in children until therapy is completed, unless complications occur. careful skin antisepsis before insertion of an intravascular catheter is critical to prevention of intravascular devicerelated bacteremia, although care in the selection of a product for use on neonatal skin is required. chlorhexidine preparations are recommended by the cdc because these products have been found to be superior to povidone-iodine in reducing the risk for peripheral catheter colonization in neonates. residues left on the skin by chlorhexidine prolong its half-life, providing improved protection for catheters in neonates that must be left in place for longer periods of timef5' umbilical veins and arteries are available for cvc insertion only in neonates and are typically used for several days; thereafter, the cvc is replaced with another, nontunneled cvc or picc if continued central venous access is required. the umbilicus provides a site that can be cannulated easily, allowing for collection of blood specimens and hernodynamic measurements, but after birth, the umbilicus quickly becomes heavily colonized with skin flora and other microorganisms. colonization and catheter-related bloodstream infection rates for umbilical vein and umbilical artery catheters are similar. colonization rates for umbilical artery catheters are estimated to be 40% to 55%; the estimated rate for umbilical artery catheter-related bloodstream infection is 5%?6 colonization rates are from 22% to 59% for umbilical vein catheters; rates for umbilical vein catheter-related bloodstream infections are 3% to 8?40.~~ a summary of the cdc recommendations for management of umbilical catheters36 is presented in table 35 -12. as mentioned earlier, nnis data indicate that nosocomial pneumonia is the second most common infection type in cleanse umbilical insertion site with an antiseptic before catheter insertion. avoid tincture of iodine; povidone-iodine can be used. add low doses of heparin to fluid infused through umbilical artery catheters. remove and do not replace umbilical catheters if signs of catheter-related bloodstream infection, vascular insufficiency, or remove umbilical catheters as soon as possible when no longer needed or if any sign of vascular insufficiency to the lower umbilical artery catheters should not be left in place for longer than 5 days. umbilical venous catheters should be removed as soon as possible when no longer needed but can be used for up to 14 nicu patients. risk factors for ventilator-associated pneumonia can be grouped as host-related (prematurity, low birth weight, sedation or use of paralytic agents), devicerelated (endotracheal intubation, mechanical ventilation, orogastric or nasogastric tube placement) and factors that increase bacterial colonization of the stomach or nasopharynx (broad-spectrum antimicrobial agents, antacids, or h, b l o c k e r~) . 5~,~"~~~ ventilator-associated pneumonia generally refers to bacterial pneumonia that develops in patients who are receiving mechanical ventilation. aspiration and direct inoculation of bacteria are the primary routes of entry into the lower respiratory tract; the source of these organisms may be the patient's endogenous flora or transmission from other patients, staff members, or the e n~i r o n m e n t .~~'~~~ few studies have been performed to assess the effectiveness of prevention strategies in pediatric patients. strategies to prevent ventilator-associated pneumonia in the nicu patient are therefore based primarily on studies performed in adults (table 35-13) . hand hygiene remains critical to the prevention of ventilator-associated pneumonia, and hcws should consistently apply the principles of standard precautions to the care of the ventilated patient, wearing gloves to handle respiratory secretions or objects contaminated by them, and changing gloves and performing hand hygiene between contacts with a contaminated body site and the respiratory tract or a respiratory tract device. because mechanical ventilation is a significant risk factor for the development of nosocomial infection or ventilatorassociated pneumonia, weaning from ventilation and removing endotracheal tubes as soon as indication for their use ceases are key infection control strategies. as an alternative to endotracheal intubation, noninvasive nasal continuous positive airway pressure (cpap) ventilation avoids some of the common risk factors for ventilator-associated pneumonia and has been used successfully for neonate^?^^"^^ respiratory care equipment that comes in contact with mucous membranes of ventilated patients or that is part of the ventilator circuit should be single use (discarded after one-time use with a single patient) or be subjected to sterilization or high-level disinfection between patients. wet heat pasteurization (processing at 76oc for 30 minutes) or chemical disinfectants can be used to achieve high-level disinfection of reusable respiratory equipment.263 ventilator circuits should be changed no more frequently than every 48 hours, and evidence suggests that extending the length of time between changes to 7 days does not increase the risk of ventilator-associated pneumonia.z70s271 circuits should be monitored for accumulation of condensate and drained periodically, with care taken to avoid allowing the condensate, a potential reservoir for pathogens, to drain toward the sterile fluids should be used for nebulization, and sterile water should be used to rinse reusable semicritical equipment and devices such as in-line medication nebulizers. 263 basic infection control measures, such as hand hygiene and wearing gloves during suctioning and respiratory manipulation, also can reduce the risk of nosocomial pneumonia. both open, single-use and closed, multiuse suction systems are available. if an open system is used, a sterile single-use catheter should be used each time the patient is suctioned. closed systems, which do not need to be changed daily and can be used for up to 7 have the advantage of lower costs and decreased environmental cross-contamination258 but have not been shown to decrease the incidence of nosocomial pneumonia when compared with open systems.273v274 although not well studied in pediatric patients, aspiration of oropharyngeal secretions is believed to contribute to development of ventilator-associated pneumonia in adults. 275 placing the mechanically ventilated patient in a semirecumbent position or elevating the head of the bed in an attempt to minimize aspiration is recommended unless medically contraindicated. also, placement of enteral feeding tubes should be verified before their to prevent regurgitation and potential aspiration of stomach contents by the sedated patient, overdistention of the stomach should be avoided by regular monitoring of the patient's intestinal motility, serial measurement of residual gastric volume or abdominal girth, reducing the use of narcotics and anticholinergic agents, and adjusting the rate and volume of enteral fee ding^.^^^,^^^ oral decontamination, with the intent of decreasing oropharyngeal colonization, has been studied in adults and seems to lower the incidence of ventilatorassociated pneumonia (although not duration of ventilation or mortality but further work is needed to determine whether this is an effective strategy in neonates. in addition, medications such as sucralfate, as opposed to histamine h, receptor antagonists and antacids, which raise gastric ph and can potentially result in increased bacterial colonization of the stomach, have been used to prevent development of stress ulcers and have been associated with lower incidence of ventilator-associated pneumonia in adults.277 two studies suggest, however, that this approach is of no benefit in pediatric patients, but the authors stress that additional studies with larger sample sizes are needed to confirm these nosocomial infections in a neonatal intensive care unit: incidence and risk factors. am 1 infect control bektas s, goetze b, speer cp. decreased adherence, chemotaxis and phagocytic activities of neutrophils from preterm neonates surgery, sepsis, and nonspecific immune function in neonates. 1 pediatr surg 24562-566,1989. stiehm er. the physiologic immunodeficiency of immaturity diminished interferongamma and lymphocyte proliferation in neonatal and postpartum primary herpes simplex virus infection importance of the environment and the faecal flora of infants, nursing staff and parents as sources of gram-negative bacteria colonizing newborns in three neonatal wards use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis colonization and infection associated with malassezia and candida species in a neonatal unit. 1 hosp infect 34123-129 requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. society for health care epidemiology of america guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee effectiveness of a hospitalwide programme to improve compliance with hand hygiene skin hygiene and infection prevention: more of the same or different approaches? molecular epidemiology of staphylococcus epidermidis in a neonatal intensive care unit over a three-year period nosocomial staphylococcus epidermidis septicaemia among very low birth weight neonates in an intensive care unit a randomized trial of 72-versus 24-hour intravenous tubing set changes in newborns receiving lipid therapy. infect control hosp epidemiol20487-493 occurrence of nosocomial bloodstream infections in six neonatal intensive care units effect of lipid emulsion on il-2 production by mononuclear cells of newborn infants and adults risk factors for nosocomial sepsis in newborn intensive and intermediate care units extended-spectrum plasmid-mediated beta-lactamases neonatal suppurative parotitis: a study of five cases molecular epidemiology of staphylococcal scalded skin syndrome in premature infants a double outbreak of exfoliative toxinproducing strains of staphylococcus aureus in a maternity unit acquisition of staphylococci by newborns. direct versus indirect transmission transmission of staphylococci between newborns. importance of the hands to personnel the role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit the"c1oud baby": an example of bacterial-viral interaction a cloud adult: the staphylococcus aureus-virus interaction revisited nosocomial transmission of methicillin-resistant staphylococcus aureus from a mother to her preterm quadruplet infants control of a methicillin-resistant staphylococcus aureus outbreak in a neonatal intensive care unit by unselective use of nasal mupirocin ointment preferential pharyngeal colonization of methicillin resistant staphylococcus airreus in infants nasal mupirocin treatment of pharynx-colonized methicillin resistant staphylococcus aureus: preliminary study with 10 carrier infants a ten year, multicentre study of coagulase negative staphylococcal infections in australasian neonatal units coagulasenegative staphylococcal bacteremia among very low birth weight infants: relation to admission illness severity, resource use, and outcome effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level 111 nicu streptococcus faecium outbreak in a neonatal intensive care unit neonatal enterococcal bacteremia: an increasingly frequent event with potentially untreatable pathogens outbreak of vancomycin-resistant enterococcusfuecium in a neonatal intensive care unit centers for disease control and prevention. recommendations for preventing the spread of vancomycin resistance: recommendations of the hospital infection control practices advisory committee (hicpac) group a streptococcal infections in newborn nurseries an outbreak of m serotype 1 group a streptococcus in a neonatal intensive care unit mother-to-infant vertical transmission and cross-colonization of streptococcus pyogenes confirmed by dna restriction fragment length polymorphism analysis clinical laboratory and epidemiological investigations of a streptococcus pyogenes cluster epidemic in a newborn nursery infection and hospital laundry nosocomial transmission of group b streptococci in a newborn nursery nosocomial transmission of group b streptococci epidemiology of the group b streptococcus: maternal and nosocomial sources for infant acquisitions nosocomial transmission of group b streptococci unusual occurrence of an epidemic of type ib/c group b streptococcal sepsis in a neonatal intensive care unit a d a m k. prematurity is the major risk factor for late-onset group b streptococcus disease neonatal group b streptococcal disease associated with infected breast milk analysis of three outbreaks due to klebsielh species in a neonatal intensive care unit enterobacter cloacae outbreak in the nicu related to disinfected thermometers enterobacter cloacae and pseudomom ueruginosa polymicrobial bloodstream infections traced to extrinsic contamination of a dextrose multidose vial enterobacter sakazakii infections associated with the use of powdered infant formula-tennessee outbreak of enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices outbreak investigation of nosocomial enterobacter cloacae bacteraemia in a neonatal intensive care unit contaminated breast milk: a source of klebsiella bacteremia in a newborn intensive care unit klebsiella pneumoniae bloodstream infections in neonates in a hospital in the kingdom of saudi arabia identification of an iv-dextrose solution as the source of an outbreak of klebsielh pneumoniae sepsis in a newborn nursery invasive disease due to extended spectrum beta-lactamase-producing klebsiella pneumoniae in a neonatal unit: the possible role of cockroaches disinfectant contaminated with klebsiella oxytoca as a source of sepsis in babies neonatal intensive care unit outbreak caused by a strain of klebsielh oxytoca resistant to aztreonam due to overproduction of chromosomal beta-lactamase nosocomial outbreak of klebsiella pneumoniae producing shv-5 extended-spectrum betalactamase, originating from a contaminated ultrasonography coupling gel epidemic outbreaks of acute pyelonephritis caused by nosocomial spread of p fimbriated eschm'chia coli in children enteropathogenic escherichia coli (epec) and enterotoxigenic (etec) related diarrhoeal disease in a neonatal unit an outbreak of gastroenteritis due to escherichia coli 0142 h6 in a neonatal department molecular epidemiology of an outbreak of serratia marcescens in a neonatal intensive care unit nosocomial outbreak of serratia marcescens in a neonatal intensive care unit serratia marcescens infections in neonatal departments: description of an outbreak and review of the literature serratia marcescens outbreak associated with extrinsic contamination of 10/0 chlorxylenol soap investigation of a nosocomial outbreak due to serratia marcescens in a maternity hospital an outbreak of serratia marcescens transmitted by contaminated breast pumps in a special care baby unit a bacteriological examination of breast pumps use of pulsed-field gel electrophoresis to investigate an outbreak of serratia marcescens infection in a neonatal intensive care unit molecular epidemiology of an shv-5 extended-spectrum beta-lactamase in enterobacteriaceae isolated from infants in a neonatal intensive care unit. c l i infect dis a hospital outbreak of extendedspectrum beta-lactamase-producing klebsielh pneumoniae investigated by rapd typing and analysis of the genetics and mechanisms of resistance outbreak of nosocomial sepsis and pneumonia in a newborn intensive care unit by multiresistant extended-spectrum beta-lactamase-producing klebsiella pneumoniae: high impact on mortality pseudomonas aeruginosa infection in very low birth weight infants: a case-control study pseudomonas aeruginosa outbreak in a neonatal intensive care unit: a possible link to contaminated hand lotion nosocomial pseudomonm pickem'i colonization associated with a contaminated respiratory therapy solution in a special care nursery neonatal infections with pseudomonas aeruginosa associated with a water-bath used to thaw fresh frozen plasma pseudomonas aeruginosa outbreak associated with a contaminated blood-gas analyser in a neonatal intensive care unit sepsis in a newborn due to pseudomonas aeruginosa from a contaminated tub bath endemic pseudomonas aeruginosa infection in a neonatal intensive care unit a prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? guideline for hand hygiene in healthcare settings. recommendations of the health care infection control practices advisory committee and the hicpacishenapiciidsa hand hygiene task force. society for health care epidemiology of association for professionals in infection control/infectious diseases society of america pertussis: adults as a source in health care settings centers for disease control and prevention. hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin infantile hypertrophic pyloric stenosis after pertussis prophylaxis with erythromcyin: a case review and cohort study red book: 2003 report of the committee on infectious diseases a continuing outbreak of multidrug-resistant tuberculosis, with transmission in a hospital nursery nursery exposure of 528 newborns to a nurse with pulmonary tuberculosis guidelines for preventing the transmission of mycobacterium tuberculosis in health-care facilities prevalence of candida species in hospitalacquired urinary tract infections in a neonatal intensive care unit association of fungal colonization and invasive disease in very low birth weight infants candida tropicalis in a neonatal intensive care unit: epidemiologic and molecular analysis of an outbreak of infection with an uncommon neonatal pathogen low rate of candida parapsilosisrelated colonization and infection in hospitalized preterm infants: a one-year prospective study when to suspect fungal infection in neonates: a clinical comparison of candida albicans and candida parapsilosis fungemia with coagulase-negative staphylococcal bacteremia evidence of nosocomial spread of candida nlbicans causing bloodstream infection in a neonatal intensive care unit vertical and horizontal transmission of unique candida species to premature newborns outbreak of candida afbicans fungaemia in a neonatal intensive care unit malassezia pachydermatis fungaemia in a neonatal intensive care unit an epidemic of malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs pichia anomah outbreak in a nursery: exogenous source? outbreak of pichia anomah infection in the pediatric service of a tertiary-care center in northern india invasive pulmonary aspergillosis in a critically ill neonate: case report and review of invasive aspergillosis during the first 3 months of life outbreak of systemic aspergillosis in a neonatal intensive care unit nosocomial infection with rhizopus microsporus in preterm infants: association with wooden tongue depressors nosocomial ringworm in a neonatal intensive care unit: a nurse and her cat clinical manifestations of rotavirus infection in the neonatal intensive care unit interruption of rotavirus spread through chemical disinfection an outbreak of diarrhea in a neonatal medium care unit caused by a novel strain of rotavirus: investigation using both epidemiologic and microbiological methods adenovirus type 8 conjunctivitis outbreak in a neonatal intensive care unit neonatal nosocomial respiratory infection with coronavirus: a prospective study in a neonatal intensive care unit an outbreak of influenza a in a neonatal intensive care unit outbreak of parainfluenza virus type 3 in an intermediate care neonatal nursery outbreaks of influenza a virus infection in neonatal intensive care units clinical and epidemiological aspects of an enterovirus outbreak in a neonatal unit severe neonatal echovirus 17 infection during a nursery outbreak an outbreak due to echovirus type 30 in a neonatal unit in france in 1997: usefulness of pcr diagnosis cytomegalovirus infection in a neonatal intensive care unit. subsequent morbidity and mortality of seropositive infants transmission of cytomegalovirus to preterm infants through breast milk cytomegalovirus infection and bronchopulmonary dysplasia in premature infants cytomegalovirus infection of extremely low-birth weight infants via breast mdk epidemiology of transmission of cytomegalovirus from mother to preterm infant by breastfeeding molecular epidemiology and significance of a cluster of cases of cmv infection occurring on a special care baby unit transmission of cytomegalovirus among infants in hospital documented by restriction-endonuclease-digestion analyses nosocomial cytomegalovirus infections within two hospitals caring for infants and children prevention of postnatal cytomegalovirus infection in preterm infants transmission of herpes-simplexvirus type 1 in a nursery for the newborn. identification of viral isolates by dna ''fingerprinting an outbreak of herpes simplex virus type 1 in an intensive care nursery two outbreaks of herpes simplex virus type 1 nosocomial infection among newborns shedding and survival of herpes simplex virus from 'fever blisters varicella exposure in a neonatal medical centre: successful prophylaxis with oral acyclovir varicella exposure in a neonatal intensive care unit: case report and control measures nosocomial hepatitis a. a multinursery outbreak in wisconsin vertical transmission of hepatitis a resulting in an outbreak in a neonatal intensive care unit hepatitis a outbreak in a neonatal intensive care unit: risk factors for transmission and evidence of prolonged viral excretion among preterm infants the efficacy of infection surveillance and control programs in preventing nosocomial infections in us hospitals prevention of nosocomial infections in the neonatal intensive care unit recommended practices for surveillance. association for professionals in infection control and epidemiology, inc. surveillance initiative working group af'ic text for infection control and epidemiology hospital epidemiology and infection control pre-publication edition. oak brook terrace, ill national nosocomial infections surveillance system (nnis): description of surveillance methods cdc definitions for nosocomial infections epidemiology of neonatal infections: experience during and after hospitalization. pediatr infect dis j 194. centers for disease control and prevention, division of health care quality promotion. national nosocomial infections surveillance the newborn nursery improving hospital-acquired infection rates: the cdc experience hospital-acquired infections in the united states. the importance of interhospital comparisons nosocomial infection rates in us children's hospitals' neonatal and pediatric intensive care units af'ic text for infection control and epidemiology outbreak investigation in a neonatal intensive care unit outbreak of necrotizing enterocolitis associated with enterobacter sakamkii in powdered milk formula outbreak of acinetobacter spp. bloodstream infections in a nursery associated with contaminated aerosols and air conditioners nosocomial neonatal outbreak of serratia marcescen+analysis of pathogens by pulsed field gel electrophoresis and polymerase chain reaction an outbreak of epidemic keratoconjunctivitis in a pediatric unit due to adenovirus type 8 a five year outbreak of methicillin-susceptible staphylococcus aureus phage type 53,85 in a regional neonatal unit outbreak of invasive disease caused by methicillin-resistant staphylococcus aureus in neonates and prevalence in the neonatal intensive care unit infection due to extended-spectrum beta-lactamase-producing salmonella enterica subsp. enterica serotype infantis in a neonatal unit an outbreak of necrotizing enterocolitis associated with a novel clostridiurn species in a neonatal intensive care unit flavobacterium) rneningosepticum outbreak associated with colonization of water taps in a neonatal intensive care unit a nursery outbreak of staphylococcus aureus pyoderma originating from a nurse with paronychia parainfluenza w e 3 viral outbreak in a neonatal nursery an organizational climate intervention associated with increased handwashing and decreased nosocomial infections improving adherence to hand hygiene practice: a multidisciplinary approach american academy of pediatrics and american college of obstetricians and gynecologists. inpatient perinatal care services the effect of rings on microbial load of health care workers' hands impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital gowning does not affect colonization or infection rates in a neonatal intensive care unit gowning on a postpartum ward fails to decrease colonization in the newborn infant guidelines for perinatal care infection control for hospitalized children guideline for preventing the transmission of mycobacterium tuberculosis in health care fac tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children's hospital single-room infant care: future trends in special care nursery planning and design the principles for family-centered neonatal care recommended standards for newborn icu design: report of the fifth consensus conference on newborn icu design. consensus committee to establish recommended standards for newborn icu design reservoirs of pseudomonas in an intensive care unit for newborn infants: mechanisms of control multi-resistant pseudomonas aeruginosa outbreak associated with contaminated tap water in a neurosurgery intensive care unit aerators as a reservoir of acinetobacter junii: an outbreak of bacteraemia in paediatric oncology patients guidelines for environmental infection control in health-care facilities. recommendations of cdc and the health care lnfection control practices advisory committee (hicpac) newborn nursery and neonatal intensive care unit association for professionals in infection control and epidemiology apic guideline for selection and use of disinfectants central services, linens, and laundry the inanimate environment guidelines for environmental infection control in health-care facilities. chicago, ill, american society for health care engineering and the american hospital association nosocomial respiratory syncytial virus infections neonatal respiratory syncytial virus infection control of nosocomial respiratory syncytial viral infections herpes simplex red book risk of cytomegalovirus infection in nurses and congenital infection in their offspring cytomegalovirus infection among employees of a children's hospital. no evidence for increased risk associated with patient care the role of understaffing in central venous catheter-associated bloodstream infections american academy of pediatrics and american college of obstetricians and gynecologists. perinatal infections fetal and neonatal varicella-zoster infections breast-feeding reduces incidence of hospital admissions for infection in infants human milk report of the committee on infectious diseases american academy of pediatrics and american college of obstetricians and gynecologists. care of the neonate bacterial contaminants of collected and frozen human milk used in an intensive care nursery preventing contamination of breast pump kit attachments in the nicu infant formula safety. pediatrics 110833-835 co-bedding twins: a developmentally supportive care strategy co-bedding of twins in the neonatal intensive care unit parents as a vector for nosocomial infection in the neonatal intensive care unit a parent as a vector of salmonella brandenburg nosocomial infection in a neonatal intensive care unit role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial 47757-782,2000. colonization and infection: review of the evidence a controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum ocular applications of povidoneiodine peripheral intravenous catheter complications in critically ill children: a prospective study guidelines for prevention of nosocomial pneumonia risk factors for nosocomial infections in critically ill newborns: a 5-year prospective cohort study nosocomial pneumonia hospital-acquired pneumonia: perspectives for the health care epidemiologist the prevention of ventilator-associated pneumonia non-invasive mandatory ventilation in extremely low birth weight and very low birth weight newborns with failed respiration ventilator-associated pneumonia with circuit changes every 2 days versus every week cost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit weekly versus daily changes of inline suction catheters: impact on rates of ventilator-associated pneumonia and associated costs incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a trach care closed-suction system versus an open-suction system: prospective, randomized study prevention of ventilatorassociated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. a randomized, placebo-controlled, double-blind clinical trial stress ulcer prophylaxis in critically ill patients. resolving discordant meta-analyses occurrence of ventilator-associated pneumonia in mechanically ventilated pediatric intensive care patients during stress ulcer prophylaxis with sucralfate, ranitidine, and omeprazole ventilator-associated pneumonia and upper airway colonisation with gram negative bacilli: the role of stress ulcer prophylaxis in children rr-1):l-79 key: cord-339705-x8l3zgfd authors: patil, vijaykumar; ingle, d. r. title: an association between fingerprint patterns with blood group and lifestyle based diseases: a review date: 2020-08-18 journal: artif intell rev doi: 10.1007/s10462-020-09891-w sha: doc_id: 339705 cord_uid: x8l3zgfd in the current era of the digital world, the hash of any digital means considered as a footprint or fingerprint of any digital term but from the ancient era, human fingerprint considered as the most trustworthy criteria for identification and it also cannot be changed with time even up to the death of an individual. in the court of law, fingerprint-proof is undeniably the most dependable and acceptable evidence to date. fingerprint designs are exclusive in each human and the chance of two individuals having identical fingerprints is an exceptional case about one in sixty-four thousand million also the fingerprint minutiae patterns of the undistinguishable twins are different, and the ridge pattern of each fingertip remain unchanged from birth to till death. fingerprints can be divided into basic four categories i.e. loop, whorl, arch, and composites, nevertheless, there are more than 100 interleaved ridge and valleys physiognomies, called galton’s details, in a single rolled fingerprint. due to the immense potential of fingerprints as an effective method of identification, the present research paper tries to investigate the problem of blood group identification and analysis of diseases those arises with aging like hypertension, type 2-diabetes and arthritis from a fingerprint by analyzing their patterns correlation with blood group and age of an individual. the work has been driven by studies of anthropometry, biometric trademark, and pattern recognition proposing that it is possible to predict blood group using fingerprint map reading. dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. apart from its use in predicting the diagnosis of disease; dermatoglyphics is also used in forensic medicine in individual identification, physical anthropology, human genetics and medicine. however, the machine and deep learning techniques, if used for fingerprint minutiae patterns to be trained by neural network for blood group prediction and classification of common clinical diseases arises with aging based on lifestyle would be an unusual research work. the study of fingerprint patterns was introduced by dr. harold cummins in 1926 but it is already in use before several hundred years ago. fingerprint patterns have been normally used for identification of an individual. now a days every organization or even may government institutes in india, use fingerprint verification to identify everyone uniquely and it also have been used as a biometric modality for gender and age identification. an individual is their own key; behind this catchy principle biometrics have become an attractive alternative to traditional identification methods such as tokens or passwords (fernandes et al. 2013) . current fingerprint matching methods were started in the sixteenth century. it was henry fauld in 1880 who first experimentally proposed the singularity and uniqueness of fingerprint. herschel (ravindran et al. 2017) added to the establishment of current fingerprinting identification. in the nineteenth century sir francis galton (mcbean et al. 2014 ) directed broad investigations and ordered the sorts of fingerprints relying on essential example as loops, whorls and arches. it was cummins (ferraz et al. 2010 ) who authored the expression "dermatoglyphics (derma ¼ skin, glyphic ¼ bends), to dermal edge arrangements on the digits, of palms and sole and furthermore demonstrated that edge design are resolved incompletely by heredity or natural impact which produce pressure and strain in their development during fetal life. the fingerprint design whorl might be winding, oval, roundabout or any assortment of a loop and record for around 30%. arches are the basic type up till now uncommon (about 5%). the fingerprint design has edges running from one side to the opposite side of the print without having any re-bend. the term composite is utilized for mix of type example that doesn't fit into any of the above characterization (azhagiri et al. 2018) . till date, analysts or researches have generally used fingerprint details as perspectives to build up any individuals uniqueness. the ridge patterns have been comprehensively classified into five different kinds called as arch, tented arch, whorl, ulnar and radial loop. an individual can have any of the above type in any of the its fingers. all things considered, dominant part of fingerprints found in populace review shows that 70 percent of the prints are loops, 20-25 percent being whorls though just 5 to 10 percent consider arch or tented arch patterns or designs (singh and majumdar 2015) . some examinations done on twins have presumed that monozygotic or indistinguishable twins have comparable however not indistinguishable examples found. dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. person identification using fingerprint algorithms are well sophisticated and are being established all over the world for security and authentication. the fingerprint also used to classify gender and age group but very few manual attempts have been made to explore relationship between fingerprint patterns with blood group and common clinical diseases like hypertension, type-2 diabetes and arthritis. it will be helpful for anthropologists to predict blood group and classify common clinical diseases than conventional pathological techniques from the fingerprints those are obtained from mined articles using deep learning techniques for early reminder to prevent such common clinical diseases those arises with aging and also crime investigators to minimize the range of the suspects it would be predicted using deep neural network. the dermatoglyphics and its important role in the diagnosis of different diseases like hypertension, type-2 diabetes and arthritis with genetic bases. apart from its use in predicting the diagnosis of disease; dermatoglyphics is also used in forensic medicine in individual identification, physical anthropology, human genetics and medicine. the research work is aimed in developing the deep neural network algorithms for accurate classification of the fingerprints obtained which include: • to enhancement fingerprint image during sampling or in data set preparation step fingers of an individual recorded using fingerprint scanner. to enhance the fingerprint images precisely, the research focuses to develop various pre-processing algorithms like-segmentation, normalization, orientation estimation, ridge frequency estimation, gabor filter and binarisation and thinning etc. • to extraction of features from fingerprints and finding similarity vector to build similarity vector using features of captured sample images of fingerprint required a feature extraction algorithm. the implementation of the biometric features extraction algorithms needs to extract features like-the ridge count, ridge thickness to valley thickness ratio (rtvtr), white lines count, ridge count asymmetry, minutiae map(mm) orientation collinearity maps(ocm), gabor feature maps(gfm), orientation map (om) for pattern type, 2d wavelet transform (dwt) • to predict blood group by using extracted feature of fingerprints the unsupervised machine learning technique will apply for classification of blood group which helps to identify relationship patterns of different features of fingerprints with abo blood type and then prediction will perform with the application of machine learning and convolutional neural network (cnn) technology with the help of rigid frequency count and distance formula to conclude blood group from feature vector. • to classify and analyse lifestyle diseases like hypertension, arthritis and diabetes normally common clinical diseases arise with the age but, now in current era these are no more only relevant to the age; due to busy schedule or lifestyle of an individual they arise at any stage of life. with the fingerprint images and blood group of an individual, the dataset include the external attributes like age, weight, height, skin color, eyes color, work nature, eating habits (vegetarian or non-vegetarian), region (rural or urban), addiction (if any like drink, smoke), etc. the rest of the paper is organized as follows. the conceptual background discussed in sect. 2. the literature review specificity discusses all the methods used in sect. 3 and the evaluation and discussion included in sect. 4 which illustrates the summary of different dataset/samples and methodologies used. finally, in sect. 5, we conclude the paper. the common types of fingerprint are as arch, tented arch, whorl, ulnar and radial loop, the fig. 2 shows the different types of whorl patterns from fingerprint design. a whorl is portrayed by two deltas and one focal roundabout center. the center may have various examples. it might be winding, concentric circles, vertically compacted circles or even of the state of eye of a peacock quill. the edges start from one end, rise and hover towards the middle and go down towards the opposite end. recent advanced studies in genetics and developmental biology have guaranteed that the various projections of the human mind are physiologically associated with various fingers of both the hands. the practical coordination represented by the left half of the cerebral side of the equator is identified with the fingers of the right hand and the other way around. consequently, the focalized left half of mind is associated with the fingers of right hand, the thumb is facilitated by the unrivaled frontal projection, index is associated with the mediocre frontal flap, middle finger with parietal projection, ring finger with the fleeting projection and little finger with the rear piece of cerebrum, which is the occipital flap. correspondingly, the left half of the mind is associated with similar flaps of the cerebrum. each projection zone is liable for a portion of the other impression of the encompassing (singh and majumdar 2015) . tented arch is a pattern that is portrayed by a straight upstanding edge at the center of a straightforward arch pattern. loops are the most ordinarily up-to-the-minute highlights on a person's fingerprints just as in a subjective example space of a few fingerprints shown in figs. 1 and 2. they are described by edges that start trickling out of a crosswise of the fingertip, circle from place to place the focal point of finger cushion, and back to a similar course where they began from. these loops can either flee from the thumb. because of an individual area of arm bones-radia and ulna, any loop opening endlessly from thumb is an ulnar loop, and the one which opening near the thumb is a radial loop. a spiral whorl is described round patterns that are fit as a fiddle at the core or center. this pattern has two deltas at the two corners. the concentric whorl pattern is showed by having concentric rings of edge patterns. lengthened whorl pattern is described by a long oval whorl flanked by two triradial on either side. every single other component of a whorl is likewise present right now a pattern. it is one of the uncommon fingerprint patterns. it appears to be a tai-chi pattern at the inside or the center, encompassed by different roundabout layers of edges. since the image has two symmetric yet oppositely situated arrangements, the subjects having imploding whorls grandstand doublemindedness. composite whorl or twofold circle is one of the uncommon fingerprint patterns. it is either present on thumb or at most, the index finger. it is once more, one of the uncommon whorl patterns that contain a peacock's eye-molded circle contained inside a whorl. the center comprises of more than one spiral which are lined by a straight line at one of the corners. it to some degree seems as though the pattern on a peacock's tail quills. this pattern ought to have one triradius on either the left or right side. at the point when a pattern can't unmistakably have the option to sort into any of the above pattern types, comprises a blend of at least two above talked about patterns like a combination of concentric whorl and transformed loop and so on., it is professed to be a variation pattern. they don't contain any plain arch or loop, be outspread or ulnar. they do exclude any regular pattern. although people have been utilizing fingerprints as a methods for recognizable proof for quite a while however right now, have put forth an attempt to make stride further to "study a connection between pattern of fingerprint and abo rh blood group", with the goal that one can get a thought regarding the normal blood group from the investigation of finger impression pattern and the other way around. natural attributes like fingerprints and blood groups can't be overlooked and imitated like keys, passwords, and so on subsequently are viewed as increasingly dependable, true and solid in scientific sciences. other than an investigation of "blood group" commonness in itself isn't just significant for transfusion medication yet additionally for organ transplantation and hereditary research, forecast of specific malignancies/infections for certain blood groups just as in advancement contemplates that help researchers to comprehend the spot person involve in development's stretching tree (fayrouz et al. 2011) . different types of fingerprint patterns are as follows: there are four unlike whorl patterns as: the plain whorl, the central pocket loop, the double loop, and the accidental whorl also it has different kinds of form shown in figs. 3, 4 and 5. their normal highlights are that they have at any rate two deltas and at least one of the ridgelines bends around the center to shape a circle or winding or other adjusted, continually bending structure. the accidental whorl can be any pattern or blend of patterns that don't fit into any of the above characterizations. the expression "composite" is utilized to portray such patterns. positive distinguishing proof utilizing fingerprints can be set up just if 16 to 20 purposes of closeness exist in the minutiae (kanchan and chattopadhyay 2006; vij 2005; subrahmanyam 1999 ). arches are the most straightforward patterns and furthermore the rarest. there are two sorts: plain arches and tented arches. in these two types, the ridgelines stream into the print from one side, an ascent in the pattern, and stream out to the opposite side of the print. loops are shaped by ridgelines that stream in from one side of the print, clear up in the middle like a tented arch, and afterward bend back around and stream out or will in general stream out as an afterthought from where they entered. loops are assigned as being either spiral or ulnar, contingent upon which side of the finger the lines enter. the loop is the most well-known of the considerable number of patterns. target/concentric whorl spiral whorl concentric whorl elongated whorl imploding whorl imploding whorl accidental whorl or variant accidental whorl or variant most programmed frameworks for unique fingerprint examination depend on minutiae coordinating minutiae are neighborhood discontinuities in the finger impression pattern. an aggregate of 150 distinctive minutiae types have been recognized some of the minutiae forms shown in fig. 6 . the ridge closure and ridge bifurcation minutiae types are employed as unique mark of acknowledgment. now a day's biometric applications are designed for • authentication or identification of an individual applications like e-records security, cellular phones access, medical records management, library access and virtual learning etc. • e-governance: like, digital signature, aadhar cards, driver's licenses, border travel control, passport control, and welfare-disbursement etc. • digital forensic: such as, corpse identification, criminal investigation, terrorist identification, parenthood determination, and missing children (ramasubramanian and alexander 2009 ). blood group structures were discovered way back in 1900 by karl landsteiner. total 19 foremost groups have been identified which vary in their occurrence of spreading various races of mankind. clinically, only 'abo' and 'rhesus' groups are of major importance. 'abo' system is additional discriminated as a, b, ab, o blood group types according to presence of corresponding antigen in plasma ). yet another biological record that remains unchanged throughout the lifetime of an individual is the blood group. determining the blood group of a person from the samples obtained at the site of crime, helps identify a person. landsteiner classified blood groups under the abo blood group system (imaq 2004) . dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. the study of possible predilection of certain disease and malignancies from blood groups are some of the factors which encourages one to carry the study further. fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. the identification of minutiae shown in fig. 6 , it shows minutiae like ridge ending & bifurcation. dermatoglyphics and its important role in the diagnosis of different diseases like hypertension, type-2 diabetes and arthritis with genetic bases. machine learning is getting popular in all industries with the main purpose of improving revenue and decreasing costs; by using machine learning technique they automate and optimize their process to solve challenging tasks very efficiently. the proposed research work aims in creating a system that finds the relationship between blood group and minutes patterns of fingerprints which will be helpful to predict blood group and common clinical diseases of an individual by analyzing its fingerprints. the fingerprint having basic four categories which are loop, whorl, arch and composites but also there are more than 100 interleaved ridge and valleys which explore unique characteristics of an individual which will help to design deep neural network or convolutional neural network (cnn) which predict blood group and common clinical diseases like hypertension, type 2-diabetes and arthritis. all ten fingerprints will be acquired in real time of both male and female from different age group and from various locations of country by using optical fingerprint scanner with external characteristics to from the large dataset as process. the fingerprint data will be acquiring using fingerprint scanner. all fingers of an individual are scanned to build dataset for training model with other necessary data collected by simple registration form where external attributes like age, weight, height, skin color, eyes color, work nature, eating habits (vegetarian or non-vegetarian), region (rural or urban), addiction (if any like drink, smoke), etc. will be recorded. the obtained fingerprint from database goes through various preprocessing stages for enhancement and removing the noise before feature extraction process which include segmentation, normalization, orientation estimation, ridge frequency estimation, gabor filter, binarisation and thinning from which the orientation estimation and ridge frequency estimation. after the preprocessing of fingerprints, it goes through four steps of feature extraction, one is frequency domain feature vector obtaining by undergoing image through different levels of processing to build feature vector from acquired finger dataset. the all combined vectors within the dataset will then be allowed to pass for unsupervised training model. it uses clustering technique which helps to find similarity measure or relationship between features of fingerprint and external attributes. the clusters formed by unsupervised learning attempts to build neural network model which is deep neural network technique including features extracted from fingers and external attributes of an individual, it will be used to generate predictive model to know the blood group of an individual as well as it used to analyses disease arises with aging. the deep neural network model uses similarity measures or minimum distance for the entire combined feature vectors database. the proposed study divided into four different cases as prediction of blood group, analysis and classification of hypertension disease, analysis of arthritis disease and analysis of diabetics disease. to work out the blood group of an individual, red cells of that individual are blended in with various neutralizer arrangements. if, for instance, the arrangement contains hostile to b antibodies and the individual has b antigens on cells, it will cluster together. on the off chance that the blood doesn't respond to any of the counter an or hostile to b antibodies, it is blood group o. a progression of tests with various kinds of antibodies can be utilized to distinguish blood group. on the off chance that the individual has a blood transfusion, the blood of the individual will be tried against an example of contributor cells that contains abo and rhd antigens. if there is no response, contributor blood with a similar abo and rhd type can be utilized. it shows that the blood has responded with certain antibody and is hence not perfect with blood containing that sort of counteracting agent if the blood doesn't agglutinate, it demonstrates that blood doesn't have antigens restricting the extraordinary immune response in the reagent. in the current framework, the blood group is resolved physically. right now, arrangements, for solutions such as anti-a, anti-b, anti-d to the three samples of blood occurred. after some time, agglutination might happen. contingent on the agglutination, the blood group can be controlled by the individual physically. the weaknesses of this framework are more odds of human blunders are conceivable. only specialists can tell the blood type by observing at the agglutination procedure. the traditional method of distinguishing the blood group is usually the plate test and the tube test . both of which are performed by under comprehensive analog procedures with human observation. in the current era of digitization, it is not an efficient way to handle such a basic yet indispensable medical technique in a full analog atmosphere. there are also a few techniques such as micro plate testing and gel centrifugation ramasubramanian and alexander 2009) . fernandes et al. (2015) presented result in his research paper allow concluding that abo, rh phenotype, reverse, and crossmatching individuals blood group is possible with the developed device and procedure. they proposed device that allows blood type identification near the patient, outdoor a conventional laboratory, without the need of to be a specialized assistant to interpret the test result of blood, and in a very short time (5 min). the fast response time by device enables us it will be used in emergency situations, which is an advantage compared with the automatic commercial systems used in clinical laboratories (in average, response time of 30 min). in addition, the methodology and test protocol applied to the sample's preparation is simple, without the need of sample dilutions or incubations. the prototype was implemented with noncomplex electronic components for a low-cost device. the implemented device distinguishes agglutinated from non-agglutinated samples using a classification algorithm (developed by the authors), based on the variation of od discrete values of samples, for each blood test. the device operation was validated for abo, rh phenotype, reverse, and crossmatching human blood typing based on donor's blood samples provided by the ipst and test results agreed with their typing using their gold standard commercial and automatic systems. the examination group is working in the advancement of programmed and scaled down gadgets for clinical applications. a case of this work is the advancement of a scaled down, minimal effort, versatile and programmed framework to blood typing in crisis circumstances, considering a spectrophotometric approach and within the sight of agglutination (cooperation between red blood cells' surface and explicit reagents). the use of a basic and quick exploratory convention permits deciding blood typing and empowers the structure of an electronic programmed framework. this framework will be helpful to decrease a few impediments of the current frameworks and techniques to blood typing. the outcomes can be influenced by a few variations that makes more enthusiastically the structure of a programmed framework, for example, the trial framework utilized for spectrophotometric estimations; the agglutination quality, which influence the contrasts among control and test samples; the time spent in test readiness since it is important blood and reagents weakening; and perform spectra estimation as quickly as time permits in light of the fact that the agglutinated cells continuously will in general settle in the base of the cuvette. proposed method by fernandes et al. (2013) depends on the examination of the rh phenotypes in human blood type dependent on the plate test and utilizing a spectrophotometric approach. this examination will be remembered for the versatile gadget recently created by the exploration group for deciding abo human blood type. in this way, this paper presents the rh phenotype assurance, including the d, c, c, e and e antigens, utilizing optical retention estimations, in the obvious range, to recognize an agglutinated test (cooperation among antigens and antibodies) from a non-agglutinated test (no association). to decide the nearness or nonappearance of every antigen five samples were set up by setting 50 f. ll of the particular reagent and 12.5 f.ll of entire blood in the plate, as depicted in the reagents manual. every arrangement was blended for around one moment in a region of 2.5 cm2. at that point, the plate was situated in the estimating set-up of the spectrophotometer. an o.d. range estimation of the 50 f.ll reagents was likewise important to set the pattern and to additionally adjust the necessary gadgets. the authors presents the standards for the improvement of a scaled down, ease, compact and programmed framework, in view of a spectrophotometric approach, are introduced. the framework will have the option to decide abo and rh blood types in a brief timeframe and in situ, which is reasonable to crisis circumstances and permit the blood typing outside an ordinary clinical research facility. for that, the essential components of the framework ought to be: a light source, a light receptor and a microcontroller. 1. approval of the general test convention the convention applied in the framework use blood samples (from the portuguese blood institute) and business antibodies as reagents (monoclonal anti-an, anti-b, anti-ab and polyclonal anti-d from hos lab diagnostic). four test samples should be set up for each blood test. each test is acquired by blending blood in with a immune response. blending blood in with the reagents it tends to be acquired two kinds of samples: agglutinated, if there is antigen-counter acting agent connection; or non-agglutinated if there is no association. for instance, blending a positive blood type with anti-a, anti-ab or anti-d it is gotten an agglutinated test since this blood type has the a and d antigens. with the anti-b, it is gotten from a non-agglutinated test. 2. scaling down of the test framework after the approval of the spectrophotometry estimations to human blood typing, with the use of a quick and straightforward convention, the following stage was the execution of a particular light source framework by utilizing light emitting diodes (leds) and a photodiode estimating gadget (s1336-5bq photodiode from hamamatsu), e.g., keeping away from the massive and costly framework dependent on a light source and monochromator. ramasubramanian and alexander (2009) a coordinated fiberoptic a microfluidic gadget for the location of agglutination for blood type crossmatching has been portrayed. the gadget comprises of a straight microfluidic channel through with a responded rbc suspension is siphoned with the assistance of a syringe siphon. the stream meets an optical way made by a producer got fiber optic pair incorporated into the microfluidic gadget. a 650 nm laser diode is utilized as the light source and a silicon photodiode is utilized to recognize the light power. the separating between the tips of the two optic filaments can be balanced. at the point when fiber separating is enormous and the centralization of the suspension is high, the dispersing wonder turns into the prevailing system for agglutination identification while at low focuses and little dividing, opto-interruption turns into the predominant component. an agglutination quality factor (asf) is determined from the information. studies with an assortment of blood types demonstrate that the detecting technique effectively distinguishes the agglutination response in all cases. a dispensable coordinated gadget can be intended for future usage of the strategy for the close bedside pre-transfusion check. stomach muscle positive blood type will respond with against a, hostile to b, and against d antibodies and cause agglutination. henceforth, we just present outcomes for ab positive sort in detail right now. the information is illustrative of the outcomes acquired mouad. ali et al. (2016) proposed fingerprint recognition framework is separated into four phases. first is the acquisition stage to catch the fingerprint picture, the second is the preprocessing stage to enhancement, binarization, thinning fingerprint picture. the third stage is the feature extraction stage to remove the element from the thinning picture by use minutiae extractor strategies to separate ridge ending and ridge bifurcation from thinning. the fourth stage is coordinating (identification, verification) to coordinate two minutiae focuses by utilizing the minutiae matcher technique in which closeness and distance measurements is utilized. the calculation is tried precisely and dependably by utilizing fingerprint pictures from various databases. the fingerprint acknowledgment framework is separated into three phases that are fingerprint picture pre-processing, include extraction and coordinating. the coordinating stage is partitioning into two procedure id and confirmation. at the hour of catch the fingerprint picture, the pre-processing stage is applied to it. the yield of this stage will be passed to the component extraction organize which separates the minutiae point (ridge ending, bifurcation) from thinning fingerprint picture, at that point the bogus minutiae evacuation is applied to remove genuine minutiae. at long last, the genuine minutiae are put away in tangle lab record. at that point if the fingerprint is as of now selecting? at that point send it to the coordinating stage in any case do the enrolment stage and store it in the database as a format. in id case (one-to-many coordinating), the info include set, which is coordinating with n format from the database, n coordinating will be finished. the outcome will be considered as a coordinating score. if coordinating score more like 1, at that point the two fingers from a similar client. if coordinating score close to zero, at that point the two fingers from deferent clients. in confirmation case (coordinated coordinating), the info includes set, which is coordinating with one layout from the database, one coordinating will be done and chosen either the information fingerprint checked or unsubstantiated. siva sundhara raja and abinaya (2019) proposed work comprises of the accompanying stages as pre-processing, feature extraction and classification, as portrayed in fig. 7 . the input pre-processing is the method to play out certain tasks for improving pictures preceding computational processing. it is a system that is utilized to conceal the data that isn't appropriate to the picture for additional processing. the pre-processing steps incorporate the accompanying: picture enhancement, picture resizing procedure, and thinning process. the picture enhancement process amends the lucidity of ridges and valley structure in the fingerprint picture. right now, the histogram evening out technique is utilized. they have taken two types of blood gatherings. mage resizing is utilized to extend or compress the all outnumber of pixels. with the goal that it has the predetermined number of lines and sections. the focal point bending is done when we zoom the focal point, it will transform into a bent shape rather than the keener shape. thinning is a morphological activity that is utilized to dispose of picking front picture components from double pictures. the feature extraction is a technique for catching the visual substance of pictures for ordering and recuperating. the methodologies depend on glcm, wavelet features, laws of surface features, minutiae extraction. the major features of the fingerprints like ridge endings, ridge bifurcations are called minutiae shown in fig. 8 . minutiae states the distinction between one fingerprint from another fingerprint. a ridge ending is the place the ridge suddenly ends while ridge bifurcation is the place the ridge isolates into at least two branches. the extraction of minutiae turns out to be even more testing on account of the commotion present and lack of difference in the picture. ravindran et al. (2017) proposed work taken blood sample images and pre-processed it by using various techniques such as color plane extraction, color to gray image conversion. these blood image pre-processing terms can dramatically increase the uniformity of a visual investigation of collected samples. also, they are applied several filter processes which strengthen or reduce certain image details enable an easier or faster assessment. operators can augment a camera image with just a few clicks. filtering encompasses several image filters for image optimization mixed filter for edge detection improvement, noise suppression, character alteration, etc. image processing includes it includes several functions for image processing. contrast increase by static or dynamic binarization, lookup tables or image plane separation. resolution reduction via binning. the methodology proposed by rhiannon s. mcbean et al. (2014) having two different genetic technologies: single nucleotide variant (snv) mapping by dna microarray and second method was massively parallel sequencing (mps), concerning blood bunch genotyping. the steadiest transmissible change related with blood group bunch antigens are snvs. to perform prediction of the blood type antigen phenotypes, snv mapping which includes profoundly multiplexed genotyping can be performed on business microarray stages. microarrays recognize just known snvs, along these lines, to type uncommon or novel alleles not represented in the cluster, further sanger sequencing of the district is frequently required to determine genotype. a model talked about right now the recognizable proof of uncommon and novel rhd alleles in the australian populace. enormously equal sequencing, otherwise called cutting edge sequencing, has a high throughput limit and maps all purposes of variety from a reference grouping, taking into consideration recognizable proof of novel snvs. instances of the use of this innovation to determine the hereditary premise of vagrant blood bunch antigens are presented here. in general, the assurance of a full profile of blood bunch snvs, notwithstanding serological phenotyping, gives a premise to the arrangement of perfect blood in this manner offering improved transfusion security. ferraz et al. (2010) has developed technique that allows to analyses an image captured by a ccd camera detecting the occurrence of agglutination, through image processing techniques developed for determine the occurrence of agglutination. secondly allows determine the blood type of the patient through the classification algorithm developed. finally, allows store the information in a database built. the built database can store images captured and used in image processing techniques (each image contain four samples of blood and reagent), the standard deviation calculated in each four samples of the image, the result based by the value of standard deviation obtained for each of the samples (if agglutinated or not agglutinated in the sample of blood and reagent) and the result obtained by the classification algorithm (corresponding of blood type).the image will be processed by image processing techniques developed with the imaq vision software from national instruments (imaq 2004) . the descriptions of all the functions presented are presented in the references mentioned (imaq 2004; relf 2003) . the strategy proposed in tejaswini and mallikarjuna swamy (2014) caught pictures of slide tests were a camera comprises of a shading picture made from three examples of blood and reagent. the picture preparing technique is probed the few pictures gained. these pictures are prepared utilizing matlab programming. the picture preparing strategies, for example, shading plane extraction, thresholding, and morphological activities were performed on the pictures. the picture got in the wake of applying auto thresholding grouping capacity it very well may be seen that the item and foundation are isolated. in the following stage, neighborhood limit activity utilizing niblack work is applied it ascertains a pixel-wise edge and it very well may be seen just the outskirt portioned picture. the narkis banu and kalpana (2018) and relf (2003) present the blood group identification using blood cell images which takes from slide tests. picture acquired by the utilization of cutting-edge morphology; it very well may be seen that the portioned picture is filled utilizing shutting activity. progressed morphological activity opening is performed it tends to be seen that it smoothens the shapes of cells by evacuating little articles. at that point the pictures acquired by applying the shading plane extraction hsl luminance plane and measure work. at long last, the blood gathering can be resolved. the utilization of picture preparing procedures empowers programmed discovery of agglutination and decides the blood sort of the patient in a short interim of time. the strategy is appropriate and accommodating in crisis circumstances. keerthana and ranganathan (2017) build up an inserted framework that utilizes an image preparing calculation to perform blood tests dependent on blood composing frameworks. along these lines, the framework permits us to decide the blood sort of an individual killing customary transfusions dependent on the rule of the all-inclusive contributor, decreasing transfusion response dangers and capacity of result without human mistakes. this paper helps in lessening human intercession and perform total test independently from adding antigens to definite age of the outcome and gives the outcomes in most limited conceivable term with exactness and precision alongside capacity of result for additional references. actualizing a quality framework in the lab limits mistakes and guarantees that the correct test is performed on the correct example, the correct outcomes got, and the correct blood item gave to the correct patient at the ideal time. the proposed framework presents the plan and usage of a smart compact gadget that gives the best possible data that we require for the investigation with the decreased expense and the profoundly prepared administrators are not required. this framework utilizes an ai calculation like a neural system that underpins matlab programming for blood bunch recognizable proof and identification of blood check examination. this framework additionally discovers an answer utilizing various calculations and strategies which gives us the most extreme precision in blood bunch distinguishing proof and tallying. the work proposed by berlitz et al. (2012) utilized protein a covering of the gold surface of qcm biosensors for the immobilization of antibodies against blood bunch antigens an and b, which allows the recognizable proof of the four principle blood bunches a, b, ab and 0 with two estimations. the rhesus framework was inspected with various examinations on and the fruitful recognition of rh-d, rh-c, rh-c, rh-e and rh-e antigens on human erythrocytes. the brisk, simple and dependable identification of blood bunch antigens an and b offers the chance of deciding the patient's association to the ab0 blood bunch framework by two estimations on hostile to an and against b sharpened quartz sensors. in satoh and itoh (2004) author also proposed a method which uses genetic analyzer for blood group prediction is recognized by the presence of three common representative alleles such as a, b, and o, in satoh et al. (2001) the author proposed the analysis of four snps at nucleotide positions 261, 796, 802 and 803 to reflect serologic specificity. sensor cells organized in equal and working on weakened entire blood without earlier planning of the blood tests will lessen the necessary time to approx. 3 min. swapping the quartz sensors, encouraged by the card mounted sensors and the licensed module holder, broadens the blood bunch investigation into the rhesus, kell and further blood bunch frameworks. in any event, for blood bunch antigens with a low antigen number for every cell, techniques are accessible to get ready biosensor coatings with satisfactorily upgraded affectability. the proposed method utilized by dalvi and kumar pulipaka (2018) three samples of blood are blended in with three distinct reagents namely anti-an, anti-b and anti-d is taken on a slide. after some time, agglutination may or may not occur. after the occurrence of agglutination, the slide containing three samples of blood blended in with three distinct reagents is captured as an image and allowed to process in matlab image processing toolbox. this framework lessens the chances of false detection of a blood group. image processing techniques utilized for blood group detection are 1. pre-processing techniques, 2. thresholding, 3. morphological operations, 4. hsl plane 5. quantification. the color plane contains color information in image s. 'comparing' sections in an image is the concept utilized in image processing. comparison in grayscale involves straightforward scalar algebraic operators. in color plane extraction, they first convert the rgb image into a gray image and then channel the obtained outcome utilizing median separating. thresholding operation in image processing is utilized to create binary images. the grayscale samples are grouped into two parts as background and object. right now, thresholding is performed utilizing otsu's method. more than one threshold is resolved for a given image and segmentation is done creating certain regions. one background with many objects is the consequence of this staggered thresholding. it is a bunching based image thresholding. morphological is a tool for extraction image components that are valuable in the representation. in morphological operation, there are two fundamental operations, for example, dilation and erosion as far as the union of an image with a translated shape called an organizing component. here, closing operation is performed where dilation is followed by erosion. also, edge detection utilizing the canny edge detection strategy is performed. morphological operations are utilized to eliminate noise spikes and ragged edges. hsl plane stands for hue, saturation, and luminance. it is the representation of the rgb color model. shade is expressed in a degree around a color wheel, while saturation and brightness are set as a percentage. quantification is expressed as a number or measure of quantity. it measures power only in the region of the intrigued area. area (percentage of surface examined for full image), mean (average value of the pixel), standard deviation, least and maximum values of pixel power are resolved. also, region properties are extracted. utilizing the value of standard deviation, the occurrence of agglutination is recognized and accordingly the blood group is resolved. fayrouz et al. (2011) study reveals an association between the pattern of the unique mark and abo blood group. with ongoing advances in unique mark detecting technology and improvement in the accuracy and matching velocity of the finger impression matching algorithms, automatic personal identification is becoming an attractive/complement to the traditional methods of identification. as biometric technology matures, there will be an increased interaction among the biometric market and its identification application, since fingerprints will remain an integral part of the preferred biometric-based identification solutions in the years to come, a relationship of unique finger impression pattern to blood group presents scope for additional identification data which can be utilized for personal identification purpose, also investigation of possible predilection of certain disease and malignancies from blood groups are some of the factors which encourages one to carry the examination further. chosen randomly having distinctive abo blood groups, with the objective to a) study the distribution of unique finger impression pattern among the subjects having diverse abo and rh blood group b) correlate any relation between their characters and blood group. the data from the investigation showed that the male: female ratio was 1.2:1. most subjects (48.9%) right now of blood group o followed by blood group a (33.1%), b (12.8%) and ab (5.2%). rh-positive cases constitute about 87.2% of all considered cases. the general distribution of the pattern of finger showed a high recurrence of loops enlisting 50.5%; followed by whorls (35.1%) and arches (14.4%). in rhþve cases of blood group an and o loops occurrences were the most elevated (52% and 4.3% individually) at that point whorls (33.4% and 30.6% separately), while in blood group b whorls were predominance in both rhþve and rh_ve cases. in all blood groups, there was the high recurrence of loops in thumb, record and little fingers. utilizes the slide test and image processing techniques utilizing the imaq vision from national instruments. the image captured after the slide test is processed and recognizes the occurrence of agglutination. next, the classification algorithm decides the blood type in the analysis. finally, all the information is stored in a database. in this way, the framework allows deciding the blood type in a crisis, eliminating transfusions based on the rule of universal donor and diminishing transfusion reaction dangers. this framework is based on a slide test for deciding blood types and the software developed utilizing image processing techniques. the slide test consists of the blend of one drop of blood and one drop of each reagent, anti-an, anti-b, anti-ab, and anti-d, being the outcome interpreted according to the occurrence or not of agglutination. the agglutination reaction means that occurred reaction between the antibody and the antigen, indicating the presence of the antigen appropriate. the combination of the occurrence of agglutination, or nonoccurrence, decides the blood kind of the patient (datasheet of diameddiaclon anti-a 2008; fingerprint identification -project 2). accordingly, the software developed based in image processing techniques allows, through an image captured after the procedure of the slide test distinguish the occurrence of agglutination and consequently the blood sort of the patient. thakar and sharma (2016) process remarkable highlights which they found inside the fingerprint designs which make us equipped for offering input. in any case, different examinations have demonstrated that even the prepared and experienced specialists submit different sorts the fingerprint, these might be a result of the utilization of discretionary/nonstandard phrasing like clockwise/anticlockwise or bearings and so forth recorded as a hard copy a report. the traditional technique for fingerprint correlation with the focal point to find details in bearings, which is a tedious system should be changed. right now, a framework, optical sensor-based per users are utilized to peruse and gained fingerprint pictures in the accompanying three phases: firstly, picture handling calculations are utilized to get dark tone impressions of the fingerprint picture. also, the prepared picture is accordingly used to extricate the details (just bifurcations and ridge finishing). the third step is examining the position of various details (bifurcations and ridge finishing) on fingerprints, with the assistance of situation coordinated calculations. the separated pictures are contrasted, and the databases present in the framework and results are gotten. in any case, as opposed to the abovementioned, in the present examination, a semi-self-enough method has been utilized. in this way, in the present examination, a far-reaching endeavor has been made to extricate physically all the particulars present in the unique mark with the assistance of adobe photoshop (cs5) software and to build up an adjusted lattice which can be utilized to methodically discover the position of the details alongside estimating certain extra element like angle. azhagiri et al. (2018) study uncovers a huge relationship of blood groups o, a, b, ab to hypertension, peptic ulcer, anemia, rheumatoid arthritis, gastritis, diabetes, and bronchial asthma. the transcendence of the circle was most noteworthy among all blood groups. as indicated by this investigation, following outcomes were watched, loops were the most well-known unique finger impression example and arches were the least normal, whorls and blended were moderate, highest quantities of loops were found in blood groups o, b contrasted with an and ab, blood bunch o positive is the most well-known, o negative and ab negative is the rarest, loops, whorls, blended and arches were most elevated in females, group a was the most widely recognized blood bunch among guys, blood bunch o, b, were the most regularly observed blood groups in females, some basic clinical grumblings were found in all the blood groups. kanchan and chattopadhyay (2006) the result shows that each fingerprint is exceptional; loops are the most normally happening fingerprint design while arches are the least normal. guys have a higher occurrence of whorls and females have a higher frequency of loops. loops are transcendent in blood groups a, b, ab and o in both rh-positive and rhnegative people except for in o pessimistic where whorls are progressively normal. they can reason that there is a relationship between the conveyance of fingerprint designs, blood gathering, and sexual orientation and along these lines expectation of sex and blood gathering of an individual is conceivable dependent on his fingerprint design. rastogi and pillai (2010) present investigation shows that there is an association between the appropriation of fingerprint designs, blood gathering and sexual orientation. the discoveries of the examination can be finished up as follows: each fingerprint is one of a kind consequently it tends to be successfully utilized as a proof for distinguishing proof in the courtroom. loops are the most generally happening unique mark example and arches are the least normal. blood bunch o positive is the most widely recognized and a negative is the rarest. loops are overwhelming in blood bunch a, b, ab and o in both rh positive and rh-negative people except for in o adverse where whorls are progressively normal. whorls are progressively normal in blood bunch o negative. loops and arches are most extreme found in blood bunch some time whorls are increasingly regular in blood bunch o. blood groups an and b were the most widely recognized (similarly dominating) among guys, blood bunch o was the most generally observed blood bunch in females. guys have a higher frequency of whorls and females have a higher rate of loops. hence prediction of sexual orientation and blood gathering of a for every child is conceivable dependent on his fingerprint design. comparative examinations ought to be led to a bigger example in order to build the precision of prediction. joshi et al. (2016) present examination uncovers that there was an association between dissemination of fingerprint (dermatoglyphic) design, gender and blood groups. the general circulation example of the essential fingerprint was of a similar request in people with abo; rh blood groups for example high recurrence of loops, moderate of whorls and low of arches. the discoveries of the examination can be finished up as the loops are the most normally happening unique mark example and arches are the least normal, blood bunch o positive is the most well-known and a negative is the rares, loops are prevalent in blood bunch a, b, ab and o in both rh positive and rh negative people aside from in o antagonistic where whorls are increasingly normal and males have a higher occurrence of whorls and females have a higher frequency of loops. jha et al. (2015) study uncovered that blood bunch ab and o had a most noteworthy rate of loops (76.92% and 71.05% separately) trailed by whorls (23.08% and 28.95% individually), comparatively in blood bunch an and b the design of the loop was normal with 57.14% in the two cases. the study inferred that there is a solid connection between blood groups and fingerprint design. from the examination, it was presumed that the recurrence appropriation loops design were most noteworthy in blood bunch ab (76.92), o (71.05%) and b (57.14%) individually. so also, the examination likewise inferred that the dispersion of whorls was most elevated in blood bunch a with 42.86% circulation, then in blood bunch b with 39.28% dissemination and for blood bunch ab it was discovered 23.08% and arches were least in blood bunch b with 3.70% appropriation. further investigation ought to be completed by expanding the example size to get the progressively exact portrayal of the populace and need increasingly comparative examinations in different districts as well with the goal that near examination should be possible. the study proposed by sudikshya et al. (2018) corresponds to the connection between different patterns of fingerprints and "abo" blood groups and "rh" blood types in nepalese guys and females. in spite of the fact that they realize that fingerprints are rarely indistinguishable and they never show signs of change from birth till death, this examination is an endeavor made to connect fingerprints with sex, diverse blood groups, and rh blood types which may thus improve the legitimacy of fingerprints in distinguishing proof and legal medication and can be utilized for conceivable prediction of specific illnesses. from the present investigation, the accompanying ends are drawn: (1) loops are the most regularly discovered fingerprint pattern and arches are minimal normal in the two guys and females and furthermore in "abo" blood groups. (2) the recurrence of loops is most noteworthy followed by whorls and arches in rh +ve blood types, while the frequency of whorls is most elevated followed by loops and arches in rh -ve blood types. (3) our outcomes uncover the most elevated rate of loops in the center and little finger in all blood groups, while the whorls are usually found in ring fingers in all blood groups. the frequencies of whorls are likewise most elevated in forefinger and thumb in all blood groups aside from in blood bunch "o" where loops are as often as possible present. (4) from this investigation, they can infer that circulation of essential pattern of the fingerprint isn't identified with sexual orientation and abo and rh blood gathering, yet its conveyance is identified with singular digits of two hands. narayana et al. (2016) they present the examination is an endeavor to relate fingerprint patterns with sexual orientation and blood gathering of a person. fingerprint patterns can be of help in anticipating the sexual orientation and blood gathering of a person. it might help in expanding the legitimacy of fingerprints in recognizable proof of people and tackling of wrongdoings. they got results areas: loops were the most generally discovered pattern and composite the least. in the loop pattern, the commonest pattern was an ulnar loop, which was measurably huge right now. blood bunch o positive was the most wellknown and ab negative was the rarest. rh-positive blood groups were more contrasted with rh-negative blood groups, which is demonstrated right now and critically dependent on the information too. blood bunch b was the most widely recognized among rh-positive blood groups followed by o, an and ab blood groups. among rh-negative b and a blood groups were similarly predominant followed by o and ab. loops were most elevated in guys, whorls and arches were most noteworthy in females. loops were prevalent in all the blood groups with the exception of a positive where whorls were prevailing. the most elevated number of the considerable number of patterns was found in blood bunch o and least in ab among rh-positive blood groups and factually demonstrated critical right now. composites were least generally found in all the blood groups. the study by sangam et al. (2011) they found the loops were connected more with o gathering, whorls with ab gathering and arches with b gathering. thumbs introduced a high recurrence of whorls in a + ves. record and ring fingers were related to the high recurrence of whorls in a-ves and ab + ves. so the prediction of blood gathering somewhat might be conceivable with the investigation of unique finger impression patterns which might be of extraordinary incentive in criminological medication, however, impact provincial varieties, sex and hereditary variables ought not to be disregarded. deopa et al. (2014) has an endeavor has been made in the present work to examine their connection with sexual orientation and blood gathering of a person. loops were the most widely recognized (58.29%) fingerprint pattern while whorls were moderate (37.00%) and arches were the least normal (4.71%). guys had a higher rate of whorls and females had a higher frequency of loops. loops are overwhelming in blood bunch a, b, ab and o in both rh-positive and rh-negative people aside from in 'a' constructive blood bunch where whorls prevail marginally. whorls were most noteworthy in an and ab positive blood gathering, and loops were most elevated in o and b blood gathering. arches were least in all blood groups. there is an association between conveyance of fingerprint patterns, blood gathering, and sexual orientation and in this way prediction of sex and blood gathering of an individual is conceivable dependent on his fingerprint pattern. shivhare et al. (2017) does the investigation which uncovered the association between dermatoglyphic, blood gathering and sex: most subjects have a place with rh-positive and o blood gathering. loops are the regular and arches are extraordinary fingerprints. loops were most noteworthy in b blood gathering and least in ab blood gathering. whorls most elevated in an and least in b blood gathering. arches were most elevated in ab and least in b. loops higher in female and most reduced in male, whorls most noteworthy in male and least in female and arches most elevated in male and most reduced in the female. loops were most noteworthy in rh-positive and least in rh-negative. whorls most elevated in rh-negative and least in rh-positive. arches were most noteworthy in rh-positive and least in rh-negative. the investigation does by radhika (2016) uncovered that there is an association between the dissemination of fingerprint patterns, blood gathering, and sexual orientation. loop was most as often as possible seen fingerprint followed by whorl curve and composite. o positive is the most regular blood gathering and ab negative is missing. loops are dominating in blood bunch o followed by b and an in rh-positive subjects, trailed by whorls. curve and composite were basic among o and a positive subjects. morris et al. (2016) proposed method having outcomes that fingerprint asymmetry could be formed into a significant instrument for anticipating the danger of type 2 diabetes mellitus and type 1 diabetes mellitus and that wavelet examination is a technique that can be utilized to evaluate asymmetry in fingerprints. the benefit of fingerprints scored utilizing wavelet-based strategies over hereditary testing, is that it can demonstrate gestational condition and would be considerably less costly. the expense is significant, given late reports that both hazard mindful and chance unconscious people were keen on hereditary testing, however distinguished the requirement for minimal effort tests. they propose an increasingly far-reaching examination of fingerprint asymmetry as a predictor of both t2dm and t1dm chance, scoring asymmetry with wavelet investigation and contrasting with the prescient capacity of hereditary qualities alone, is justified. the propose work by used information digging veena vijayan and anjali (2015) which can be used for evaluating distinctive disease patterns, remedial data extraction, quiet support and organization and finding of clinical parameters. here a choice emotionally supportive network is recommended that predicts diabetes which utilizes choice stump as a base classifier in adaboost calculation. the framework utilizes a worldwide dataset taken from uci vault of ai for preparing which contains 768 cases and 9 characteristics and utilizations nearby dataset for approval which had been gathered from better places in kerala. the pc data framework with the adaboo-choice stump classifier gives a precision of 80.729% for anticipating diabetes with an extremely low estimation of blunder rate. tafa and pervetica (2015) study the dataset which comprises of 402 examples taken from three unique areas in kosovo. the characteristics of the database are bmi (weight file), glucose level before dinner and after the feast, the systolic and diastolic blood pressure, the genetic factor, the customary eating regimen, and day by day physical exercises. the last two qualities are assessed as follows. with respect to the issue of customary eating routine, while depending on contributions from the clinical clinicians, patients were inquired as to whether they took their dinners in roughly the same equidistant everyday interims, in any event, three times each day and furthermore if their suppers were not voluminous. the introduced approach depends on the joint usage of two calculations in matlab that have been executed on the recently gained dataset with the various credits when contrasted with the past work right now. the calculations are executed and assessed freely however the dynamic depends on the joint results from the two calculations. the point of this methodology is to settle on the choice progressively dependable. mehta and mehta (2015) study the one hundred type ii diabetes mellitus patients (50male and 50 female) were chosen for study and contrasted and equivalent number of controls. fingerprints were acquired by a printing technique. parameters contemplated were arches, whorls, loops. circulation of fingertip patterns indicated a noteworthy contrast between diabetics and controls. the appropriation of fingertip patterns on both ways submit male diabetics and controls. the whorls were altogether expanded though loops and arches were essentially diminished in male diabetics when contrasted with controls. the whorls were fundamentally expanded while loops were essentially diminished in female diabetics when contrasted with female controls. nonetheless, arches were fundamentally diminished in the left hand of female diabetics. ameer et al. (2014) investigation right now spellbinding. an aggregate of one hundred patients partook right now was a completely known instance of diabetes mellitus. out of these one hundred patients, most of the patients were having a place with a whorl pattern of fingerprints i-e. fifty half while the number of patients having a place with the loop pattern was forty-five 45%, the composite was just 2,2%, and no specific patient having a place with arch pattern. there is having to build up a definite and tremendous examination to investigate the association of fingerprint pattern with diabetic disease. this investigation offered reasonable weighting on the circulation of fingerprint pattern among diabetic disease patients. confinements of study where it was just restricted to clinical opd patients and limited uniquely to diabetes mellitus patients. the investigation by roshani et al. (2016) concluded whorls are the most regular pattern in both right and left hands of both male and female diabetic subjects and loops are the most normal pattern in both right and left hands, in the two guys and females in non-diabetic subjects. the arches were fundamentally diminished in both the right and left hand of males and females in diabetics and non-diabetic subjects. this examination shows a huge association between fingerprint patterns and diabetes in both genders. study might be helpful to distinguish the high-chance people in the populace, for type-2 diabetes mellitus; the most punctual prediction and finding of patients with type-2 diabetes mellitus will improve the aftereffect of treatment and further entanglements. notwithstanding; there are a few investigations that appeared inverse outcomes to our examination; subsequently, there is having to do additionally contemplates and bigger examples ought to be analyzed in detail to additionally approve the discoveries of this examination and arrive at a complete resolution. smail et al. (2019) examination demonstrated that the type of loop in typical guys is 37.50%, even with the diabetes female gathering the type of loop is 18.75%. this investigation demonstrated that the control male arches bunch is no worth which is zero, while in the patient female the arches bunch esteem is high to 25%. confinements of the examination gave us that the control male whorls run is 6.25%, however for the female patients is 12%. 50 which expanded worth. their investigation demonstrated that the type of loop in typical females is 31.25%, yet in the diabetes male gathering, the type of loop is 0%. this investigation indicated that the control female arches bunch is 6.25%, yet in the patient's male, the arches bunch esteem is high to 25%. another impediment of the examination gave us that the control female whorls run and the diabetes male or equivalent worth which is about 18.75%. for the all-out typical and diabetes guys, the loop bunch in the ordinary male is higher than diabetes (68.75% > 18.75%). for the all-out ordinary and diabetes male the arches bunch in the typical male is lower than diabetes (6.25% < 50%). for the allout typical and diabetes male, the entire gathering in the ordinary male is underestimating than diabetes (25% < 31.25%). arches are found in five percent of fingerprint patterns. the ridges run starting with one side then onto the next of patterns, making no retrogressive turns. usually, there is no information in a curve pattern. igbigbi et al. (2001) have inspected the plantar and advanced prints of the sole of 99 indigenous malawian patients matured 25-66 years going to the clinical outpatient center for diabetes mellitus, fundamental hypertension and a mix of the two conditions at lilongwe and queen elizabeth focal emergency clinics. the gathering comprised of 27 diabetics (15 guys, 12 females), 21 hypertensives (9 guys, 12 females) and 51 diabetics with hypertension (21 guys, 30 females). all patients were analyzed as type 2 diabetics after the age of 20 years. their outcomes indicated that soles of all patients had a greater number of loops than arches and a greater number of arches than whorls, which were limited to the distal zones. in hypertension, whorls were found in zones i, ii and iii though, in patients with diabetes and hypertension, the whorls were found in zones i, iii and iv. in digits, the most prevalent ridge pattern was arches in all patients, trailed by loops and whorls were missing. in the principal digit, diabetic patients had no arches, yet ladies' hypertensives demonstrated arches. in patients with diabetes and hypertension, arches were available in both genders yet in men it was limited to the correct foot. loops were discovered distinctly in the first digit in quite a while. the recurrence of loops was most noteworthy in diabetic patients, high in diabetics with hypertension and least in patients with hypertension alone. tarca and tuluc (2005) have considered a complete number of 133 patients with type 1diabetes mellitus, out of which 58(33 guys and 25 females) were youngsters and adolescents of ages somewhere in the range of 4 and 18 years. the disease showed in these cases between the age of 2 and 17 years. among the female patients, the loop was found in around equivalent extents in both the hands (58.95% on the left hand and 60.60% on the correct hand) while if there should arise an occurrence of typical subject the loops were found on the left side as it were. the loop dissemination on the five fingers indicated an expanded recurrence on the fingers from v and iii. whorls were increasingly visited in the male arrangement and on the correct hands. arches were increasingly visiting in the female arrangement. the presence of these markers, before the clinical sign of the disease, makes workable for their utilization in anticipation of insulin subordinate diabetes mellitus. udoaka and lawyer-egbe (2009) have considered an absolute number of 90(50 guys and 40 females) grown-up diabetic patients and the contrasted and the same number of ordinary subjects as controls. there was no huge contrast in the computerized patterns in the two groups. the atd point, dat edge, the absolute ridge include were fundamentally more noteworthy in the diabetic patients contrasted with the typical subjects. the pattern force record was higher in the diabetic guys however it was lower in the female diabetics. their perceptions can be utilized for distinguishing proof of diabetics. nezhad and shah (2010) have considered 30 patients of diabetes type 1 and 30 typical subjects as control gathering. the mean period of patients and control bunch was 22 ± 11 and 38 ± 8 individually. among these 42% were guys and 58% were females. they have discovered that the state of loop and whorl are heterogeneous, and their number varies altogether contrast with a control gathering (p = 0.001, p = 0.004.). the a-b 32 ridge includes demonstrated an expansion in the ridge considers as a real part of the diabetic men than control gathering. the atd point size in both the experimental group and control gathering of females was more than guys. these creators are of the sentiment that dermatoglyphics can be an appropriate strategy for hereditary examinations and diabetes type 1. sumathi and desai (2007) have considered a sum of 100 patients of diabetes mellitus type 2 and hypertension of either sex or age gathering of 35-55 years. they were coordinated with hundred controls. they discovered diminished a-b ridge include in female diabetics. the accompanying huge parameters have been found in their investigation in the palmar dermatoglyphics in type 2 diabetes with hypertension. in both male and female patients, there is the nearness of diminished i1 pattern and nearness of expanded i3 pattern in the left hand. the nearness of diminished whorls saw in two hands of male patients. the nearness of expanded ulnar loops and whorls in two hands of female patients. padmini et al. (2011) their exploration concentrate on dermatoglyphics in diabetes mellitus underlined that however dermatoglyphics by and large don't assume any significant job in clinical analysis yet, it can fill in as a pointer to pick out subjects from a huge gathering of individuals for additional examinations to affirm or preclude diabetes mellitus have studied fingerprints and palmar prints from 200 subjects, 100 guys and 100 females in the age gathering of 25 years to 80 years, of which 95% of cases were non-insulin subordinate diabetics and 5% of cases were insulin subordinate diabetics contrasted and 200 controls. higher occurrence of variety in methods for ulnar loops (83.2), composite whorl (1.8), all-out finger ridge tally 33 (108.6), total finger ridge check (138.55), dat points of the right hand (59.77) and left hand (62.3) in diabetics than in controls was seen by them. the rest of the parameters were low in diabetics than in controls. in male diabetics increment in methods for ulnar loops (41.6), outspread loops (1.7), complete finger ridge check (106.25), supreme finger ridge tally (137.58),atd edge of right hand (41.68) and left hand (41.67), dat edges of left hand (62.42) and adt of right hand (80.45) was seen than in controls. in female diabetics, huge increment in basic arches (5.7), all-out finger ridge tally (110.94), total finger ridge tally (139.52), dat points of two hands right (61.6) and left hand (62.17) was seen than in controls. sharma and sharma (2012) their investigation of 50 diabetic cases and 50 controls chose from the sms hospital, jaipur, india, found that the complete finger ridge check, total finger ridge tally, and the a-b ridge include were higher in all the patients. the atd points in the hands of the two sides in the patients were expanded in all the groups aside from left side in guys. in any case, they varied fundamentally on the correct side and on the left side in females, p < .001. in the general groups right tda edge was huge. the smidgen and the tda edges on the two sides of the hands in all the groups were lower in the patients aside from left tda edge in 34 guys. be that as it may, they varied just all together in the left bit, right tda in females. the aftereffects of their examination work demonstrated that dermatoglyphic variations from the norm might be utilized as an indicative instrument for anticipating the chance of the advancement of diabetes sometime in the future. taiwo and adebanjo (2012) have completed an examination to explain whether fingerprint pattern of dermatoglyphics is related to withtype2 diabetes or not. dermatoglyphic information was acquired from controls and type 2 diabetic subjects going to the diabetic clinic of lagos university teaching hospital. they saw all-out finger ridge tally was fundamentally higher (p < 0.05) in diabetic subjects than in nondiabetics. considering the association between fingerprint pattern and type2 diabetes, dermatoglyphics might be utilized for the early id of hazard bunch people for reconnaissance purposes so as to forestall disease beginning. rakate and zambare (2014) have looked at the distinctions in the complete finger ridge tally, a-b ridge includes and atd point in patients with type 2 diabetes mellitus with a control gathering. their examination was completed on 75 type 2 diabetic patients (51 male and 24 female) of 30 to 60 years and 75 non-diabetic persons (47 guys and 28 females) of the equivalent 35 age bunch as a benchmark group. in their examination, they found an expansion in the number of whorls, absolute finger ridge tally, a-b ridge tally alongside more extensive atd point in type 2 diabetes mellitus patients. desai and hadimani (2013) have opined that dermatoglyphics is a developing order and its simple and prepared pertinence renders it as a valuable device to the clinician. the dermatoglyphics isn't to analyze and not for characterizing a current disease yet to forestall by anticipating a disease and to distinguish individuals with hereditary inclination to build up specific diseases. they have attempted to decide noteworthy palmar dermatoglyphic parameters if there should be an occurrence of sputum positive tuberculosis, diabetes mellitus type 2 with basic hypertension, dermatitis, innate coronary illness, and down disorder and contrasted and the benchmark group. their investigation demonstrated that there were some hereditary components that were engaged with the causation of different diseases referenced previously. itis conceivable to anticipate from dermatoglyphics people's possibility of gaining disease. noteworthy discoveries they watched were:1. the nearness of diminished whorls, 2. the nearness of expanded ulnar loops,3. the nearness of expanded simian line in the left hand of considered patients. shivaleela et al. (2013) have done an investigation to discover the recurrence of different fingerprint patterns in type 2 diabetes mellitus with and without ischemic coronary illness. their examination likewise planned to discover the recurrence of fingerprint patterns in type 2diabetes mellitus patients having the family ancestry of cardiovascular disease. twenty-five type 2diabetes mellitus male patients in the age gathering of 38-65 years were chosen, of which 18 had an ischemic coronary illness and 16 patients had the family ancestry of cardiovascular occasions. there was a higher recurrence of whorls in type 2diabetes mellitus patients than different patterns. less recurrence of arches, high recurrence of whorls and ulnar loops were seen in type 2diabetes mellitus patients contrasted and type 2diabetes mellitus patients without ischemic coronary illness. the thing that matters was not factually huge. dermatoglyphics in type 2diabetes mellitus and in patients with family ancestry of cardiovascular disease didn't show dominance of any of the fingerprints in ischemic coronary illness. therefore, they opined dermatoglyphics might be symptomatic apparatus in type 2diabetes mellitus however not in recognizing the hazard class for ischemic coronary illness. umana et al. (2013) completed an examination to decide the association between fingerprints patterns and diabetes mellitus utilizing subjects in zaria, nigeria. their consequences of 101 type 2 diabetic patients were contrasted and 126 typical subjects. from their outcomes, there was an association between fingerprint patterns of guys with diabetes mellitus. from the above investigation, they reasoned that the male with a arch pattern of fingerprint in their correct hand is inclined to create diabetes mellitus at a later stage. mittal and lala (2013) have endeavored to discover an association of the dermatoglyphics patterns of the sound people and diabetes mellitus patients. an aggregate of 200 subjects took part in their investigation of which 100 were diabetic patients (50 guys and 50 females) and 100 were solid people utilized as controls (50 guys and 50 females). they signify 'atd' point in both the hands of both the genders of diabetic patients was fundamentally more extensive when contrasted with that of the controls. contrasted with that of control, the mean tda edges in both the hands of both the genders of diabetics were restricted. they signify 'dat' edges were essentially thin just in the left hand of diabetic females when contrasted with left hands of female controls. burute et al. (2013) have meant to contemplate the different dermatoglyphic patterns in the patients of the development beginning diabetes mellitus (type 2 diabetes mellitus) and contrasted and the dermatoglyphic patterns of controls. they did their investigation on 101 (51 male and 50 female) clinically analyzed patients of development beginning diabetes mellitus. for correlation, solid controls (total = 100, 50 guys and 50 females) were considered. in female diabetics, essentially higher recurrence of arches and lower recurrence of whorls were seen than in controls. in diabetic female's outright finger ridge tally and complete finger ridge include were essentially lower than in controls. discoveries of their examination feature on the potential markers to foresee type 2 diabetes mellitus on a bigger example size after a fastidious investigation of various fingertip dermatoglyphic factors. rakate and zambare (2014) have looked at the distinctions on the fingertip patterns to be specific, curve, loop, and whorl in patients with type 2 diabetes mellitus with a control gathering. test for their investigation included palmar prints of 350 type 2diabetic patients old enough gathering between 30 and 60 years out of them 240 were guys and 110 were female contrasted and same age gathering of 350 non-diabetic people as control the gathering, out of the 240 were guys and 110 were females. in the example of 350 type 2 diabetes mellitus patients, they watched an expansion in the number of whorls in two hands of guys and females. the p-esteem was 0.001. the ulnar loop and curve patterns were available in less incentive in diabetic patients which were measurably inconsequential. the plain whorl was available essentially higher in esteem in diabetic patients of guys and females. in diabetic guys in right hand 482 whorls where present. yet, in charge just 326 whorls were available; this distinction was critical at 0.000 levels. in the left hand of diabetic, whorl was altogether more 418 than control 267, p-esteem was 0.000. diabetic females additionally indicated higher recurrence of whorl pattern in two hands; on right hand 158 contrasted and control 121 and 184 on left hand contrasted and 130. the p values were 0.010 on the right hand and 0.000 on the left hand. the central pocket loop whorl pattern watched more in diabetic patients. in the diabetic male they 40 discovered 96 on the right hand and on the left hand 99 central pocket loop whorl pattern which was more contrasted and control right hand 82 and left hand 82. the p-values were 0.138 and 0.094 separately. in diabetic females additionally central pocket loop whorl was watched all the righter hand 36, left hand 40 than control bunch right hand 29 and left hand 36; p-values were 0.237 and 0.320. the twofold loop whorl was watched more in diabetic patients. in diabetic guys on the right hand, 54 twofold loop whorls were available which were more than control 38. likewise, on left hand 69 in diabetic though 67 in charge. the p-values were 0.044 and 0.430 separately. in diabetic females, likewise, more recurrence of twofold loop whorl was seen on right hand 28 contrasted and control 15 and left hand 25 contrasted and 20 in charge. the p-values were 0.021 and 0.223. at the point when they thought about a wide range of whorls together among diabetic and control gathering, noteworthy contrasts were seen in the two guys and females. in diabetic guys on the right hand, 632 whorls were available which were more than 446 in ordinary. comparative discoveries were seen on left hand 586 in diabetic while 416 in charge. the p-values were 0.000 and 0.000 separately. in diabetic females, likewise, more recurrence of whorl was seen on right hand 222 contrasted and control 165. the p values were 0.000. karim et al. (2014) have looked at the distinctions in the fingerprint patterns and finger ridge include in patients with type 2 diabetic mellitus with a control bunch in erbil city, kurdistan area, iraq. in their examination, 50 non-insulin subordinate diabetes mellitus patients, 25 guys, and 25 females were contrasted and 50 (25 guys and 25 females) sound controls. the appropriation of fingertip patterns of male patients indicated no noteworthy contrast in ulnar loops, spiral loops and rose arches while plane arches expanded altogether (p < 0.05) in diabetic type 2 patients contrasted and controls, whorls diminished fundamentally (p < 0.05). higher frequency of ulnar loops, spiral loops and plane arches in female diabetics contrasted and control females. they saw that essentially expanded (p < 0.05) center finger ridge include in the left hand of male diabetic patients. fundamentally expanded (p < 0.05) file and little finger ridge check of the right hand was seen in female diabetic patients contrasted and control female groups. bala et al. (2015) have considered an all-out 210 subjects out of which 70 subjects having diabetes (32 guys and 38 females), 70 subjects having diabetes with hypertension (32 guys and 38 females) and 70 typical sound people (32 guys and 38 females) as control having a place with gangtok area of sikkim. all were clinically analyzed and affirmed by examinations as diabetic and diabetic with hypertensive patients. in their investigation, an examination of diabetic with control bunch indicated the mean estimations of atd and dat edges in two hands of diabetic patients lower than control, though mean estimations of adt edges were higher than control bunch on both right and left sides. the huge distinction was found in the correct hands of diabetes mellitus gathering. in both right and left hands of males and females, the mean estimations of atd point and dat edge of the diabetic gathering were lower than in charge. the mean estimations of adt edge were higher than control. no noteworthy contrast was found. the mean estimations of a-b ridge include in two hands were higher in diabetic male and female aside from in the left hands of male and profoundly noteworthy distinction was found in both hands of the female. mehta and mehta (2015) have analyzed fingertip patterns of type 2 diabetic patients with controls. one hundred type 2 diabetes mellitus patients (50 male and 50 female) were chosen for study and contrasted and equivalent number of controls. in two hands of guys and females' diabetic patients' frequency of whorls was essentially expanded. frequency of loops was fundamentally diminished in two hands of male and female diabetics contrasted with controls. arches were essentially diminished in both ways' hands of male diabetes mellitus patients. arches were fundamentally decreased in left hand of female diabetics. in their investigation, they expressed that dermatoglyphics can be utilized as a screening device for the conclusion of people who are progressively inclined to create diabetes mellitus and, in this way, forestalling the future diabetic intricacies. bala et al. (2016) have examined a sum of 100 type 2 diabetic patients (50 guys and 50 females) were contrasted and 100 diabetics with hypertension patients of hilly district. the mean estimations of all-out finger ridge check and total finger ridge include were higher in male and lower in female diabetic gathering than diabetic with hypertension gathering. the mean estimations of a-b ridge include were lower in males and higher in females in diabetic gathering and a critical contrast was found. the mean estimations of atd edge were higher in diabetic gathering than diabetic with hypertension gathering. the mean estimations of dat edge were lower in the right hands and higher in the left hands of diabetic gathering. the mean estimations of adt point were higher in guys and lower in female diabetic gathering than diabetic with hypertension gathering. in the right hands, the mean estimations of fingertip ridge include were lower in all digits aside from in 2nd, fourth, and fifth digits in the male diabetic gathering. in left hands, the mean estimations of fingertip ridge include were lower in all digits of diabetic gathering apart from in 2nd, fourth and fifth digits and no critical contrast were found. in their examination, they watched an expansion in ulnar loops in the correct hand of male diabetic and diminished frequency in the left hand of male and in two hands of female diabetics. tafazoli et al. (2013) collected samples for this exploration was gotten from 40 patients with acquired essential hypertension disease and 20 ordinary subjects with no indications of essential hypertension disease until 2 ages prior. print of their palm and fingers was acquired in two groups by printing ink. patterns of fingertips, atd edges, a-b ridge and the various types of details were found, recognized and measured outwardly within four divisions of fingerprints. the consequence of this investigation indicated two patterns of fingertips; whorl and curve in diseases are more than ordinary individuals. the most widely recognized tips in ordinary individuals is loop. in normal the quantity of the a-b ridge in female diseases and male-typical are individually more on normal than female ordinary and male sicknesses. the atd point is lower in patients than in typical. consequences of the overview on details demonstrated that frequency of the ridge ending (e) is between with the most elevated frequency. the frequency of bifurcation (b) is lower than the ridge finishing which it is between % in the left hands. additionally, in some part of the fingers noteworthy distinction was found. 32-52.52 17.39-35 but in the right hand the second most patterns intermingling (c) which is between 14.13 and 38.66%. the third most patterns in the left hand was seen in pattern unions (c) with a rate between 8.62 and 32.6, however, in the right hand, the third most patterns are bifurcations (b), which is between 3.57 and 24.81%. the method proposed by chakravathy et al. (2018) does observational examination included a correlation of palmar dermatoglyphic parameters among cases and controls. parameters were dissected quantitatively-atd edge; subjectively outspread loop, ulnar loop, curve, whorl and composite. as appeared in (graph i) out of all-out of 250 cases, 120 (48%) were guys and 130 (52%) were females. of the absolute 250 controls, 137 (54.8%) were guys and 113 (45.2) were females. as indicated by (graph ii), they found that signify "atd" edge was higher in cases than controls and there was the factually critical association of signifying "atd" point in cases contrasted and controls. they likewise discovered both ways signify "atd" point was higher in cases than controls with solid factually huge association of right signify "atd" edge in cases than controls. by dissecting subjective parameters in study gathering, conveyance of dermatoglyphic patterns was measurably noteworthy in situations when contrasted and controls. the outspread loop was increasingly visiting in cases while ulnar loop was more ordinarily found in normotensive controls. the examination of subjective parameters in each hand of cases and controls demonstrated an appropriation of dermatoglyphic parameters that were factually huge. as appeared, looking at subjective parameters in each finger of the two cases and controls for the conveyance of dermatoglyphic patterns indicated factually noteworthy association. lahiri et al. (2013) used digital and palmar dermatoglyphic investigation of 145 normotensive subjects and 131hypertensive subjects was performed. the parameters utilized were advanced ridge pattern, complete ridge tally, and atd edge. the outcome demonstrated that the twofold loop whorl patterns are available with higher frequency in hypertensives. if there should be an occurrence of the hypertensive people, frequency of twofold loop whorl pattern and curve are 4.57% and 5.79% individually yet those are simply 0.44% and 1.33% in normotensives. in spite of the fact that the distinctions of occurrences of whorl just as ulnar loop between two groups are not all that obvious, yet factually huge (p < 0.05). the occurrences of explicit patterns in the hypertensive and the normotensive populace have appeared. the all-out ridge tally unmistakably expressed that it is horribly raised if there should be an occurrence of the hypertensive populace contrasted with the normotensive populace. the various estimations of average total ridge count of hypertensive and normotensive people have appeared with their comparing frequency. subsequent to processing the remedied atd edge, a normal of the atd points of the two hands is made. the mean worth, most extreme and least qualities and model estimation of rectified atd edge (normal of both hands considered) in hypertensive gathering and normotensive gathering. the general pattern of this parameter is best comprehended by measurable examination (t trial) of all out arrangement of information which shows contrasts in estimations of atd edges of the hypertensive and normotensive gathering are of factual hugeness (p < 0.05). tafazoli et al. (2013) does the examination and conclude an observational, systematic and handy examination utilizing a case-control observational methodology with straightforward irregular testing and without substitution did on two groups of solid subjects and patients experiencing hypertension; individuals with no other explicit hereditary diseases which thus influence dermatoglyphic readings. that loops were the most widely recognized patterns on left digits in all patients (guys and females). from a factual perspective, there is an important distinction in frequency of various patterns on the left digit 4 (p = 0.05) between genders yet other left digits indicated no measurably noteworthy contrast. on the correct digits, loops were higher in rate in the two sexual orientations however no huge factual distinction was seen between sexes for frequency of various patterns on right digits (p < 0.05). the higher occurrence of whorls on digit ii and of loops on different digits. their is no huge distinction in the frequency of the patterns between two hands (p < 0.05). as illustrated, frequency in the dissemination of loops were 70 and 58.8% for the left hand and 63.3 and 66.7%, for the correct submit guys and females, separately. the distinction between frequencies of patterns was not measurably huge on any of the two h ands in both genders neither the right nor the left nor both frequency of loops on the left and the correct digits were 70-63.3% in guys and 57.8-66.7% in females, separately. the contrast between frequencies of the patterns was not factually critical on two hands of both genders. the information shows that the frequency appropriations of whorls in the control and test (hypertensive) bunch were 75 and 63% on the correct hand and 79 and 70% on the left hand of guys, individually. no factually critical contrast was seen between the frequency appropriation of patterns on two hands of guys in the two groups (p = 0.04, p = 0.02) level of whorl and arch is more in charge bunch than intolerant gathering while the level of loop is more in-understanding gathering than solid gathering in the two sexual orientations. the percent dispersion of whorls on digits of guys was as high as 77 and 66.5% in the control and the hypertensive gathering, individually. there has been no factually noteworthy contrast between two groups for frequency of patterns on digits in guys. level of whorl digit patterns in females was 53.7 and 62.5% in the benchmark group and in the hypertensive gathering, individually. there has been no factually huge distinction between the two female groups in the frequency of patterns on digits. the dataset utilized and examination by wanga et al. (2015) was gathered from the behavior risk factor surveillance system (brfss) of centers for disease control and prevention (cdc) and is openly accessible and downloadable from the brfss site. brfss is the world's biggest and persistently led phone-based wellbeing study in regard to social hazard factors, incessant wellbeing conditions and utilization of preventive administrations. built-up in 1984 with 15 states taking an interest in the study, it has a long history in conduct and incessant disease observation. the essential point of brfss is to track and measure singular wellbeing conditions and hazard practices that add to the main source of high grimness and death rates in the grown-up populace who are matured 18 years and the older in united states. the review covers a wide scope of wellbeing hazard factors, preventive wellbeing practices and wellbeing conditions, including hypertension, diabetes and carcinoma related things. by gathering an assortment of data and sharing them with general society, brfss empowers scientists to examine the connections between interminable diseases and their hazard factors. we propose to anticipate hypertension just utilizing the surveys other than clinical test information, anthropometric information or hereditary information. its adequacy exhibits the practicability of building up a hypertension observation framework for an enormous size of the populace in a non-obtrusive and prudent way. what's more, the outcomes from this examination might be utilized to manage the advancement of projects outfitted towards forestalling and relieving explicit hypertension chance elements. (2) they propose to coordinate calculated relapse examination and fake neural systems for synchronous hazard factor determination and hypertension prediction. in spite of the fact that theyt now, the proposed approach is basically a general system that can encourage specialists to break down other ceaseless diseases and different types of information. (3) they detail the choice of fake neural system engineering and the setting of applicable parameters, which is a troublesome and testing task in model learning. this can conceivably assuage analysts of the mind-boggling model determination issue and empower them to concentrate on the issues under scrutiny. (4) to manage the class irregularity issues, they propose a viable under-examining method. based on a bunch calculation and choosing the delegate tests from each group in the extent of the group size, the proposed strategy can choose the most discriminative examples from the greater part class while making us lose the minimal measure of data. ravindranath et al. (2003) proposed qualitative dermatoglyphics involving identical fingerprint pattern, interdigital pattern, hypothenar pattern and palmar wrinkle was concentrated on 26 female and 11 male rheumatoid joint pain patients. examination between understanding male and control male; and patient female and control female has been finished. 'chi' square test was performed. in male patients, with hands together, arches were expanded, loops/whorls were diminished. incomplete simian wrinkle was fundamentally expanded. in the correct hand, patterns were expanded in the third interdigital zone. then again, in female patients there was a noteworthy increment in whorls and diminishing in loops on the principal finger on both the hands, increment in arches on the third finger; the two arches and whorls on the fourth finger of left hand. the present examination has accentuated that dermatoglyphics could be applied as a symptomatic device to patients with rheumatoid joint pain. mazumdar et al. found there is an association between rheumatoid joint pain and dermatoglyphics. the conceivable relationship amongst ra and dermatoglyphics may empower dermatoglyphics as a marker device in the analysis of rheumatoid joint pain. the present examination has been attempted to discover the likelihood that the fingerprints and palmprints assume a significant job in the analysis of rheumatoid joint pain. the frequency of twofold loop whorl in the rheumatoid joint pain bunch was seen in pointing finger and center finger of right hand and left hand separately (mazumdar 2015) . the ulnar loops were altogether present in right and little finger of the left hand of rheumatoid joint pain patients contrasted and control. the complete fingerprint ridges were progressively various in right and left hand of rheumatoid joint inflammation gathering. narayanan et al. (2017) investigation was a case-control concentrate with 60 cases with rheumatoid joint pain and 60 controls. the result appears out of the all-out 60 cases, 12(20%) were male and 48(80%) were females. of the complete 60 controls, 12(20%) were guys and 48(80%) were females. the subjective parameters in female was a measurably critical increment in the number of whorls morally justified and left hands of female patients contrasted with the controls. there was a factually noteworthy reduction in the outspread loops in both the hands of female patients contrasted with the controls and the abatement is increasingly huge in the correct hand. there was no measurably huge distinction in the ulnar loop pattern circulation in either hand of female there was a factually critical increment in the finger ridge includes of right to deliver male patients contrasted with controls. there was a critical increment in the ridge check of patients. there was a factually noteworthy reduction in arches in the left hand of females with rheumatoid arthritis contrasted with the benchmark group. the left hand in male patients contrasted with the controls. absolute finger ridge check (included ridge tally of both ways hand) was fundamentally expanded in male rheumatoid joint pain patients contrasted with the controls. the ridge includes of the correct submit female patients was altogether higher than that of controls. the ridge includes left-hand fingers in female patients was fundamentally higher than that of controls. the complete finger ridge tally (right-hand ridge tally + left-hand ridge tally) was essentially expanded in female patients contrasted with controls. the expansion in all-out finger ridge include was increasingly huge in female patients contrasted with the male patients. there was no critical contrast in the pattern force in male patients contrasted with the controls. there was a measurably critical increment in the pattern power in the correct hand of females in examination with controls. rajangam et al. (2008) perform examination of male patients indicated a pattern towards criticalness for 'all-out finger ridge tally', centrality in left hand for 'total finger ridge check', and morally justified for 'a-b ridge tally'. then again, in the female patients, 'supreme finger ridge check' was seen as critical for the right hand and 'a-b ridge means' left hand. the watched contrasts between the male and female patients just as with that of the control might be a direct result of the expanded whorl pattern adding to two tallies and the width of the palm and fingers, along these lines a more noteworthy number of ridges might be available. obviously, the detail of spreading the fingers and the palm, likewise should be remembered. hwang et al. (2004) concluded that the outspread loop and whorl were progressively visit while the curve and ulnar loop were less continuous; these attributes of the spiral loop and whorl were unmistakable in the correct hand and fifth finger. the frequency of the spiral loop was turned around in their left hands and the third fingers. the complete fingerprint ridges were increasingly various in the ra gathering. contrasts of both palmprint ridges and palmprint point atd between the ra and the benchmark groups were not conspicuous, then again, palmprint ridges c-d was progressively various in the ra gathering. the shut wrinkle was progressively visit though open and meeting wrinkles were less incessant in the ra gathering. the typical wrinkle was less continuous though simian and sydney wrinkles were progressively visit in the ra gathering; the general attributes were unmistakable in their correct hands. the general attributes of sydney's wrinkles were turned around in the left hands of female ra gatherings. the all-out level of palm wrinkle transversely was lower in the ra gathering; the attributes of the sydney wrinkle were progressively conspicuous. swati and sujata (2016) used conventional radiograph which has been a standard path for distinguishing the jsw in ra since bones are obviously noticeable in x-beam. toward the beginning of the disease, 90% of the side effects of arthritis are found in hands. manual reviewing strategies are not ready to separate a little contrast in jsw figuring. electronic appraisal of joint space has an effect in dynamic and observing the treatment of joint pain patients. the info hand x-beam picture of the typical hand is of 1000 × 2000 pixels, this picture is resized in the preprocessing step, resized picture goals is 500 × 500 pixels. the division utilizes asm strategy, the quantity of emphases required is 1000. the state of hand i followed flawlessly after the 1000 emphasis. the consequence of the asm division after 900 emphasizes. to separate bone and non-bone districts binarization activity is performed. figure 6 shows the aftereffect of binarization. binarization is finished by otsu's calculation. at that point, the skeletonization of the paired picture is completed. skeletonization brings about midline discovery it utilizes a diminishing procedure. at that point, the pinnacle and valley focuses are recognized along with the skeleton. the key focuses that is the specific joint area is followed by llm. ra tolerant joint area estimation process is appeared. at that point the different factual highlights are determined like mean, middle, change. joint area precision is determined by considering the number of exact joints recognized partitioned by the absolute number of joints that are 14. gobikrishnan et al. (2016) collected patient's data with rheumatoid joint pain in knee locale with disease span short of what one year and ordinary people with no knee disease utilized for this investigation. what's more, this examination was endorsed by the institutional moral council. absolutely 5 patients and 5 control subjects warm picture information was gathered. the mean period of patients utilized for the investigation was 40 ± 10. what's more, the disease length was 5 ± 2. the benchmark group mean age was 40 ± 10. the patients with no clinical proof of knee inclusion was dismissed for this examination. the information was gathered by directing a camp at srm organization of clinical science. before the picture obtaining method composed endorsement from the patient to take part in the investigation was taken. the patients who had knee torment other than rheumatoid joint inflammation were dismissed for this investigation. the highlights like standard deviation, mean, skewness and kurtosis were extricated for patients and control subjects fragmented picture. the acquired outcome indicated essentialness. the standard deviation was beneath 10 for control bunch above 10 for patients experiencing rheumatoid joint pain. mean worth was underneath 5 for control gathering or more 5 for patients experiencing rheumatoid joint inflammation. kurtosis was beneath 10 for control gathering or more 10 for patients experiencing rheumatoid joint inflammation and skewness was underneath 10 for patients experiencing rheumatoid joint pain or more 10 for control gathering. the worth discovered higher for patients because of higher temperature variety. the table 1 shows the different methods of blood group identification, which includes some of the traditional as well as unusual those are build using electrical or electronics components such as diode, sensors. the few researchers tried a software-based approach by processing image of blood sample, but only few used method called fingerprint pattern analysis to predict blood group with limited accuracy because thy apply this method with traditional paper and ink as sample collection mechanism, so it not provide high accuracy. in current era of digitization there are several image (fingerprint) computation techniques which explore a greater number of features from fingerprint image which extends the accuracy of prediction process. as per literature, there are many methods are available for determination of blood group from those some having pros and cons, but the popular and most traditional one is to take blood sample of an individual and test it against various antibodies to determine blood type 3 to 5 min but it not convenient to the small children's and individual having blood phobia. the fingerprint having lots of potential which explore different unique patterns those may leads to identify blood group very quickly and accurately. the table 2 show various methods and dataset or samples which are used for analysis and prediction of lifestyle-based diseases such as diabetes, blood pressure/hypertension, rheumatoid arthritis. the diseases arise with age but not all humankind suffers from such agebased disease. the methods and dataset used to study age-based disease are limited only daily activity, x-ray samples and some are the techniques used after arrival of such diseases. the age, blood group, daily activity, lifestyle of individual and fingerprint patterns analysis helps researchers to generate indication or risk prediction in early age of an individual. as per literature, all authors attempt traditional method for sample collection as ink and paper, so they were only analyses the fingerprint patterns visible to human eyes those are like loops, arches and whorls. above literature shows relation between blood group and finger-print pattern summaries as follows: • loops were the determined common finger-print design and arches were the least common. • whorls and mixed were moderate. • more no of loops was originating in blood groups o, b related to a and ab. • blood group o +ve is the maximum found in samples, o −ve and ab −ve is the fewest. • loops, whorls, mixed and arches were uppermost in females. • group a was the utmost common group among sampled males. • blood group o, b, were the record usually seen in females. in type 1 dm there is increased frequency in whorls, and decreased ulnar loop, increased frequency of sydney line, and increased incidences of arches in females (ravendranath and thomas 1995) . in maturity onset diabetes mellitus, there is decrease in mean value of tfrc, afrc, increase in arches and decrease in whorls (ravindranath et al. 2003) . the fingerprint of an individuals with t2dm would be more irregular than an individual without t2dm, regulatory for gender and age. diabetes regulate if wavelet analysis, a technique already used in forensics for fingerprint archival and matching, but not in previous studies of fingerprints as disease markers, would give results like the traditional ridge count or pattern analysis. the fingertips with whorls or double loops, applied a which rc formula that comprised half-unit values for those ridges situated between the core and delta point or between multiple cores. all ridge counting was as blinded to the diabetic and anthropometric status of the participants. the type 1 diabetes, there is increased frequency in whorls, and decreased ulnar loop, increased frequency of sydney line, and increased incidences of arches in females (roshani et al. 2016 ). • surge in arches in diabetes in both sexes • growth in rate of recurrence of loops and arches and a lessened frequency of whorls especially in mid finger • reduced number of arches in the right hand of male and left hand of female having diabetics, it was more in diabetic males and females than in the controls • growth in radial loop, ulnar loop in both male and female diabetics. • increase in frequency of whorls in both types of gender in diabetics there is increase in tfrc, decreased frequency of axial triradius 't' in right palm of females and 't and t' in right palm of male, decreased atd angle and absence of axial of triradial in 10% cases (mandasescu et al. 1999) . above literature shows relation between patients having hypertension and not a hypertension finger-print pattern summary as follows: • higher prevalence of whorls and loops are associated with higher level of blood pressure • whorls and loops are prime ridge patterns in hypertensive patients • atd angle showed the mean of angle in patient surge rather than in control group • larger frequency of ridge endings in the thumbs and index fingers • amplified frequency in bifurcations and convergences in the middle, ring and little fingers there is increase in arches and decrease in loops and whorls in males, whereas in females there is increase in whorls and decrease in loops on the 1st finger of both hands (sengupta and boruah 1996) , with increase in arches on 3rd digit and whorls on 4th digit of left hand (bala et al. 2015) . above literature study shows change in fingerprint patterns of patients having summarized as follows: • ulnar loop was the most prominent digital pattern in both genders, • decrease in the radial loop in both male and female patients • loops were significantly decreased in the third finger of males and a first and fourth finger of females • decrease in the ulnar loops in both the hands of male and female patients. • increase in the whorl pattern in the right hand of male patients and in both the hands of female patients • decrease in the arches of the left hand of female patients. the strength of the present research work is that fingerprint itself having lots of unique and hidden patents and it also currently used as a traditional, effective, and unique identification method of an individual. the dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. there are more than 100 fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. the weaknesses are in acquisition of fingerprint and finding different unique patterns from people of different age group due to the human digital fingerprint varies in texture as person ages, so it is very difficult to classify fingerprints because there are the fingerprints having the characteristics of two or more patterns changes with age of an individual. normally common clinical diseases like hypertension, arthritis and diabetes arises with aging, but due to busy schedule or lifestyle of an individual, it arises at any stage of life. so, it may lead to increase sample size and distribution of features required. the large datasets of fingerprint images acquired in real operational conditions are, rightly so, secured under data protection regulations that severely restrict the access to these data, even for research purposes. the fingerprints are having immense potential to have an effective method of identification. in this research, it investigates the problem of blood group identification and analysis of disease those arises with aging or disease called as lifestyle-based like hypertension, type 2-diabetes and arthritis from fingerprint by analyzing their patterns correlation with blood group and age of an individual. with the literature review study, it is observed that fingers of an individual are having multiple unique patterns those are need to be extracted with computerized method with fingerprints image captured using digital device which allow to find known association of fingerprints patterns which may enhance the authenticity of the fingerprints in blood group identification and early indication of lifestyle-based diseases of an individual. the fingerprint used as a traditional, effective, and unique identification method of an individual, in future it allows researchers to investigate with various diseases other than those are arised with age but also helps to explore different antibodies or reactive process of human body in several diseases. also, similar study helps to predict the risk of any kind of diseases in early age of an individual. the analysis and classification of community based on age, blood group, fingerprint patterns and lifestyle diseases help to tackle any pandemic in future like covid-19 in which mankind may suffer a lot having lifestylebased diseases like hypertension, type 2-diabetes. fingerprint recognition for person identification and verification based on minutiae matching finger prints pattern variation in diabetic patients analysis of left thumb print pattern among different human blood groups palmar dermatoglyphics patterns in diabetes mellitus and diabetic with hypertension patients in gangtok region comparative study of dermatoglyphic patterns of diabetes mellitus and diabetic with hypertension patients of hilly region rapid automated blood group analysis with qcm biosensors a role of dermatoglyphic fingertip patterns in the prediction of maturity onset diabetes mellitus (type ii) a handy tool for hypertension prediction: dermatoglyphics determination of blood group using image processing a study of fingerprint in relation to gender and blood group among medical students in uttarakhand region dermatoglyphics and health relation between fingerprints and different blood groups rh phenotypes analysis by spectrophotometry in human blood typing a complete blood typing device for automatic agglutination detection based on absorption spectrophotometry automatic system for determining of blood type using image processing technique automatic system for determination of blood types using image processing techniques development of a human blood type detection automatic system diagnosis of rheumatoid arthritis in knee using fuzzy c means segmentation technique. international conference on communication and signal processing ieee dermatoglyphic characteristics of patients with rheumatoid arthritis plantar and digital dermatoglyphic patterns in malawian patients with diabetes, hypertension and diabetes with hypertension an approach for minutia extraction in latent fingerprint matching fingerprint pattern examination of right hand thumb in relation to blood group efficacy of fingerprint to determine gender and blood group distribution of fingerprint patterns among medical students dermatoglyphics study of fingerprints pattern's variations of a group of type ii diabetic mellitus patients in erbil city design and development of blood sample analyzer using intelligent machine vision techniques a study on relationship between dermatoglyphics and hypertension detection of pre-diabetics by palmar prints: a computer study leading to a low-cost tool a case study on dermatoglyphics in rheumatoid arthritis approaches to determination of a full profile of blood group genotypes: single nucleotide variant mapping and massively parallel sequencing study of fingerprint patterns in type ii diabetes mellitus study of fingerprint patterns in type ii diabetes mellitus dermatoglyphics: an economical tool for prediction of diabetes mellitus a new method to assess asymmetry in fingerprints could be used as an early indicator of type 2 diabetes mellitus study of fingerprint patterns in relation to gender and blood group use of palmar dermatoglyphics in rheumatoid arthritis: a case-control study an automatic system to detect human blood group of many individuals in a parellel manner using image processing application of dermatoglyphic traits for diagnosis of diabetic type 1 patients spectrophotometric approach for automatic human blood typing development of an automatic electronic system to human blood typing the study of dermatoglyphics in diabetics of north coastal andhra pradesh population pattern of fingerprints and their relation with blood groups dermatoglyphics-quantitative analysis in rheumatoid arthritis fingertip patterns: a diagnostic tool to predict diabetes mellitus an integrated fiberoptic-microfluidic device for agglutination detection and blood typing a study of fingerprints in relation to gender and blood group finger ridge count and fingerprint pattern in maturity onset diabetes mellitus determination and classification of blood types using image processing techniques dermatoglyphics in rheumatoid arthritis dermatoglyphics in rheumatoid arthritis comparative study on the dermatoglyphic pattern among diabetic (type-2) and non-diabetic adults in north indian population dermatoglyphic patterns among type 2 diabetic adults in north indian population finger print pattern in different blood groups forensic abo blood grouping by 4 snps analyses using an abi prismr 3100 genetic analyser evaluation of abo subtyping by dna sequencing finger dermatoglyphic patterns in diabetes mellitus dermatoglyphics: a diagnostic tool to predict diabetes utility of dermatoglyphics in type ii diabetes mellitus (t2dm) to assess the risk for ihd: apilot study a study of dermatoglyphic pattern in relation to abo, rh blood group and gender among the population of chhattisgarh dermatoglyphics: blueprints of human cognition on fingerprints a cost-effective method for blood group detection using fingerprints comparative study of the fingerprint pattern among diabetic (type 1) & non-diabetic children in koya city modi"s medical jurisprudence and toxicology qualitative analysis of primary fingerprint pattern indifferent blood group and gender in nepalese study of dermatoglyphics in patients with type ii diabetes mellitus essential hypertension in the age group between 35-55 years international conference on automatic control and dynamic optimization techniques (icac-dot). international institute of information technology (i 2 it), pune, 2016 ieee tafa z, pervetica n (2015) an intelligent system for diabetes prediction the study of dermatoglyphic patterns and distribution of the minutiae in inherited essential hypertension disease comparison of dermatoglyphic patterns between healthy and hypertensive people evaluation of association between digital dermatoglyphic traits and type-2 diabetes in lagos dermatoglyphics in insulin: dependent diabetes or diabetes mellitus type 1 (t1 dm) determination and classification of blood types using image processing techniques digital grid method for fingerprint identification and objective report writing dermatoglyphic patterns of diabetic mellitus patients of ijaw origin in port harcourt dermatoglyphic and cheiloscopic patterns among diabetic patients: a study in ahmadu bello university teaching hospital zaria prediction and diagnosis of diabetes mellitus -a machine learning approach textbook of forensic medicine and toxicology predicting hypertension without measurement: a noninvasive, questionnaire-based approach key: cord-326887-lyewg2c9 authors: bloomfield, sally f.; aiello, allison e.; cookson, barry; o'boyle, carol; larson, elaine l. title: the effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers date: 2007-12-10 journal: am j infect control doi: 10.1016/j.ajic.2007.07.001 sha: doc_id: 326887 cord_uid: lyewg2c9 infectious diseases (id) circulating in the home and community remain a significant concern. several demographic, environmental, and health care trends, as reviewed in this report, are combining to make it likely that the threat of id will increase in coming years. two factors are largely responsible for this trend: first, the constantly changing nature and range of pathogens to which we are exposed and, secondly, the demographic changes occurring in the community, which affect our resistance to infection. this report reviews the evidence base related to the impact of hand hygiene in reducing transmission of id in the home and community. the report focuses on developed countries, most particularly north america and europe. it also evaluates the use of alcohol-based hygiene procedures as an alternative to, or in conjunction with, handwashing. the report compiles data from intervention studies and considers it alongside risk modeling approaches (both qualitative and quantitative) based on microbiologic data. the main conclusions are as follows: (1) hand hygiene is a key component of good hygiene practice in the home and community and can produce significant benefits in terms of reducing the incidence of infection, most particularly gastrointestinal infections but also respiratory tract and skin infections. (2) decontamination of hands can be carried out either by handwashing with soap or by use of waterless hand sanitizers, which reduce contamination on hands by removal or by killing the organisms in situ. the health impact of hand hygiene within a given community can be increased by using products and procedures, either alone or in sequence, that maximize the log reduction of both bacteria and viruses on hands. (3) the impact of hand hygiene in reducing id risks could be increased by convincing people to apply hand hygiene procedures correctly (eg, wash their hands correctly) and at the correct time. (4) to optimize health benefits, promotion of hand hygiene should be accompanied by hygiene education and should also involve promotion of other aspects of hygiene. the effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers there can be no doubt that advances in hygiene during the 19th and 20th centuries, along with other aspects of modern medicine, have combined to improve both the length and quality of our lives. however, since the middle of the 20th century, following the development of vaccines and antimicrobial therapy, and with serious epidemics of the ''old'' infectious enemies such as diphtheria, tuberculosis, and others apparently under control, hygiene has tended to lose its prominent position, and the focus of concern has shifted to degenerative and other chronic diseases. nowhere has the decline in concern about hygiene been more evident than in the home and community. however, whereas advances in medicine and public health seemed, at one time, to offer the possibility that infectious diseases (id) might soon be a thing of the past, it is now clear that this is not the case. in the past 20 years, concern about id and the need for prevention through home and community hygiene has moved steadily back up the health agenda. between 1980 and 1992, deaths attributable to id increased by 22% in the united states alone, representing the third leading cause of death among us residents. 1 two factors are largely responsible for this trend: first, the constantly changing nature and range of pathogens to which we are exposed and, secondly, the changes occurring in the community, which affect our resistance to infection. to what extent our more relaxed attitudes to hygiene practice have contributed to these trends is not known, but poor hygiene is a significant factor for a large proportion of the gastrointestinal (gi), skin, and respiratory tract (rt) infections, which make up the greatest part of the id burden. prior to approximately 1980, common pathogens such as rotavirus, campylobacter, legionella, escherichia coli (e coli) o157, and norovirus were largely unheard of. whereas methicillin-resistant staphylococcus aureus (mrsa) and clostridium difficile (c difficile) were once considered largely hospital-related problems, this is no longer the case. now, community-associated mrsa (ca-mrsa) strains are a major public health concern in north america and, increasingly, in europe. most recently, the severe acute respiratory syndrome (sars) outbreak and concerns about avian flu have raised awareness of the potential for transmission of respiratory viruses via hands and surfaces. demographic trends mean that the proportion of the population in the community who are more vulnerable to infection is increasing, whereas trends toward shorter hospital stays and care in the community also demand increased emphasis on care of ''at-risk'' groups in the home who require protection from infection. in assessing the potential for reducing id transmission through hygiene practice, it is recognized that contaminated hands and failure to practice hand hygiene are primary contributors. in this report, we review the evidence base related to the impact of hand hygiene in reducing transmission of id in the home and community. this report focuses on developed countries, most particularly north america and europe, within the context of renewed public health concerns about ids and their impact on health and well-being. the review also evaluates the use of alcohol-based hand hygiene procedures as an alternative to, or in conjunction with, handwashing. these products are defined by a number of different terms in europe and north america (hand sanitizers, handrubs, and others). for the purposes of this report, we will refer to them as alcohol-based hand sanitizers (abhs). although this report focuses primarily on the home, it is recognized that the home forms a continuum with public settings such as schools, offices, and public transport and cannot be considered totally in isolation. nevertheless, the hand hygiene practice framework proposed in this review is largely also applicable to ''out of home'' settings. this report compiles data from intervention studies and considers it alongside risk modeling approaches based on microbiologic data. currently, there is a tendency to demand that, in formulating evidence-based policies and guidelines, data from intervention studies should take precedence over data from other approaches. although there are those who still adhere to this, it is accepted increasingly that, as far as hygiene is concerned, because transmission of pathogens is highly complex and involves many different pathogens each with multiple routes of spread, decisions regarding infection control must be based on the totality of evidence including microbiologic and other data. this document is intended for infection control and public health professionals who are involved in developing hygiene policies and promoting hygiene practice for home and community settings, including those involved with food and water hygiene, care of domestic animals, pediatric care, care of elderly adults, and care of those in the home who may be at increased risk for acquiring or transmitting infection. the purpose of the review is to provide support for those who work at the interface between theory and practice, particularly those involved in developing policies for the home and community, by providing a practical framework for hand hygiene practice together with a comprehensive review of the evidence base. in recent years, a significant amount of research has been done to identify strategies for changing hygiene behavior. whereas those who manage hygiene improvements often choose to promote hygiene by educating people on the links between hygiene and health, one of the lessons that has been learned is that traditional (cognitive) approaches can raise awareness but do not necessarily achieve the desired effects. if practices such as handwashing are to become a universal norm, a multidimensional promotion that engages the public is needed to persuade people to change their behavior. although we recognize that this aspect is fundamental, it is outside the scope of this report and is reviewed elsewhere. [2] [3] [4] [5] [6] whereas, in the past, research and surveillance largely focused on health care-associated and foodborne illnesses, increasing resource is now being allocated to generating data that give a better view of the extent to which infections are circulating in the community; how they are being transmitted; and how this varies from one region, country, or community to another. although the data in the following section represent a useful overview, we note that the data collection methods differed significantly from one study to another, which means that comparisons from different geographic locations must be interpreted with care. current trends in communicable ids in europe are described in more detail in the recent (2007) european communicable disease epidemiological report from the european centre for disease prevention and control (ecdc). 7 infectious gi disease and hygiene foodborne disease. rates of foodborne illness remain at unacceptably high levels, despite the efforts of food producers to ensure the safety of the food supply. raw meat and poultry and fruits and vegetables bought at retail premises may be contaminated with pathogens. good hygiene practices during food preparation in the home are therefore essential in preventing cross contamination of prepared foods from raw foods and preventing contamination of food by infected household members or domestic animals. the european food standards agency (efsa) 2005 report 8 and the 2007 ecdc report 7 cite campylobacteriosis as the most reported animal infection transmitted to humans. in 2005, reported campylobacter infections increased by 7.8% compared with the previous year, rising to an incidence rate of 51.6 cases per 100,000 people. the efsa states that the source of most human campylobacter infections is related to fresh poultry meat. on the other hand, salmonella infections fell by 9.5% in 2005 to an incidence of 38.2 cases per 100,000 (176, 395 reported cases). the 2003 world health organization (who) report 9 concluded that approximately 40% of reported foodborne outbreaks in the who european region over the past decade were caused by food consumed in private homes. the report cites several factors as ''critical for a large proportion of foodborne diseases'' including use of contaminated raw food ingredients, contact between raw and cooked foods, and poor personal hygiene by food handlers. united kingdom data show that food poisoning notifications reached a peak in 1997-1998 and has since declined but remains in excess of 70,000 per year. 10 in reality, the burden of food poisoning is much higher because most cases go unreported; according to the uk food standards agency, 11 the true number of cases is approximately 4.7 million per year. in 1999, mead et al 12 reported on food-related illness in the united states, using data from a range of sources including national surveillance and community-based studies. they estimated that foodborne illness in the united states causes 76 million illnesses, 500,000 hospital admissions, and 9000 deaths each year. most frequently recorded pathogens were campylobacter, salmonella, and norovirus, which accounted for 14.2%, 9.7%, and 66.5%, respectively, of estimated foodborne illnesses. data suggest that the total number of reported outbreaks has not declined substantially in recent years, ranging from 980 to 1400 outbreaks and between 20,000 and 80,000 cases per year for the years 2000 to 2005. 13 other infectious gi disease. from recent investigations, it is now recognized that a substantial proportion of the total infectious gi disease burden in the community is because of person-to-person spread within households, particularly for viral infections, where it is most often the cause. person-to-person transmission in the home can occur by direct hand-to-mouth transfer, via food prepared in the home by an infected person, or by transmission because of aerosolized particles resulting from vomiting or fluid diarrhea. apart from transmission by inhalation of airborne particles, these infections are preventable by good hygiene practice. the 2003 who report 9 stated that, of the total gi infection outbreaks (including foodborne disease) reported in europe during 1999 and 2000, 60% and 69%, respectively, were due to person-to-person transmission. in the united kingdom, it is estimated that up to 50% of gi infection results from person-to-person tranmsission. 11 a study of united kingdom outbreaks 14 suggested that 19% of salmonella outbreaks and more than half of e coli o157 outbreaks are transmitted by nonfoodborne routes. national surveillance systems vary in their methods of data collection but mostly focus on foodborne disease. inevitably, this means that data on gi illnesses relate mainly to large foodborne outbreaks in restaurants, hospitals, and others, whereas sporadic nonfoodborne cases in the general community go largely unreported. in the united kingdom, even when ''household'' outbreaks are reported, they mostly involve home catering for parties and other functions and are therefore mainly foodborne outbreaks. 15 because milder cases of gi illness often go unreported, this means that the overall gi infection burden, particularly that which is not foodborne, is unknown; the most informative data on the overall burden of infectious gi illness (both foodborne and nonfoodborne) in the community come from various community-based studies, which have been carried out in europe and the united states and are reviewed below. two large community studies have been carried out in europe: one in the united kingdom and the other in the netherlands. the uk study, carried out from 1993 to 1996 involving 460,000 participants in the community presenting to general practice, estimated that only 1 of 136 cases of gi illness is detected by surveillance. the study indicated that as many as 1 in 5 people in the general uk population develop gi illness each year, with an estimated 9.4 million cases occurring annually of which about 50% are nonfoodborne. 11, 16 it was estimated that, for every 1 reported case of campylobacter, salmonella, rotavirus, and norovirus, another 7.6, 3.2, 35, and 1562 cases, respectively, occur in the community; based on the number of laboratory reports, it is possible to estimate the true number of infections occurring in the community (table 1) . from the community study carried out in the netherlands between 1996 and 1999, 17 it was estimated that approximately 1 in 3.5 people experience a bout of infectious gi disease each year. campylobacter was detected most frequently (10% of cases), followed by ghiardia lamblia (5%), rotavirus (5%), norovirus (5%), and salmonella (4%). relative to the population of the netherlands (16 million), 650,000 norovirus gastroenteritis cases occur annually. 18 the us study of mead et al, 12 which also included data from community-based studies, indicated that the total number of cases of infectious gi illness annually is approximately 210 million (of which approximately 64% are nonfoodborne). they estimated that the number of episodes of acute gastroenteritis per person per year is approximately 0.79. from the available data, the authors were also able to estimate the proportion of total episodes that were nonfoodborne. as shown in table 2 , by far the most frequently reported causes of gi illness were norovirus, rotavirus, and campylobacter. for campylobacter, e coli, and norovirus, a significant proportion of cases was estimated as nonfoodborne, whereas, for hepatitis a (hav), shigella, and rotavirus, almost all cases were estimated as nonfoodborne. for salmonella on the other hand, only 5% of cases were considered as nonfoodborne. davis et al reviewed outbreaks of e coli o157 related to family visits to animal exhibits. 19 indications are that norovirus is now the most significant cause of infectious gi illness in the developed world, both outbreak related and endemic. 20, 21 currently, we are seeing increased outbreaks of norovirus, a major concern in japan 22 and also in europe. 23 expert opinion is that norovirus strains now circulating are more ''virulent'' and more easily spread from person to person via hands and surfaces or during food handling. 20 infection with hav is common worldwide, 24 and adenovirus is also a frequent cause of gastroenteritis. c difficile-associated disease now occurs with increasing frequency in the community, in which it usually affects persons receiving antibiotic therapy but also healthy individuals. 25 recently, a new strain (027) of c difficile has emerged in north america, causing infections in the community among individuals with no predisposing factors. 25 a recent study 26 indicated that exposure to a family member with helicobacter pylori gastroenteritis was associated with a 4.8-fold increased risk of infection in another family member and that infection most usually involved person-to-person transmission, associated with conditions of crowding and poor hygiene. using data from the 2006 e coli o157:h7 outbreak in 2006 in the united states associated with contaminated spinach, seto et al developed a model that showed that secondary person-to-person transmission was similar to that in previous e coli outbreaks (12%). the model suggests that even a modestly effective hygiene promotion strategy to interrupt secondary transmission (prevention of only 2%-3% of secondary illnesses) could result in a reduction of 5% to 11% of symptomatic cases. 27 respiratory tract infections are largely caused by viruses. in the united states, viruses account for up to 69% of respiratory infections. 28 the common cold is reported to be the most frequent, acute infectious illness to humans. 29 data from the united states suggest that the mean number of respiratory illnesses experienced per year in adults is approximately 1.5 to 3.0, and, in children under 5 years of age, it is approximately 3.5 to 5.5. 28 approximately 80% of upper rt infections are caused by rhinoviruses. other species causing acute rhinitis are coronaviruses, parainfleunza viruses (piv), respiratory syncytial viruses (rsv), and adenoviruses. 30 although colds are generally mild and self-limiting, they represent a significant economic burden because of loss in productivity and medical costs. furthermore, secondary infections produce complications, such as otitis media, sinusitis, or lower respiratory infections including pneumonia, with its risk of mortality, particularly in elderly adults. several studies have demonstrated that colds are also a trigger for asthma. 31 rsv is the major cause of viral rt infection in young children worldwide. child day care attendance in north america caries with it a very high risk of rsv infection within the first 2 years of life and accounts for 0.5% to 1.0% of hospitalized infants in the united states. 32 influenza is a more serious rt illness, which can cause complications that lead to increased physician visits, hospitalization, and death, the risks being highest among persons aged .65 years, children aged ,2 years, and persons who have medical conditions (eg, diabetes, chronic lung disease). [33] [34] [35] influenza must also be considered in terms of days absent from work and school and pressure on health care services. 35 an important aspect of influenza is the threat associated with the emergence of novel subtypes capable of causing an influenza pandemic. 36 according to bridges et al, 37 influenza epidemics in the united states result in an annual average of 36,000 deaths and 114,000 hospitalizations; among those with influenza who belong to an ''at-risk'' group, a significant proportion develop pneumonia, and up to 1 in 10 can die of related complications. in europe, the 2004-2005 influenza season annual report 38 showed that, of 25 countries, 15 recorded what is regarded as high activity (150 up to 3000 influenza-like or acute respiratory illnesses per 100,000 population). although data indicating the role of hands and other surfaces in the transmission of colds have been available for some time, it is only in the last few years that there has been any real awareness that hands and surfaces may also be a transmission route for flu viruses. 32 evidence that measures such as hand hygiene can reduce spread of rt infections comes from the sars outbreaks in hong kong, which coincided with the latter part of influenza season, when it was observed that, as extensive personal and community public health measures took place, influenza case numbers fell significantly, more so than usual for the time of year. 39 skin and wound infections are common in the home and community, but most are self-limited. because these infections, apart from s aureus infections go unreported, little or no data are available on the burden of skin and wound infections in the community. s aureus is the most common cause of infections of skin and soft tissue, which, in a small proportion of cases, lead to the development of bacteremia or pneumonia. 40 serious infections usually occur in health care facilitiesin patients who are immunocompromised-in which s aureus is mostly usually associated with wounds and intravenous devices and in which the antibioticresistant strain, mrsa, is a major concern. infected patients discharged from hospitals and health care workers (hcws) caring for mrsa-infected patients can bring mrsa into the home and pass it on to healthy family members, who become colonized, thereby spreading the organism into the community and facilitating the circulation of these strains. [41] [42] [43] mrsa colonization in an individual can persist for up to 40 months. 44, 45 in recent years, mrsa has been increasingly found to cause infections in healthy members of the community without apparent risk factors. 25 these ca-mrsa strains are different from health care-associated (hca) mrsa strains and are a concern because they equally infect children and young adults. these strains primarily cause skin and soft tissue infections but can also cause invasive infections such as sepsis, pneumonia, and osteomyelitis, which is some cases can be fatal. 25 some ca strains are known to produce panton-valentine leukocidin (pvl), which has been implicated as a virulence factor, 46 although opinion is, however, divided as to whether this is the case; whereas some studies support this notion, 47 others do not. 48 in the united states, ca-mrsa is now a significant concern. ca-mrsa strains have also now been detected in france, switzerland, germany, greece, the nordic countries, australasia, the netherlands, and latvia. 25 in the united kingdom, cases of ca-mrsa and pvlproducing strains have been reported, but the number of reported cases is still small. 25, 49 within the global population that affect our resistance to infection.''at-risk'' groups cared for at home include not only newborn infants whose immune system is not fully developed but also the rapidly increasing elderly population whose immune system is declining. ''atrisk'' groups include patients discharged recently from hospital, immunocompromised family members, and family members with invasive devices such as catheters. it also includes people whose immunocompetence is impaired as a result of chronic and degenerative illness or because they are undertaking certain drug therapies. all of these groups, together with those who carry hiv/aids, are increasingly cared for at home by a caregiver, who may be a household member. a survey of the united states and 3 european countries-germany, the netherlands, and the united kingdom-suggests that up to 1 in 5 of the population belongs to an ''at-risk'' group (table 3) . the data suggest that between 12% and 18% of the population of these countries are .65 years of age. in an intervention study of 148 patients with aids, it was found that patients assigned to the intensive handwashing intervention group developed fewer episodes of diarrheal illness (1.24 6 0.9 vs. 2.92 6 0.6 new episodes of diarrhea, respectively, during a 1-year observation period. 50 gi pathogens are now implicated as causative or contributory factors in the development of cancers and other chronic conditions; examples include hepatitis b virus (hepatocelluar carcinoma), 51 h pylori (peptic ulcer disease), 52 and campylobacter jejuni (guillain barrã© syndrome). 53 foodborne illness has been estimated to result in chronic sequelae in 2% to 3% of cases 54 ; a european commission report 55 cites evidence of chronic disease, such as reactive arthritis, following 5% of salmonella cases, with 5% of e coli o157 cases progressing to serious and even fatal complications. even mild viral infections can be predisposing factors to more severe and possibly fatal secondary bacterial infections. 56 in devising a strategy for home hygiene and producing hygiene practice advice, the international scientific forum on home hygiene (ifh) has developed an approach based on risk management that involves identifying the ''critical control points'' for preventing the spread of id in the home. risk management (also known as hazard analysis critical control points [haccp] ) is now the standard approach for controlling microbial risks in food and other manufacturing environments and is becoming accepted as the optimum means to prevent such risks in home and hospital settings. 57 the key feature of the ifh approach is that it recognizes the need to look at hygiene from the point of view of the family and the total range of problems it faces to reduce id risks, including food hygiene, personal hygiene (particularly hands) and hygiene related to the general environment (toilets, baths, hand basins, surfaces, and others), domestic animals, and family members at increased risk. adopting a holistic approach makes sense because all these issues are interdependent and based on the same underlying microbiologic principles. haccp also forms the basis for developing an approach to home hygiene that can be adapted to meet differing needs. indeed, it is only by adopting such a holistic approach that the causal link between hands and infection transmission in the home can be addressed properly because hand hygiene is a central component of all these issues. the ifh risk management approach to hygiene starts from the principle that pathogens are introduced continually into the home by people (who may have infection or may be asymptomatic), food, and domestic animals and also sometimes via the water or the air. additionally, sites at which stagnant water accumulates, such as sinks, toilets, waste pipes, or items, such as cleaning or face cloths, readily support microbial growth and can become a primary reservoir of infection; although microbial species are mostly those that represent a risk to vulnerable groups, primary pathogens can also be present. 58 so long as there are people, pets, and food in the home, there will always be the risk of pathogenic microbes. in many homes, there will also be at least one family member who is more susceptible to infection for one reason or another. within the home, there is a chain of events, as described in fig 1, that results in transmission of infection from its original source to a new recipient. to an extent, we can limit the exit and entry of pathogens from and into the body, but the link that we have most control over is that related to the ''spread of pathogens.'' the spread of infection can be interrupted by good hygiene practice, which includes adherence to hand hygiene recommendations and cleaning and disinfecting contaminated environmental surfaces. the risk-based approach to home hygiene is described in more detail by bloomfield and scott 59 and bloomfield. 60 they suggest that sites and surfaces in the home should be categorized into 4 main groups: reservoir sites, reservoir/disseminators, hands and hand and food contact surfaces, and other surfaces. risk assessment is then based on the frequency of occurrence of pathogenic contamination at that site, together with the probability of transfer from that site such that family members may be exposed. this means that, even if a particular environmental site is highly contaminated, unless there is a high probability of transfer from that site, the risk of infection transmission is low. from this, it is possible to determine the ''critical control points'' for preventing spread of infection. the data suggest the following: d for reservoir sites such as the sink waste pipes or toilets, although the probability of contamination (potentially pathogenic bacteria or viruses) is high, the risk of transfer is limited unless there is a particular risk situation (eg, a family member with enteric infection and fluid diarrhea, when toilet flushing can produce splashing or aerosol formation that can settle on contact surfaces around the toilet). 58,61 d by contrast, for reservoir sites such as wet cleaning cloths, not only is there high probability of significant contamination, but, by the very nature of their usage, they carry a high risk of disseminating contamination to other surfaces and to the hands. d for hands and hand contact and food preparation surfaces, although the probability of contamination is, in relative terms, lower, it is still significant, for example, particularly following contact with contaminated food; people; pets; or other contaminated surfaces such as door, faucet, and toilet-flush handles. because there is a constant risk of spread from these surfaces, hygiene measures are important for these surfaces. d for other surfaces (floors, walls, furniture, and others), risks are mainly due to pathogens such as s aureus and c difficile, which survive under dry conditions. because the risks of transfer and exposure are relatively low, these surfaces are considered low risk, but where there is known contamination, for example, soiling of floors by pets, crawling infants may be at risk. cleaning can also recirculate dust-borne pathogens onto hand and food contact surfaces. overall, this approach allows us to rank these various sites and surfaces (fig 2) according to the level of transmission risk; this suggests that the ''critical control points'' for breaking the chain of infection are the hands, together with hand and food contact surfaces, cleaning cloths, and other cleaning utensils. however, although this is a useful ''rule of thumb'' ranking, it is not a constant. for example, although risks from toilets, sinks, floors, and others relate mainly to the relatively lower risk of transfer from these sites to hands, hand and food contact surfaces, and cloths, this risk can increase substantially during occasions when an infected family member has fluid diarrhea or when a floor surface is contaminated with vomitus, urine, or feces. in the following section, we evaluate data indicating the extent to which the hands, both alone and in combination with other surfaces, are responsible for the spread of infection. the criteria for assessing causal inference of a link between hygiene practice and id risk reduction have been reviewed by aiello and larson. 62 establishing the potential health impact of a hygiene intervention such as hand hygiene requires examination of the evidence related to a range of criteria that should include the strength, consistency, and temporality (cause and effect) of the association, together with data on plausibility (biologic or behavioral rationale) and biologic gradient. aiello and larson recognize that, although a single factor such as the hands may be a ''sufficient cause'' of infection transmission, spread of infection frequently involves a number of ''component causes,'' which, together or independently, work to determine the overall risk. the risk assessment approach, as outlined above, indicates that the ''critical control points'' or ''component causes'' of infection transmission in the home are the hands, together with hand and food contact surfaces and cleaning cloths. based on plausibility, the role of the hands relative to other surfaces can be understood by mapping the potential routes of spread of gi, rt, and skin infections in the home as shown in fig 3. this suggests that, for all 3 groups of infections, the hands are probably the single most important transmission route because in all cases they come into direct contact with the known portal of entry for pathogens (the mouth, nose and, conjunctiva of the eyes) and are thus the key last line of defense. figure 3 shows, however, that, although in some cases the hands alone may be ''sufficient cause'' for transmission of an infection (eg, from an mrsa carrier, to hands, to the wound of a recipient), in other cases transmission involves a number of component causes (eg, from contaminated food, to a food contact surface, to hands, to the mouth of a recipient). what this means is that the transmission risk via the hands also depends on the extent to which surfaces become contaminated with pathogens during normal daily activities, ie, the risk of hand-to-mouth transfer will be increased if extensive transfer from raw food to food preparation surfaces also occurs. defining the importance of hand hygiene relative to other hygiene practices, such as surface and cloth hygiene, is difficult because of the close interdependence of these factors. although the focus of this review is the prevention of infection through hygiene practice, fig 3 shows that in some cases airborne transmission can operate independently, without involving the hands, whereas, for gi infection, transmission can operate independently via food. although handwashing intervention studies provide data supporting the causal link between hand contamination and id transmission, defining the importance of hand hygiene relative to other hygiene practices, such as surface and cleaning cloth hygiene, or the risks associated with airborne transmission is difficult because of the close interdependence of these factors. currently, such assessments can only be made on a qualitative basis, using microbiologic data (as in the following section) together with some limited epidemiologic data. in this section, we present epidemiologic and microbiologic data to support the causal relationship between hygiene and id risk. because the risks of hand transfer increase as the risks of contamination of other surfaces increases, data related to relevant surfaces are also included. in recent years, a range of studies has been published, many related specifically to the home, which indicate the extent to which id agents occur and are spread in home and community settings during normal daily activities and their potential to cause infection. these studies include assessments of frequency occurrence of sources of pathogens in the home, their rate of ''shed'' from an infected source into the environment, their rate of die away on hands and other surfaces, their rate of transfer via the hands to the mouth, nose, conjunctiva, and others and/or to ready-to-eat foods, and their the infectious dose. the infectious dose (ie, the number of particles to which the recipient is exposed), their immune status, and the route by which they are infected are key factors that determine the infection risk. the ''infectious dose'' varies for different pathogens and is usually lower for people who are ''at-risk'' than for healthy household members. transmission of infectious gi disease. risks from exposure to gi pathogens via the hands. as shown in fig 3 , exposure to gi pathogens can occur by direct hand-to-mouth contact or indirectly via contaminated food. in the home, food can be contaminated either directly by an infected food handler or indirectly by cross contamination via hands and surfaces from another source, which may be contaminated food, another infected household member (or carrier), or a household pet or farm animal. hand-to-mouth contact is a frequent occurrence, particularly among children; a study of mouthing behavior in 72 young children showed that children ,24 months of age exhibit the highest frequency, with 81 events/hour; for children .24 months of age, this was reduced but was still of the order of 42 events/hour. 63 the potential for transmission of pathogens from hands to ready-to-eat foods is supported by a number of studies: d in a model domestic kitchen, 29% of food preparation sessions using campylobacter-contaminated chicken resulted in positive campylobacter isolations from prepared salads, cleaning materials, and food contact surfaces. 64 d bidawid et al 65, 66 showed that touching lettuce with finger pads contaminated with hav and feline calicivirus (fcv), used as a surrogate for norovirus, for 10 seconds resulted in transfer of 9.2% and 18%, respectively, of the virus. based on the load for hav in feces (10 6 to 10 9 viral particles/g), an estimated 1300 particles were transferred to the lettuce. d rusin et al showed that, when volunteers' fingertips were inoculated with a pooled suspension of micrococcus luteus (m luteus), serratia rubidea (s rubidea), and bacteriophage prd-1 and held to the lip area, transfer rates were 40.99%, 33.97%, and 33.90%, respectively. 67 as stated above, the infection risk from oral consumption depends on the number of bacterial cells or viral particles that are consumed. table 4 shows that, for many of the commonly occurring gi pathogens, the infectious dose is relatively small. sources and spread of gi pathogens to the hands. figure 3 illustrates that the risk of exposure to gi pathogens via the hands depends on the extent to which these pathogens are brought into the home (either by infected people or pets or via contaminated food) and the extent to which they are spread via hands and other surfaces and by airborne transmission. relevant data from various sources, as summarized below, suggest that exposure to gi pathogens via the hands is a frequent occurrence during normal daily activities and that the numbers of organisms transferred by handto-mouth contact can be well within the numbers required to cause infection. household members who are infected, or who are carriers, are a primary source of infection in the home. pathogens that can be carried persistently by otherwise healthy people include salmonella species and c difficile. approximately 3% of adults (mainly those .65 years of age), and up to two thirds of babies, are known to carry c difficile in their gut, although it is not known what proportion are toxin producing. 25 people or animals that carry gi pathogens shed large numbers of organisms in their feces or when they vomit. a single vomiting incident following norovirus infection may produce 30 million viral particles, 72 and, at the peak of a rotavirus infection, .10 11 virions may be excreted per gram feces. 74 surfaces in the home may become contaminated by enteric organisms that are aerosolized during vomiting or by transfer of vomitus and fecal matter via hands. viruses aerosolized from flushing the toilet can remain airborne long enough to contaminate surfaces throughout the bathroom. 75 infectious agents introduced into the home via food include salmonella, campylobacter, listeria, and e coli o157. a variety of foods can act as a source of these organisms, including meat, fish and poultry products, dairy products, fruits, and vegetables. organisms in particles, and moisture or juices, from food will contaminate any surface they come into contact with. an salmonella species up to 10 6 but could be as low as 10-100 cells. 68 contamination may be amplified by transfer to foods, which are then stored incorrectly. campylobacter species 500 organisms can result in human illness. 69 oral dose for e coli 0157 may be as little as 10 cells. 70 in one outbreak, a median dose of ,100 organisms per hamburger was reported. 71 norovirus 10-100 units or even less. 72 may be as few as 10 particles. 73 ward et al showed that 13 of 14 adults became infected after consuming rotavirus (10 3 particles) picked up from a contaminated surface via the hands. 73 efsa survey 76 of salmonella in chicken indicates significant differences among eu member states, with isolation rates between 0% and 68.2%; the level reported for the united kingdom was 7.1% to 9.4%. the efsa also reported that up to 66% of samples from fresh poultry were positive for campylobacter. 77 in the united states, more than half of raw chicken is estimated to be contaminated with camplylobacter. 76 chapman et al 78 showed that 0.4% to 0.8% of meat products purchased from uk butchers were positive for e coli o157. in a recent study in canada, c difficile was isolated from 20% of 60 samples of retail ground meat purchased over a 10-month period, and 11 isolates were toxigenic. 79 the home is frequently a shelter to a range of different pets; more than 50% of homes in the englishspeaking world have cats and dogs, with 60 million cats and dogs in the united states. in the united states, up to 39% of dogs may carry campylobacter, and 10% to 27% may carry salmonella 80 ; cats are also carriers of these organisms. carriage of c difficile in household pets is quite common; up to 23% of pets are affected, although these mostly involve noncytotoxigenic strains. 25 kramer et al, 81 sattar et al, 82 and rzezutka and cook 83 reviewed data showing that gi pathogens can survive on surfaces for several hours and, in some cases, days, particularly on moist surfaces, although infectivity depends on the numbers that survive (table 5) . studies to quantify transfer between hands, foods, and kitchen surfaces 67, 84 showed that transfer rates were highly variable, ranging from as high as 100% to as low as 1%. transfer to hands was highest from nonporous surfaces but lower from surfaces such as carrots, sponges, and dishcloths (,1%). rusin et al 67 sampled volunteers hands after touching surfaces contaminated with m luteus, s rubidea, and phage prd-1. activities included wringing out a dishcloth/sponge, turning off a faucet, cutting up a carrot, making hamburger patties, holding a phone receiver, and removing laundry from the washing machine. transfer efficiencies for the phone receiver and faucet were 38% to 65% and 27% to 40%, respectively. paulson 85 showed that, when gloved hands were contacted for 5 to 10 seconds with surfaces such as cutting boards and doorknobs contaminated with fcv (log 5.9 particles), the log number of particles recovered from hands was 4.7 to 5.4. these laboratory studies are supported by a range of field studies showing spread via the hands and other surfaces during normal daily activities: d following preparation of salmonella and campylobacter-contaminated chickens in domestic kitchens, these species were isolated from 17.3% of hands and hand and food contact surfaces. isolation rates were highest for hands, chopping boards, and cleaning cloths (25%, 35%, and 60%, respectively, of surfaces sampled). 86 d in homes containing an infant recently vaccinated for polio (during which time shedding occurs in feces), virus was isolated from 13% of bathroom, living room, and kitchen surfaces. 87 most frequently contaminated were hand contact sites such as bathroom taps, door handles, toilet flushes, soap dispensers, nappy changing equipment, and potties. d following handshaking with a volunteer whose hands were contaminated from touching a viruscontaminated door handle, successive transmission from one person to another could be followed up to the sixth person. 88 d where fingers were contacted with noroviruscontaminated fecal material, the virus was consistently transferred via the fingers to melamine surfaces and from there to hand contact surfaces, such as taps, door handles, and telephone receivers. contaminated fingers sequentially transferred the virus to up to 7 clean surfaces. 89 d a study 90 with fcv showed survival for up to 3 days on telephone buttons and receivers, for 1 or 2 days on computer mouse, and for 8 to 12 hours on keyboard keys and brass disks representing faucets and door handles. the time for 90% virus reduction was ,4 hours on computer keys, mouse, and brass disks; 4 to 8 hours on telephone receivers; and 12 to 24 hours on telephone buttons. d in homes of infants with recurrent c difficile infection, 12% of environmental surfaces were positive for c difficile, and 1 of 4 other household members carried c difficile in stool. in a control home with no household carriers, none of 84 environment samples were positive for c difficile. 91 d in 4 out of 6 homes in which there was a salmonella case, the causative species was isolated from fecal soiling under the flushing rim and scale material in the toilet bowl for up to 3 weeks after notification of infection. 58 flushing toilets seeded with salmonella enteritidis resulted in contamination of hand contact surfaces such as toilet seats and toilet seat lids. these represent recent examples of studies that have been reported. these and other studies are also reviewed elsewhere. 82, [92] [93] [94] in developing hygiene policies for preventing gi infections, one of the difficulties is assessing risks associated with hand transmission relative to other risks such as inadequate cooking or storage of food or inhalation of infected vomit particles. gillespie et al 15 reported an evaluation of reported outbreaks linked to uk households for 1992 to 1999 that suggested, of the 85% of outbreaks designated as foodborne, cross contamination was implicated in 20% of outbreaks compared with 30% and 31% of outbreaks for which inadequate storage and cooking, respectively, were thought to be the cause. there were no data to suggest what percentage of cross contamination events involved the hands, and gillespie et al 15 expressed concern that most of the reported outbreaks were linked to home catering, thus not necessarily representative of normal daily routine. aerosol transmission can result from settling on hand and food contact surfaces, but, for norovirus, infection can sometimes result from direct inhalation of infected particles of vomit by people immediately adjacent to the person who vomits. the potential for airborne transmission of norovirus was demonstrated in studies in a restaurant and a primary school, in which close proximity to infected persons in the immediate aftermath of a vomiting attack was identified as a risk factor. 95, 96 transmission of rt infections. the last 2 years have seen an unprecedented global focus on developing strategies for preventing transmission of influenza. the who 97 is taking a lead on pharmaceutical interventions such as vaccines and antivirals but has also made recommendations for other interventions, 98 which include highlighting the importance of hygiene, and in particular hand hygiene, in minimizing spread in the home and community. risks from exposure to respiratory pathogens via the hands. as shown in fig 3, exposure to rt viruses can occur either by inhalation of infected mucous or inoculation of the nasal mucosa or eyes with viruscontaminated hands, which then cause infection via the mucous membranes and upper rt. rhinovirus and rsv are deposited into the front of the nose or into the eye (where they pass down the lacrymal duct), either on the end of the finger or possibly sometimes in aerosolized droplets. 99 rubbing the eyes and nose with the fingertips is a common occurrence; hendley et al found that 1 in 2.7 attendees of hospital rounds rubbed their eyes, and 33% picked their nose, within a 1-hour observation period. 100 a review of the data 94 (table 6 ) suggests that the infectious dose for respiratory viruses is relatively small. alford et al suggest that aerosolized doses of as little as 1 tcid 50 (tissue culture infective dose) of influenza virus could infect volunteers. 101 evidence for transmission of rhinovirus and rsv infections via contaminated hands comes from a number of studies: d a number of studies have demonstrated that selfinoculation by rubbing the nasal mucosa or conjunctivae with rhinovirus-contaminated fingers can lead to infection. 100, 102 over a period of 10 years, gwaltny and hayden performed intranasal challenges on 343 healthy young adults who had no antibody to the challenge, and infected 321 (95%). 103 after handling contaminated coffee cups and other objects, more than 50% of subjects developed infection. 104 hall et al showed that volunteers touching contaminated objects and/or the fingers of symptomatic individuals had a higher attack rate of colds if they touched their eyes or nose. 105 d in a 4-year family trial, hendley and gwaltney 104 found that prophylactic treatment of mothers' fingers with iodine reduced the incidence of rt infections. when illness occurred in the family, mothers were instructed to dip their fingers in iodine upon awakening in the morning, then every 3 or 4 hours or after activities that washed the iodine from the skin. the secondary attack rate in mothers was 7% in the iodine group and 20% in placebo families. no infections occurred in mothers after 11 exposures to an infected index case in the iodine group, compared with 5 infections after 16 exposures in the placebo group. d hall et al showed that infected infants excrete prodigious amounts of rsv in their nasal secretions for several days 105 and that rsv could be recovered from hands that had touched surfaces contaminated with secretions from infected infants. 99 hall and douglas found that close contact with symptomatic infants who were producing abundant secretions, or their immediate environment, was necessary for infection. 106 sources and spread of rt pathogens to the hands. figure 3 illustrates that the risk of exposure to rt pathogens via hands depends on the extent to which these pathogens are spread from an infected person during normal daily activities. relevant data come from various sources and are summarized below. taken together, the data suggest that, when a household member is infected, exposure of other household members via hands is likely to occur during normal daily activities and that the numbers of organisms involved are within those required to initiate infection if transferred to the eyes or nose. people infected with cold viruses shed large quantities of virus-laden mucus. droplets of nasal secretions generated by coughing, sneezing and talking can travel over a distance .3 m to contaminate surrounding surfaces. 37, 98, [107] [108] [109] up to 10 7 infectious influenza particles per milliliter has been detected in nasal secretions. 110 the mean duration of a cold is 7.5 days. viral shedding may occur 24 to 48 hours before illness onset but generally at lower titers than during the symptomatic period. titers generally peak during the first 24 to 72 hours of illness and decline within several days, with titers low or undetectable by day 5. children can shed virus for up to 3 weeks, whereas immunocompromised people may continue to shed virus for weeks to months. 98 infectious material can also be deposited directly on hands and tissues during sneezing and blowing the nose. contamination of hands can occur by handshaking or touching contaminated surfaces. pathogens shed into the environment from these sources can survive for significant periods and are readily spread around the home to and from the hands and via handkerchiefs and tissues, tap and door handles, telephones, or other hand contact surfaces: d gwaltney and hendley demonstrated that most subjects with experimental colds had rhinovirus on their hands and that virus could be recovered from 43% of plastic tiles they touched. 104 for people with rhinovirus colds, virus was found on 39% of hands and 6% of objects in their immediate environment. 100 opinion as to the importance of the hands relative to the airborne route for transmission of rhinovirus colds is divided. some investigators 30, 99, 103, 104 maintain that contamination of the hands followed by inoculation of the eyes or nose is of paramount importance; in fact, gwaltney et al found that it was exceedingly difficult to transmit virus orally or by kissing and found little evidence of droplet or droplet nuclei transmission. 100, 113 others maintain that the evidence favors droplet and droplet nuclei transmission as the most important mode of spread. 118 for rsv, there is general agreement that the hands are the primary route for the spread of infection. 32, 105, 106 for influenza, although more data are needed, it is increasingly accepted that not only airborne (both true airborne transmission involving droplet nuclei [,5 mm in diameter] and ''droplet transmission'' involving droplets .10 mm that deposit onto surfaces quite rapidly) but also surface (including hand) transmission come into play. 98, 119, 120 the relative contribution of each mode of transmission is unknown but appears to vary depending on the circumstances, symptoms, respiratory tract loads, and the viral strain. 121 data from animal studies and influenza outbreaks suggest that droplets generated when infected persons cough or sneeze are the predominant mechanism of airborne transmission, 37 although data supporting droplet nuclei spread are also available. 101, [122] [123] [124] it is possible, however, that influenza is less transmissible via hands and surfaces compared with rhinovirus and others because of its lower ability to survive outside a human or animal host. data suggest that, to some extent, airborne droplets and droplet nuclei cause infection as a result of settling on hand contact surfaces. the frequent occurrence of diarrhea and the detection of viral rna in fecal samples tested suggest that the h5n1 influenza virus may replicate in the human gut and could be a source of transmission via hands and surfaces. 125 at present, however, it is thought that this is unlikely. the growing evidence base related to the survival, transmission, and human exposure to rt viruses via hands and other surfaces is also reviewed elsewhere. 32, 35, 37, 82, 94, 99 transmission of skin and wound infections. risks from exposure to skin and wound pathogens via the hands. as shown in fig 3, exposure to skin pathogens such as s aureus can occur via the hands. exposure can produce colonization and/or infection that usually occurs in areas in which there are cuts, abrasions, and others that damage the integrity of the skin. where there are predisposing factors, the numbers of organisms required to produce infection may be relatively small. marples 126 showed that up to 10 6 cells may be required to produce pus in healthy skin, but as little as 10 2 may be sufficient in areas in which the skin is occluded or traumatized. risks associated with exposure to hca-mrsa and ca-mrsa are different. hca-mrsa usually affects elderly adults and those who are immunocompromised, particularly those with surgical or other wounds or who have indwelling catheters. for ca-mrsa, those at particular risk appear to be younger, generally healthy people who practice contact sports or other activities that put them at higher risk of acquiring skin cuts and abrasions. 127 us experience suggests that ca-mrsa may be more virulent than other strains and is easily transmissible within households and community settings (eg, schools, day care centers, sport teams) in which skin-to-skin contact or sharing of contaminated items (eg, towels, sheets and sport equipment) are vehicles for person-to-person transmission. 128 a case-control study 129 involving 55 cases of mrsa in a us prison showed that inmates who washed their hands #6 times per day had an increased risk for mrsa infection compared with inmates who washed their hands .12 times per day. sources and spread of skin and wound pathogens to the hands. figure 3 illustrates that the risk of exposure to skin pathogens via the hands depends on the extent to which people or animals colonized or infected with pathogenic strains are present in the home and the extent to which these pathogens are spread during normal daily activities. transfer of skin pathogens to the hands can occur either by direct contact with an infected source or indirectly via hand contact surfaces or the surfaces of clothing or household linens. relevant data, as outlined below, suggest that, when there is a person in the home who is infected or colonized with s aureus, exposure of other household members as a result of transfer via hands, surfaces, clothing, and others is likely to occur during normal daily activities and that the numbers of organisms involved are within the numbers of particles that could initiate an infection in a susceptible recipient. a study by kluytmans et al suggests that s. aureus is carried as part of the normal body flora in up to 60% of the general population, 130 although a 2006 us study 131 suggests that the carriage rate is much less (31.6%). in the united kingdom, indications are that the proportion of the general population carrying antibiotic-resistant strains of s aureus (either hca-or ca-mrsa) is somewhere between 0.5% and 1.5%, the majority being carriers of hca-mrsa who are .65 years of age and/or have had recent association with a health care setting. 132 although cases of ca-mrsa and pvlproducing mrsa have been reported, indications are that the prevalence of mrsa and pvl-producing strains circulating in the community is currently very small. 25 in the united states, although it is concluded that colonization rates for mrsa in the community are still low, it is nonetheless thought to be increasing. 127, 133 graham et al 131 report on an analysis of 2001-2002 data from the national health and nutrition examination survey (nhanes) to determine colonization with s aureus in a noninstitutionalized us population. from a total of 9622 participants, it was found that 31.6% were colonized with s aureus, of which 2.5% were colonized with mrsa. of persons with mrsa, half were identified as strains containing the sccmec type iv gene (most usually associated with ca-mrsa), whereas the other half were identified as strains containing the sccmec type ii gene (most usually associated with hca-mrsa). several other investigators have examined the epidemiology of mrsa in the us community; differences in the data suggest a sporadic distribution of ca-mrsa, with carriage rates ranging from 8% to 20% in baltimore, atlanta, and minnesota 127 up to 28% to 35% for an apparently healthy population in new york. 134 domestic pets can also be a source of s aureus, including mrsa and pvl-producing strains. [135] [136] [137] [138] [139] manian 136 described 2 dog owners suffering from persistent mrsa infection, who suffered relapses whenever they returned home from the hospital; further investigation revealed that the dog was carrying the same strain of mrsa. people who carry s aureus can shed the organism in large numbers most usually associated with skin scales. 140 kramer et al 81 review data showing that s aureus (including mrsa) can survive on dry surfaces for periods from 7 days up to 7 months. scott and bloomfield showed that, during a 4-hour drying period, up to 50% of s aureus inoculated onto laminate could be transferred to fingertips by contact. transfer to fingertips also occurred when a cloth contaminated with s aureus was used to wipe a clean surface. 141 studies in health care settings, as reviewed by bloomfield et al, 25 147 found that transmission of the mrsa strain from an index case to 2 siblings and the mother occurred at least 3 times, and one family member was colonized for up to 7 months or more. these represent recent examples of studies that show survival and transfer of mrsa around the home. these and other studies are also reviewed by bloomfield et al. 25 intervention studies to establish the causal link between hand hygiene and infectious disease in the home and community both observational and interventional study designs have been used to assess the relationship between hand hygiene and id transmission. by definition, observational studies are not randomized and must utilize careful methods to preserve internal validity. control of confounding and the potential for selection, recall, and other biases are also a concern, for example, individuals who wash their hands less frequently are also less likely to report symptoms. intervention studies on the other hand compare infection rates in groups in which handwashing is, or is not, promoted. intervention studies employing randomization of treatment groups have been considered the ''gold-standard'' in terms of reducing selection biases. these studies have the ability to ensure that randomized groups are similar, apart from treatment allocation and differences that occur by chance. for these reasons, we limit discussion to intervention studies, focusing on gi and rt illnesses, because these are the most common infectious illness symptoms in home and community settings. a range of intervention studies have been carried out to evaluate the causal link between handwashing and id transmission and have been reviewed in a series of papers to assess the consistency and strength of the link. [151] [152] [153] overall, these studies indicate a strong and consistent link between handwashing and gi disease and a significant link between handwashing and rt illnesses. for the most part, these studies have been carried out in child day care centers, schools, and military and other public settings in which the outcome is often measured against a high baseline level of infection. relatively few studies have been carried out in household settings in the united states and europe. difficulties associated with studying households in developed areas include fewer children under the age of 5 years, higher level of hygiene infrastructure, and difficulties in collecting data. given that there are likely fewer susceptible individuals clustered within household settings, the prevalence of gi and rt illnesses is relatively much lower, making it more difficult to detect a significant influence of hand hygiene on the occurrence of illness. whereas some intervention studies are not relevant to this review and have been omitted, others give useful insight into the potential impact of handwashing in the home and in the general community. studies that are included have been selected on the basis of whether transmission routes are likely to reflect those in the home, most particularly whether the relative rates of transmission via these routes (as shown in fig 2) are likely to be similar. for this reason, studies on gi infection in developing countries have been excluded; in these settings, limited access to sanitation means that rates of direct hand-to-mouth transmission from feces is high relative to other routes of transmission (eg, person-to-person transmission via hands, or inadequate food hygiene), compared to settings with adequate water and sanitation in which transmission is more likely to involve person-to-person transmission and transmission via food, rather than direct feces-to-hand-to-mouth. for gi illnesses, we have, therefore, focused on studies carried out in developed country communities, although, even for studies such as those in child daycare centers, in which food preparation is not undertaken by study participants, the data probably reflect mainly the impact on person-to-person transmission. for rt infections, studies conducted in both developed and developing countries are included on the basis that relative rates of airborne transmission versus transmission via hands are likely to be similar regardless of setting. in a recent review, aiello et al assessed the relationship between handwashing and gi outcomes 154 focusing on studies conducted in north america and europe. table 7 summarizes studies providing an effect estimate (risk ratio, rate ratio, and others) as well as 95% confidence intervals (95% ci). in all of the studies, handwashing with soap was the factor studied, although in some, this was combined with hygiene education measures. all studies assessing handwashing and hand hygiene education were conducted in school or day care settings. among the studies in table 7 , the reduction in gi illness associated with handwashing ranged from 210% to 157%. however, 3 of the 5 studies were not statistically significant, including the study that identified a value of 210%. the studies that gave statistically significant results all describe reductions close to 50%. overall, these reviews suggest a consistent causal relationship between handwashing and reduction in gi illness, although the findings are less consistent and of a lesser magnitude than in lesser developed settings in which studies considered statistically significant suggested reductions from 26% to 79%. 154 in assessing rt infections, the reviews of aiello and larson 151 and aiello et al, 154 mentioned above, 161 they reported that hand hygiene (handwashing, education, and waterless hand sanitizers) can reduce the risk of respiratory infection by 16% (95% ci: 11%-21%). these investigators have now updated their estimate with 2 further, more recent, studies that, when all studies are taken together, give a pooled impact on respiratory infection of 23%. 162 based on these studies, table 8 summarizes the results of community-based interventions (excluding health care-related and military settings) on rt illnesses. most studies were conducted in economically developed countries (83%, 5/6). the range of reduction in illness was 5% to 53%, but only 33% (2/6) of the studies were statistically significant. the results suggest that hand hygiene education and promotion of handwashing can reduce rates of rt illnesses, but the impact is less than for gi infections, although it must be borne in mind that the available data are more limited. 154 there are also several studies of handwashing that do not distinguish between gi and rt outcomes. 157, 167, 168 these studies measure outcomes such as illness-related absenteeism, making it difficult to assess the impact on specific disease etiologies. of these studies, only one reported a significant reduction (25%). 157 two were conducted in day care centers, and 1 was conducted in an elementary school. all 3 studies were conducted in economically developed areas (united states, sweden, and israel). 157, 167, 168 several methodologic issues must be considered for these studies. studies that use randomization are more likely to produce study groups with similar baseline characteristics. surprisingly, 40% of the 11 studies in tables 7 and 8 did not randomize. in some studies, randomization may not be an option (eg, in community settings) because the intervention is too complicated to randomize to multiple groups rather than assigning it to a single geographic area. controlling for potential confounding variables is also an important issue, for example, if a study did not control for age and included adults as well as children, the effect of a hygiene intervention may be diluted because adults are at lower risk for diarrheal disease compared with children. in randomized studies, adjustment for confounding in the statistical analysis may not be required if potential confounders associated with intervention and control groups appear balanced, for example, randomization of households in the same geographic area may produce intervention and control arms with the same age distributions, hygiene habits, and health profiles. as summarized in table 9 , of the 11 studies, only 50% (9/18) reported controlling for at least 1 potential confounding factor. although masking (also known as blinding) can be difficult to implement in hygiene studies because subjects, observers, and interviewers are usually aware of the intervention status, a few studies (2/18) were able to employ masking to reduce knowledge of the intervention. masking can reduce biases associated with knowledge of intervention, including changes in behaviors, practices, and data collection methods. for intervention studies, disregarding clustered sample design may cause bias. for example, a handwashing program in a day care center may affect a child's risk of disease through its individual-level effect (the effect of handwashing of a child on his or her own risk of disease) and through its group-level effect (the effect of centerwide handwashing on risk of disease, even if the child is not following the handwashing program). clustered interventions must take into account the grouped data structure in subsequent analyses or must analyze data at the in the section above, which describes the development of a risk-based approach to home hygiene, we evaluated how pathogens are introduced into the home and the chain of events that can lead to healthy household members becoming infected. an assessment of the microbiologic data related to each stage of the infection transmission cycle suggests that the critical control points for preventing the spread of infection in the home are the hands, hand contact surfaces, food contact surfaces, and cleaning cloths and utensils. intervention at the appropriate time (eg, during raw food handling, rather than as part of daily routine cleaning) is an equally fundamental part of a riskbased approach to hygiene. in practice, pathogens may be transmitted by more than one route, and it is impossible to achieve 100% hand hygiene compliance. therefore, interventions to reduce id transmission in the home must be multifaceted. key to preventing infection transmission via the hands (and other surfaces) is the application of effective hygiene procedures. because the evidence reviewed in the earlier sections shows that the ''infectious dose'' for many common pathogens such as campylobacter, norovirus, and rhinovirus can be very small (1-500 particles or cells), intuitively one must argue that, in situations in which there is significant risk, the aim should be to get rid of as many organisms as possible from critical surfaces. organisms can be removed from hands and other surfaces by the following: d physical removal using soap or detergent-based cleaning; or d microbes can be killed in situ by applying a disinfectant or sanitizer. in principle, handwashing using soap or detergent and water mechanically dislodge organisms, but, to be effective, it must be applied in conjunction with a rubbing process that maximizes release of microbes from the skin and a rinsing process that washes the organisms off the hands. although elimination of transient contamination from the hands by the application of a hygiene procedure is plausible, the evidence considered below suggests that, in practice, procedures vary considerably in the extent to which they achieve this. in this section, data on the efficacy of hand hygiene procedures are summarized. a range of test methods has been used to measure the efficacy of hand hygiene products and procedures. although these methodologies yield valuable data, the results can vary considerably depending on the method used. in 2004, sickbert-bennet et al 169 produced a study, based on published literature and their own data, which indicated that factors that affect efficacy measurements are as follows: use of experimental contamination versus normal flora, application method of test organism, type of hand hygiene agent, concentration of active ingredient, volume, duration of contact and application method of the agent, and study method (in vivo panel test vs in vitro suspension test). interpretation of data is made difficult by failure to compare multiple agents in the same study; because of these limitations, comparisons of results from different studies must be interpreted with care. in vivo ''panel test'' studies of the effectiveness of handwashing. in europe, the efficacy of handwashing is established by panel tests that determine the reduction in the number of organisms released from artificially contaminated hands. the test applicable to handwash products is the committee european normalisation hygienic handwash test en1499. 170 in this test, e coli is inoculated onto the hands and dried. the handwash product is applied to the hands with a rubbing action for either 30 seconds or 1 minute. the residual number of bacteria present on the hands is assessed pre-and postwash by a rinse sampling process and the log reduction determined. to make a claim that a product is a hygienic handwash, it must produce a log reduction in release of e coli from the hands at least equivalent to that produced by a reference soft soap product (mean, 2.76 log in 1 minute; range, 2.02-4.27). in the united states, handwashing is evaluated by a similar panel test using serratia marcescens as 171 the product, when evaluated by this method, must produce a 2-log reduction after 5 minutes. a range of studies, based on these methodologies, has been carried out to determine the efficacy of handwashing, and are reviewed by boyce and pittet, 172 kampf and kramer, 173 and sickbert-bennet et al. 169 from their assessment, kampf and kramer estimated that handwashing produced a mean reduction of up to 2.4 log within 1 minute. data from individual studies are summarized in table 10 and suggest that, for e coli, the greatest reduction is achieved within the first 30 seconds, ranging from 0.6 to 1.1 log after 15 seconds to 1.8 to 2.8 log after 30 seconds. extending the washing time to 1 minute produces a reduction of 2.6 to 3.23 log, but increasing the process for more than 1 minute does not appear to gain any additional reduction. relatively few data are available on the effectiveness of handwashing in removal of viruses, but the available data (table 10) suggest that handwashing may be less effective for viruses compared with bacteria. although panel test data suggest that handwashing efficacy is similar across a range of bacterial species, some field-based studies suggest that efficacy can vary quite significantly. in some cases, organisms can be attached to the hands too firmly and may not be removed by handwashing. a study of the spread of salmonella and campylobacter from contaminated chickens via hands during handling and preparation in a kitchen 176 showed that, although campylobacter were efficiently released from the hands by a 30second rub and rinse process, a 2-minute process was necessary to eliminate salmonella. the hand rinsing process is also important; cogan et al 86 showed that, following preparation of salmonella and campylobacter-contaminated chickens in domestic kitchens, 15.3% of hands and hand and food contact surfaces still showed evidence of contamination even after participants had carried out a washing-up routine with detergent and hot water and then used a cloth to wipe surfaces. sites contaminated most frequently were hands (20%); dishcloths, utensils, and tap handles (25%); and sink surrounds (30%). these results were confirmed in further studies 176, 177 in which, after cleaning up with a typical routine involving a bowl of hot soapy water and a cloth, although isolation rates from hands of participants were 5% (1/20) for campylobacter, 45% (9/20) of participants still had salmonella on their hands, and, on 3 occasions, counts recovered were .10 3 colony-forming units. in a further study in which participants cleaned up in the same way but then rinsed their hands under running water for 10 seconds, no samples were positive for campylobacter. however, 15% (3/20) still had low numbers of salmonella isolated from their hands. larson et al showed that the quantity of soap (1 ml and 3 ml) used can also have an impact on the microbial reduction achieved by handwashing. 178 bidawid et al 65, 66 studied the impact of handwashing in preventing transfer of hav and fcv from artificially contaminated finger pads to pieces of lettuce (table 11 ). touching the lettuce for 10 seconds resulted in transfer of 9.2% and 18%, respectively, of the virus. when finger pads were washed before the lettuce was touched, the amount of virus transferred was reduced to 0.39% and 0.4%, respectively. amounts of hav and fcv remaining on treated finger pads were 6.5% and 7%, respectively. surprisingly, virus transfer to lettuce when the finger pads were rinsed with water alone was between 0% and 0.3%, depending on the volume of water used for rinsing. barker et al showed that a thorough 1-minute handwash with soap was sufficient to eliminate norovirus from fecally contaminated hands to levels that gave negative reverse-transcription polymerase chain reaction assays. 89 however, schurmann and eggers 175 concluded that enteric viruses, particularly poliovirus, may be more strongly bound to the skin and that the inclusion of an abrasive substance in handwash preparations is needed to achieve effective removal. handwashing was also found to be ineffective in eliminating adenovirus from hands of a physician and patients. 179 for handwashing, a hand-rubbing time of 15 seconds with soap is generally recommended, although the data in table 10 indicate that 30 seconds to 1 minute is needed to achieve the optimum of 2-to 3-log reduction. in practice, it is doubtful whether people comply with even a 15-second handwash, although there are few data to confirm this. a study of 224 healthy another study with 52 office workers and students showed a mean log prewash count of 4.81 compared with 5.07 postwash. 181 kampf and kramer 173 also reviewed studies from health care settings in which increased bacterial counts were found on the hands after handwashing, and handwashing failed to prevent transfer of bacteria from hands to surfaces. although there are no data available to confirm this, increases in contamination may result from sweating induced by hot water, which flushes resident bacteria from the sweat glands onto the hand surface or aids detachment of bacteria attached to skin scales. it is important to bear in mind that, although soap and water removes contamination from the hands, soap itself has a limited antimicrobial effect, which means that contamination will be transferred to the sink. hospital studies show that pseudomonas aeruginosa and burkholderia cepacia 182 can form reservoirs of contamination in sink waste pipes and can be a source of infection at times when splashes of contaminated water come in contact with hands. mermel et al reported that hands of hcws became recontaminated from faucet handles during a shigella outbreak. 183 soap bars also have the potential to spread contamination from person to person via the hands. 88 efficacy of abhs abhs are formulations that contain either ethanol 1propanol or 2-propanol or a combination of these products. their antimicrobial activity is attributed to their ability to denature proteins. although products containing 60% to 95% alcohol are most effective, higher concentrations are less effective because proteins are not easily denatured in the absence of water. a range of in vivo and in vitro studies have been carried out to determine the effectiveness of abhs and are reviewed by boyce and pittet, 172 kampf and kramer, 173 and sickbert-bennet et al. 169 in vivo panel testing of abhs. in europe, the efficacy of abhs is established by panel tests that determine the reduction in the number of organisms released from artificially contaminated hands. the test applicable to abhs is the committee european normalisation hygienic handrub test en1500. 184 in this test, e coli is inoculated onto the hands and dried. the sanitizer is applied to the hands with a rubbing action for a specified period. the residual number of bacteria present on hands is assessed pre-and posttreatment by a rinse-sampling process and the log reduction determined. to claim that a product is a hygienic handrub, it must produce a log reduction at least equivalent to that produced by a reference product containing 60% vol/vol 2-propanol (mean, 4.24 log in 1 minute; range, 3.17-6.46). in vivo panel testing against bacterial strains. data from in vivo panel tests, summarized in table 12 , indicate that abhs show good and rapid activity against bacterial stains such as e coli and s aureus. efficacy is at least as good, if not better, than that achieved by handwashing with soap (table 10) ; log reductions obtained after a 30-second contact period were of the order of 3.4 to 3.7 or more compared with 1.8 to 2.8 for a 30-second handwashing process. boyce and pittet 172 conclude that, typically, log reductions of the release of test bacteria from artificially contaminated hands average 3.5 log after 30 seconds and 4.0 to 5.0 log after 1 minute. paulson et al 185 compared the efficacy of abhs containing 62% ethanol (contact time 5 minutes) with handwashing against s marcescens, which showed that handwashing (20 seconds rubbing followed by 30 seconds rinsing) produced a log reduction of 2.29 compared with 3.83 for the abhs. hammond et al 186 recorded a 2.84-log reduction for 62% ethanol against s marcescens in 10 seconds using the astm method. sickbert-bennet et al, 174 however, showed that exposure of s marcescens to 60% to 62% ethanol for 10 seconds produced only a 1.15-to 1.55-log reduction compared with 1.87-log reduction for handwashing for 10 seconds, when tested by the astm 1147 method. leischner et al 187 carried out in vivo tests that showed that alcohol gels were significantly less effective against c difficile spores (1.68-to 1.94-log reduction) compared with handwashing with chlorhexidine soap (2.46-log reduction). residual spores were readily transferred by handshaking following abhs use. 187 the reduction in spore counts is higher than expected in view of their known resistance to alcohol and may result from the friction associated with application of the gel rather than a bactericidal action; kampf and kramer 173 state that water alone can produce a reduction of 0.5 to 2.8 log within 1 minute for e coli. using the standard astm 1174 method, sickbert-bennet et al evaluated the effect of exposure time and volume of product used on the efficacy of 62% ethanol. 169 they showed that the use of 7 g of the abhs produced a higher log reduction compared with 3 g (2.7-to 3.8-log reduction compared with 1.0-to 1.8log reduction). rubbing the hands until dry (3-12 minutes) was more effective compared with a 10-second application (1.0-to 1.6-log reduction compared with 0.6-to 1.1-log reduction). two recent field studies indicate that an abhs is equally or slightly more effective than handwashing in reducing bacterial contamination on hands. davis et al 19 compared the reduction of bacterial counts on hands using soap and water or a 62% ethanol-based hand sanitizer (contact time 30 seconds) after animal handling at a us livestock event. there was no significant difference in the distribution of log reductions obtained using abhs compared with handwashing; log reductions in total count ranged from 21.4 to 1.4 and 23.0 to 3.5 for total coliforms. traub-dargtz et al carried out a study at 2 clinics in canada to evaluate the efficacy of handwashing compared with use of abhs (62% ethanol, contact time 30-60 seconds) on veterinary staff performing routine equine physical examinations. 188 mean bacterial load on hands increased by 0.36 and 0.91 log (for the 2 clinics, respectively) as a result of handling the animals, whereas the mean log reduction produced by handwashing with soap was less than 0.6, compared with 1.29 and 1.44 log (for the 2 clinics, respectively) produced by abhs. in vivo panel testing against viral strains. a number of in vivo studies have been carried out to determine the efficacy of abhs in reducing the release of viruses from hands. test methods were variants of the method of ansari et al 189 or the astm e1174 method, 171 in which the virus is applied to the fingertips and the efficacy of the product in reducing the numbers of viral particles recoverable from the hands determined. the residual number of viral particles present on the hands is assessed pre-and posttreatment and the log reduction determined. data collated by boyce and pittet 172 (table 13) indicate that ethanol at 60% to 80% produces a 0.8-to .3-log reduction against a range of viruses, the extent of the reduction depending on the viral strain, the nature and concentration of the alcohol, and contact time. data indicate that activity of abhs against viral strains is less than against bacterial strains and that ethanol has greater activity against viruses than 2-propanol. however, all of the strains referred to in table 13 are nonenveloped viruses, which are known to be more resistant to disinfectants than enveloped viruses. as far as hand hygiene in the home and community is concerned, however, this is key because many of the viral strains responsible for hygiene-related id commonly occurring in community settings (rotavirus, norovirus, rhinovirus, and adenovirus) are nonenveloped. that having been said, the data suggest that, although nonenveloped viruses such as hav and enteroviruses (eg, poliovirus) require 70% to 80% alcohol to be reliably inactivated, studies by sattar et al 194 in a number of these studies, handwashing with soap was also investigated. these studies 175, 189, 196 showed that the action of abhs against hav, polio, and rotavirus was significantly better than that achieved by handwashing with soap. however, in the test model used by ansari et al 189 and mbithi et al, 196 inoculated fingertips are exposed to soap solution or abhs by inverting them over a vial containing the product. in practice, handwashing involving rubbing and rinsing is likely to remove larger numbers of organisms from hands. in a further experiment, ansari et al 115 also demonstrated that 2-propanol (70%) was more effective (98.9% reduction after 10 seconds) than liquid soap (77% reduction) against rotavirus. mbithi et al showed that the log reduction of polio and hav virus (0.89-1.34) by application of 70% ethanol was sufficient to prevent transfer to another surface via the fingertips. 196 using similar methodology, bidawid et al 65, 66 studied the impact of ethanol hand sanitizers in preventing transfer of hav and fcv from artificially contaminated finger pads to pieces of lettuce. results (table 11) show that touching the lettuce for 10 seconds resulted in transfer of 9.2% and 18%, respectively, of the virus. when finger pads were treated with 62% ethanol or 75% ethanol (contact time 20 seconds) before the lettuce was touched, the amount of virus transferred was reduced to 0.64% and 0.46%, respectively, for hav and 2.1% and 1.2%, respectively, for fcv. although both 62% and 75% alcohol produced significant reductions in virus transfer, significant amounts of virus were found to remain on treated finger pads. in all cases, treatment with ethanol was less effective than handwashing. kampf and kramer 172 and boyce and pittet 173 suggest that, to achieve satisfactory activity against nonenveloped viruses, higher alcohol concentrations and extended contact times are needed. absolute ethanol reduced viral release from hands by 3.2 log, 80% ethanol by 2.2 log, and absolute 1-propanol by 2.4 log 197 but with a contact time of 10 minutes. schurmann and eggers 175 concluded that high alcohol-concentration products are effective against enteroviruses only under favorable conditions (large disinfectant/ virus volume ratio, low protein load). other studies also demonstrate superior activity of high ethanol concentrations against nonenveloped viruses such as polio, hav, and adenovirus. 198, 199 in vitro testing against bacteria, viruses, and fungi. whereas in vivo tests can be used to indicate the efficacy of products under use conditions, in vitro suspension tests are used to establish whether efficacy extends to a broad range of organisms. in vitro testing bacterial and fungal strains. alcohols have excellent and rapid activity against gram-positive and gram-negative vegetative bacteria and fungi when tested in vitro. 172, 173 a study by fendler et al 200 (table 14) shows the efficacy of an abhs containing 62% ethyl alcohol against a range of bacterial and fungal species, giving 4-to 6-log reduction in 15 to 30 seconds. in vitro testing against viral strains. data, as reviewed by boyce and pittet, 172 confirm that enveloped viruses such as herpes, influenza, piv, and rsv are very susceptible to alcohols. data from individual studies (table 15) suggest that activity against enveloped viruses is equivalent to that against bacterial strains. however, in agreement with in vivo data, alcohols tend to be less effective against nonenveloped viruses, although this is not the case for all strains. fendler et al 200 confirmed good activity for ethanol (62%) against piv and herpes viruses (.4-log reduction in 30 seconds) and some, but relatively less, activity against the nonenveloped rhinovirus, cocksackie virus, adenovirus, and hav (1-to 3-log reduction in 30 seconds). hammond et al 186 showed .5-log reduction against herpes and influenza virus but also .4.25-log reduction against rhinovirus type 16. there are no data on efficacy against rotavirus in vitro. in vitro tests suggest that alcohols are relatively effective against fcv, although gehrke et al 190 (table 15) found that 1-propanol was more effective than 2-propanol and ethanol. it was also found that these alcohols were less effective against fcv at 80% than at 50% and 70%. at this concentration (80%), 1-propanol, 2-propanol, and ethanol produced log reductions of only 1.9, 1.35, and 2.16, respectively. by contrast, duizer et al 201 showed that 70% ethanol produced less than a 2-log reduction for fcv after 8 minutes and a 3-log reduction after 30 minutes. these data are confirmed by a further study (mcneil-ppc unpublished) using in vitro suspension test methods as used to generate data in table 15 . the data (table 16) show that 62% ethanol gave a 3to 6-log reduction in 30 seconds against a range of nonenveloped viruses including not only rsv, piv, and influenza a and b but also against some strains of rhinovirus and echovirus. efficacy of abhs under conditions of soiling. alcohols are considered inappropriate when hands are visibly dirty or soiled because they fail to remove soiling. however, in a number of in vitro studies, in which the efficacy of abhs was determined in the presence and absence of soil (10% fetal calf serum or 0.3% bovine serum albumin), soil produced little or no loss of efficacy. 198, 202 larson and bobo showed that, in the presence of small amounts of protein material (eg, blood), ethanol and 2-propanol were more effective than soap in reducing bacterial counts on hands. 203 using the astm 1174 method, sickbert-bennet et al 169 showed that applying protein to hands did not produce any significant reduction in efficacy of abhs or handwashing but produced a modest but significant increase; log reductions for handwashing were 1.18 to 1.39 and 1.56 to 1.87 in the absence and presence of protein, respectively. log reductions for abhs were 0.18 to 1.07 and 1.35 to 1.55 in the absence and presence of protein, respectively. one of the problems in developing hygiene promotion policies is the lack of quantitative data on the relative health impact of different hygiene interventions. although intervention studies yield quantitative data on health impact, as discussed in section 4.2, the reliability of these estimates is difficult to confirm. by contrast, in vivo and in vitro tests are more economic to perform and can be used to determine relative efficacy of different procedures but give no assessment of how the contamination reduction on hands correlates with health impact. in an attempt to overcome these problems, haas et al have applied the technique of quantitative microbial risk assessment (qmra) to estimate the relative health benefits resulting from use of different hygiene procedures. 204 this approach involves using microbiologic data from the published literature related to each stage of the infection transmission cycle to calculate infection risk. in a recent study, 205 these investigators developed a model for studying the effect of hand contact with ground beef during food preparation, which was used to study the impact of handwashing and use of abhs in preventing subsequent transference from the hands to the mouth compared with no handwashing. pathogenic e coli and e coli o157:h7 were selected for this study because it is known from other investigations 206 that handling ground beef during home food preparation poses a risk of infection with e coli. to perform the risk assessment, data on the density of pathogens in ground beef, transference from beef to hands, removal by handwashing or abhs, rate of transfer from hand to mouth, and infectivity of ingested pathogens were obtained from the literature and, after screening for data quality, were used to develop probability distributions. for assessing log reductions produced by hand hygiene procedures, only in vivo panel testing data were considered. the median log reduction used in these calculations was 0.3 (range, 0.2-3.0) for handwashing and 4.3 (range, 2.6-5.8) for abhs. table 17 shows the estimates of the infection risk from handling raw beef, as obtained from the analysis. the authors note that these risks are conditional in the sense that they quantify the risk to an individual who has handled ground beef and who engages in hand-to-mouth activity. the probability that an individual will engage in such behavior is not known, and, therefore, a direct comparison with actual disease rates cannot be made. however, with some plausible assumptions, it was assessed that, assuming that there are 100 million individuals in the united states, each of whom handles ground beef once per month, this results in 1.2 3 10 9 contacts per year. assuming that 10% of these individuals contact hand to mouth after handling ground beef, this amounts to 1.2 3 10 8 incidents per year. for e coli o157:h7, using the median risk, this would result in an estimate ranging from 0.014 infections per year if all individuals washed their hands with soap following contact with ground beef to 0.7 infections per year if no handwashing is done. this would equate to a 98% median risk reduction for handwashing compared with no handwashing. if an abhs was used, this would result in an estimate of 0.00005 infections per year if all individuals used abhs following contact with ground beef. this would equate to a 99.9996% median risk reduction for use of abhs compared with handwashing. this study follows an earlier study by haas et al 207 to calculate risks associated with hand-to-mouth transfer after diaper changing of a baby infected with shigella. based on this model, it was calculated that the probability of acquiring infection was between 24 of 100 and 91 of 100 for those who used handwashing with soap after changing diapers. this was based on panel test data 205 conclude that quantitative microbial and id risk models offer a useful tool to assess the relative extent to which different hygiene procedures can impact on id risks. they concede, however, that, although risk modeling represents a promising approach, there are limitations to most models because of the multifactorial nature of infection transmission, the dynamic environment in which transmission takes place, and the paucity of data to specify model parameters. in an earlier section, we evaluated intervention study data to assess the strength of the causal link between hand hygiene and id transmission. in this section, we use these data to evaluate the effectiveness of handwashing as a hygiene measure and in relation to the effectiveness of using abhs as an adjunct or an alternative to handwashing. despite the methodologic limitations, the collective weight of evidence from intervention and microbiologic studies described earlier suggests that handwashing with soap can have a significant impact in reducing the incidence of gi and rt infection. the data, however, show that the health impact from handwashing promotion varies significantly according to the setting and outcome. statistically significant reductions ranged from 48% to 57% for gi illness and 20% to 51% for rt illness. although all studies were carried out in settings such as day care centers and schools, we believe that the modes of transmission in these settings and the relative rates of transmission of rt and gi infections are likely to reflect those occurring in the home. in 2004, meadows and le saux published a review of the effect of rinse-free hand sanitizers in elementary schools over a 20-year period. 208 they concluded, however, that the data were of poor quality and that more rigorous intervention trials are needed. in a more recent study, aiello et al examined the epidemiologic evidence for a relationship between waterless hand sanitizers and infections in the community setting over several decades. 154 in table 18 , we present the studies that specifically examined abhs. only studies with an effect estimate and 95% ci are presented. the type and content of the abhs varied across studies, for example, one study reported the use of a 60% isopropyl alcohol rinse and another study utilized an alcohol-based foam sanitizer. however, most studies used alcohol-based gels or other alcohol-based emollients. the alcohol content included ethanol and 2-propanol at concentrations ranging from 60% to 90%. of the 8 intervention studies, 7 were conducted in the united states (88%, 7/8) and 1 in finland (13%). most were conducted in child day care centers, elementary schools, or universities (88%, 7/8), and one was conducted in the household (13%, 1/8). outcomes included gi-related illnesses/symptoms and/or upper rt-related illnesses/symptoms examined as separate outcomes or in combination with other infectionrelated symptoms as part of a school absence-related definition of ''infectious-illness.'' of the 8 studies, 88% (7/8) reported significant results for at least one age group or outcome. the effect was stronger in younger compared with older age groups for studies providing age stratified data. the reduction in gi illness ranged from 0% to 59% for the 4 intervention studies that examined gi illnesses as separate outcomes. [209] [210] [211] 215 of these, all but one showed statistically significant reductions. 210 the study by uhari et al showed a significant reduction in gi illness only among children #3 years of age. 211 all but one of these studies was conducted in child care settings. 215 when evaluated separately, reductions in gi illness appeared more robust compared with the findings for upper rt illness. for upper rt illness, the reduction in infectious illness/symptoms ranged from 26% to 26%. only 2 of the 5 studies (44%) examining upper rt illness as a main outcome reported a statistically significant reduction. uhari et al reported a 13% reduction in rt illnesses among children #3years of age, but no significant effect in older children. 211 white et al reported a 20% reduction in upper rt illness among students using abhs in residence halls. 213 however, this study suffered from several methodologic shortcomings, including lack of control for clustered units, no randomization, no masking, and no monitoring of product use. all but one of the intervention studies included a hygiene education component, but, in 7 of these studies, this was only provided in the intervention arm. the level of education varied widely, ranging from basic information on when to use the abhs (ie, after sneezing and coughing, after use in the restroom, before lunch) to in-depth education programs 214 and biweekly instructional material designed to educate families on hand hygiene and infection transmission. 215 in all studies, abhs was promoted as a supplement to handwashing, or as an alternative to handwashing when soap was unavailable, and it is likely that the hygiene education would have had the effect of encouraging more frequent handwashing as well as use of abhs. although almost all studies indicated that hygiene education combined with promotion of abhs can reduce the risks of gi or rt illness, only 2 studies allowed any assessment of the independent effect of the abhs. of these 2 studies, both studies showed a significant reduction in illness-related absences (20% and 44%, respectively), but it is not clear whether the illnesses were predominantly gi or rt because these studies used a loose definition of absence-related illnesses. sandora et al 215 was the only study carried out in the household setting and, of all the studies, reported the highest reduction for gi illness. the trial involved 292 families with children enrolled in 26 child care centers. intervention families received a supply of abhs and biweekly hand hygiene educational materials for 5 months; control families received only materials promoting good nutrition. a total of 252 gi illnesses occurred during the study; 11% were secondary illnesses. the secondary gi illness rate was significantly lower (59%) in intervention families compared with control families (see table 18 ). a total of 1802 rt illnesses occurred during the study; 25% were secondary illnesses. although rt illness rates were not significantly different between groups, families with higher abhs usage had marginally lower rt illness rate than those with less usage (19% reduction). sandora et al 215 suggested that the difference may be due to heightened diligence associated with using abhs after a gi-related incident compared with an rt incident, such as sneezing. overall, based on relatively limited data available, the results in table 18 suggest that the impact of abhs promotion, as part of a hygiene education and promotion program in reducing the incidence of gi infections in young children, is similar to that observed for promotion of handwashing with soap. promotion of abhs in this manner also produced some reduction in the incidence of rt infections, which was less than that associated with promotion of handwashing alone. assessing whether there might be an added health benefit of using abhs above and beyond the effect of hygiene education is hampered by the fact that most studies used hygiene education and abhs in the intervention arm but did not provide an educational component to the control arm. several important methodologic issues were evident, although more recent studies have improved designs and conduct. in most studies, either parents or school personnel provided information on id among children in the study populations. in all but one study, 34 the parents, participants, or personnel monitoring and reporting infections were not masked as to their own or their child's intervention status. although masking of participants and interviewers to the intervention status is important, because it might influence reporting, it is often difficult to conduct masked hygiene interventions and may not be ethical. sandora et al determined that it was neither feasible nor ethical to mask subjects or interviewers because it is difficult to devise a formulation that could act as a ''placebo'' for abhs, and using a placebo abhs product might endanger the control group via inadequate hand hygiene. 215 in many of the abhs studies, especially the recent ones, efforts were made to control for potential confounding factors. however, many of the studies did not collect information on baseline hand hygiene practices (nor methods and frequency of cleaning/disinfecting soiled/contaminated environmental surfaces in homes) as well as abhs use. the studies also excluded participants who reported current abhs use in the home. furthermore, participants were asked to refrain from using abhs in settings outside the home. these are all important design strategies minimizing bias associated with noncompliance or differential usage. two of the 8 intervention studies failed to use systematic monitoring for hygiene practices, such as frequency of hand-sanitizing episodes, frequency of handwashing, or duration of handwashing. 212, 213 this is especially concerning because the study by sandora et al suggests that the quantity of abhs influences the risk of infection in a dose-response manner. 215 moreover, if frequency of handwashing and abhs use is not recorded, it is impossible to isolate the independent effects of abhs from that of handwashing on infection rates. in these studies of abhs use, surveillance measures included calculating use from monthly demand, total amount supplied, observation by research assistants, participant report, and reported use by primary caregivers in households. 186, 209, 212, 214, 215 overall, the microbiologic data, together with the intervention study data (both those involving abhs as well as those involving handwashing) as presented in this review, provide consistent evidence of a strong causal link between hygiene and the spread of infection in the home and community, and suggest that probably the single most important route for the spread of infection is the hands. if the data from intervention studies (summarized in table 19 ) are an accurate reflection of the true picture, it is suggested that, for up to 60% of gi illnesses, the hands are the ''sufficient,'' or a ''component'' (see earlier for definitions), cause of spread of infection. this correlates with microbiologic and other data reviewed in this report, which suggest that, although there is a tendency to assume that gi infections are mostly foodborne and result from inadequate cooking and inadequate storage of food, in reality, most gi infections in the home result from person-to-person spread or contamination of ready-to-eat foods within the home, much of which involves the hands as the sufficient or a component cause. for rt illnesses, the intervention study data (summarized in table 19 ) suggest that transmission via hands could be a sufficient or component cause of up to 50% of illnesses; whereas there has been a tendency to assume that the lower impact of hand hygiene on rt compared with gi infections is due to the fact that spread of rt pathogens is mainly airborne, the microbiologic and other data in this review correlate with the intervention data in suggesting that, for rt infections commonly circulating in the community, such as rhinovirus and rsv, the hands are the major route of spread. although up to 50% to 60% reduction in id risk was observed in some intervention studies, in other studies the reduction was much less. this variability could well be due to methodologic issues but could also be due to other factors within and between study communities. one possibility is that it relates to differences in the range of pathogens with differing modes of spread prevalent in different study groups, which means that hand hygiene has greater impact in some intervention groups than others. alternatively, the differences may reflect differing levels of hand hygiene compliance in different intervention groups. in some studies, the quality of the hygiene education, the manner in which the hygiene promotion was conducted, and the enthusiasm with which it was received may have given the intervention group a better understanding of what was required, with the result that they used better hygiene technique and were more likely to apply it at critical times. although there are no intervention study data to confirm this, the microbiologic data together with the qmra assessments suggest that even a relatively modest increase in log reduction on hands within a population could produce a significant increase in the health impact of a hand hygiene promotion campaign, which could, in turn, be achieved by addressing the issues in the next 2 sections. although panel tests carried out under controlled conditions showed that handwashing can reduce the numbers of bacteria and some viruses on the hands by up to 2-to 3-log within 30 seconds to 1 minute, in practice it is doubtful whether people wash their hands properly, even for the prescribed period of 15 seconds, to achieve this. at present, there is a paucity of data on the efficacy of handwashing in relation to how people actually wash their hands on a day-to-day basis, both in the duration of handwashing and handwashing technique; in most of the intervention studies described earlier no attempt was made to time handwashes or to determine residual levels of contamination on the hands after handwashing. microbiologic data suggest that, for some pathogens (eg, salmonella), mechanical removal by handwashing alone is inefficient. these data, together with the results of in vivo panel testing of the effectiveness of handwashing and of abhs, as described above, question the efficacy of handwashing in community-based groups and suggest that more work is needed to determine the efficacy of hand hygiene procedures under conditions normally encountered in the home and how hand hygiene procedures could be improved. for abhs, in vivo and in vitro testing suggest that these formulations are highly effective against bacterial pathogens and can produce a 3.5-log reduction on hands within 30 seconds and 4.0-to 5.0-log reduction after a 1-minute application against a wide range of species including salmonella. it is possible, however, that the potential for increased benefits against bacterial infections compared with handwashing may be offset by reduced efficacy against important nonenveloped viruses such as rotavirus, some strains of rhinovirus, and possibly also norovirus. it has been argued that the higher impact of abhs interventions against gi compared with rt infections is due to the fact that rt infections are predominantly viral. however, because the intervention data indicate that handwashing also supports a stronger reduction in gi diseases compared with rt diseases, this seems unlikely. some studies suggest that, to achieve satisfactory activity that includes all types of viruses, higher concentrations up to 80% ethanol should be advised. other studies suggest that the efficacy of abhs may be increased by increasing the volume of agent applied to the hands. 215 in formulating policies for hand hygiene, it would be convenient to be able to define what represents a ''safe'' residual level of contamination on the hands after hand hygiene, ie, sufficient to prevent infection transmission, but, because the infectious dose varies from one species to another and is dependant on the immune status of the recipient, this approach is untenable. the qmra approach, as outlined earlier in this review, however, demonstrates that strategies that produce an increase in the log reduction on hands from 2 to 3 to 4 are accompanied by a significant incremental reduction in the risk of infection in a given population and could thus be worthwhile. this suggests that the health impact from promoting hand hygiene could be increased by developing and promoting procedures for use in the home and community that increase the log reduction of contamination on the hands. this involves identifying products and procedures (both soap-based and waterless products or wipes) that achieve high levels of removal and/or ''kill'' (alone or in combination) of the full range of gram-negative and gram-positive bacteria and enveloped and nonenveloped viruses and that deliver hand hygiene under conditions that people are prepared to employ in their busy and mobile daily lives. it also suggests that, particularly for ''high-risk'' situations as outlined below, there is advantage to be gained by promoting handwashing followed by use of abhs to increase the log reduction. applying hand hygiene at the correct time: the need for hygiene education the data presented in this review suggest that the favorable health impact from promoting hand hygiene could be further increased by getting people to practice hand hygiene not just more frequently but also at the right time. a number of studies show the relatively poor understanding of the principles of hygiene that is present in the community. this may be one of the factors responsible for the higher risk reductions observed in intervention studies of gi compared with rt infections. for example, knowledge regarding the need for handwashing after coughing or sneezing may not be as pervasive as knowledge about handwashing after defecation, and it may be that people understand better when to wash their hands during food-associated activities but not, for example, while handling contaminated tissues. although some intervention studies described in this review involved a component of education, it was not possible to determine the extent to which hygiene education that enhanced people's understanding of infection transmission also enhanced health outcome. because visible soiling is an unreliable indicator of the presence of pathogens on the hands, people are unlikely to wash their hands at the correct time unless they have been taught to do so or have some awareness of the chain of infection transmission in the home, ie, they are aware of when their hands may be contaminated. whereas risks associated with food handling are largely confined to defined periods of time, for rt and skin infections (and person-to-person transmission of gi infection), the risk is ongoing and involves a large proportion of our ongoing daily activities. thus, whereas it is possible for hand hygiene advice associated with food hygiene to be rule based, this is not the case for other types of infections. in the event of a flu pandemic, the advice issued by the uk health protection agency 216 to ''wash hands frequently'' is unlikely to be effective unless people have some idea of the times when their hands are likely to be contaminated with flu virus. although current thinking about hygiene promotion tends toward a view that the most effective way to change behavior is by mass social marketing of single rule-based hygiene messages, 4 the data presented in this review suggest that the complexity and shifting nature of the id threat is such that a rule-based approach to hygiene is inadequate to meet current public health needs. the need is for an approach founded on awareness of the chain of infection transmission and how it differs for different groups of infections. hygiene education needs to be consistently incorporated as part of hand hygiene promotion programs if people are to properly understand the risks and adapt their behavior accordingly. based on the data presented in this review, we propose that, in promoting hand hygiene, significant improvements in health impact could be achieved by giving better guidance to people, first, on how to choose the best methods for hand hygiene (handwashing and/or use of abhs) based on the situation and showing them how to apply it properly and why this is important. secondly, it means stressing when it is important to apply hand hygiene, ie, what are the risk situations or critical control points at which hand hygiene needs to be applied. although the level of risk varies according to the occupants of the home (eg, presence of children, pets, ill people) and their immune status, based on the risk assessment approach as outlined earlier in this review, the critical control points or situations in which hand hygiene is indicated are as follows: d after using the toilet (or disposing of human or animal feces); d after changing a baby's diaper and disposing of the feces; d immediately after handling raw food (eg, chicken, raw meat); d before preparing and handling cooked/ready-to-eat food; d before eating food or feeding children; but also d after contact with contaminated surfaces (eg, rubbish bins, cleaning cloths, food contaminated surfaces); d after handling pets and domestic animals; d after wiping or blowing the nose or sneezing into the hands; d after handling soiled tissues (self or others', eg, children); d after contact with blood or body fluids (eg, vomit and others); d before and after dressing wounds; d before giving care to an ''at-risk'' person; and d after giving care to an infected person. in choosing the appropriate option for hand hygiene, there are 3 possibilities: either handwashing with soap, use of abhs (or other effective waterlessbased sanitizers), or handwashing followed by use of abhs. a possible framework for informing appropriate choice according to the particular situation is outlined in fig 4. this suggests that, in situations in the home and community that are ''standard risk'' (perhaps better described as situations not specifically regarded as ''high risk''), either handwashing or use of abhs may be chosen. within this, however, there are factors that advise, or in some cases dictate, choice, for example, handwashing is only an option when there is access to soap and water, whereas use of abhs is not an option when hands are heavily soiled (although people are likely to choose handwashing in this situation, prompted by the need to ''clean'' their hands). as discussed previously, there will always be situations in the home in which there is increased risk, either because there is a known source of infection or someone who is at increased risk of becoming infected. these situations are summarized in table 20 . these situations may relate to activities that are carried out routinely in the home, such as handling of raw meat and poultry, or involve household members such as pregnant women or young babies who are otherwise healthy but at increased risk of (or from) infection. they also relate to ''nonroutine'' situations such as a person in the home who is infected with a cold, or norovirus or other gi infections, or to situations in which there is someone who is at increased risk of infection as a result of underlying illness, immunosuppressive drug treatment, or needing catheter or wound care. although much of the ''health care'' carried out at home is done by trained caregivers, increasingly, there are situations in the home in which simple but risky actions are carried out by household members. in all of these ''increased risk'' situations, as outlined in table 20 , it is suggested that handwashing followed by use of an abhs should be encouraged. in persuading people to change behavior, one of the key factors is ''removing barriers to action.'' 217 lack of convenient access to a sink is a significant barrier to compliance, and time pressure is a barrier to getting people to wash their hands thoroughly. a key benefit of abhs is that they offer the means to apply hand hygiene in situations in which there is limited or no access to a soap and water. in home care situations, abhs offer an alternative to handwashing in situations in which other pressures mitigate against finding the time to visit the bathroom for handwashing, for example, when caring for a baby in the nursery or a sick person. they also offer a substitute for handwashing in ''out of home'' settings such as offices and public places, such as public transport or animal exhibits, at which access to soap and water is a particular problem and all of which offer frequent opportunities for hand transmission of infection. promoting use of abhs has the potential to get people to undertake hand hygiene more frequently and at critical times. in response to concerns about the possibility of a flu pandemic, the centers for disease control and prevention recommend the use of abhs for use as an alternative to handwashing. 218 in the event of a flu pandemic, it seems particularly important to encourage people to adopt good hand hygiene in public places. in health care settings, links between use of abhs and increased hand hygiene compliance and reduced infection rates has been observed. 219 in applying the framework outlined in fig 4, our intention is that this should not be regarded as an ''either handwashing or abhs'' situation; the fundamental aim should be to encourage more people to undertake hand hygiene procedures wherever possible at critical times. in view of the fact that hands are part of a complex system of infection transmission pathways, it must also be considered whether hand hygiene can, or should, be promoted in isolation. because people are reluctant to comply with handwashing, together with the microbiologic data showing the potential for transfer via hand and food contact surfaces and cloths to hands, which increase as the frequency occurrence of contamination of these surfaces increases, it would seem that, to maximize the health impact from hand hygiene promotion, it should be s56 vol. 35 no. 10 supplement 1 combined with promotion of hygiene in general, including hygienic cleaning of critical surfaces. if nothing else, this could raise awareness that hand contamination can arise from touching apparently clean surfaces. we are concerned that emphasis on handwashing alone without putting it within the context of other aspects of hygiene is encouraging the perception that handwashing is all that is required, ie, ''if you wash your hands you won't get sick.'' the aim of this report has been to review the evidence base for hand hygiene and develop a practical framework from it for promoting an effective approach to hand hygiene in home and community settings. provision of detailed guidelines for hand hygiene is outside the scope of this review. for such guidelines the reader is referred to the ifh guidelines and training resource on home hygiene. as part of its work in promoting home hygiene, the ifh has produced ''guidelines for prevention of infection and cross infection in the domestic environment'' and ''recommendations for selection of suitable hygiene procedures for use in the domestic environment.'' 220, 221 these documents are based on the concept of a risk-based approach and give detailed guidance on hand hygiene in the context of all aspects of home hygiene including food hygiene, general hygiene, personal hygiene, care of pets, and others. most recently, the ifh has also produced a teaching/self-learning resource on home hygiene. 222 this is based on the ifh guidelines and recommendations but is designed to present home hygiene theory and practice in simple practical language that can be understood by those with relative little infection control training or background. infectious diseases circulating in the community remain a significant concern, both in developed and developing countries. the global burden of id accounts for over 13 million deaths annually but, whereas the majority of deaths occurs in the developing world, infection also causes approximately 4% of deaths in developed countries. 223 although mortality from id has declined in the developed world, trends in morbidity suggest a change in the pattern of id rather than declining rates. several demographic, environmental, and health care trends, as reviewed in this report, are combining to make it likely that the threat of id will increase in coming years, rather than decline. one such factor is the rising proportion of the population in the community who are more vulnerable to infection. an important part of current european and us health policy is commitment to shorter hospital stays. a key requirement is to ensure that the increased health provision at home is not accompanied by an increase in id risks; otherwise, the cost savings gained by care in the community are likely to be overridden by costs of rehospitalization. even for the ''healthy community,'' id represents a significant economic burden because of absence from work and school and added health care costs. secondary infections can produce complications, and some infections may be associated with the development of diseases such as cancer or other chronic conditions, which can manifest at a later date. those responsible for ensuring that the public are protected from infection in health care facilities are now realizing that their ability to manage the problem is hampered by spread of pathogens such as mrsa, c difficile, and norovirus in the community and the home, and the number of infected people or carriers who come into their facilities, and are looking for ways to address this by engaging the public to adopt more rigorous standards of hygiene. one of the things that is apparent from newly emerging data, and that is reflected in this review, is the extent to which common infections circulating in the community are hygiene related. this suggests, in turn, that hygiene promotion could have a significant benefit in terms of improved public health and well-being; in particular, the data highlight the extent to which viruses (norovirus, rotavirus, rhinovirus, influenza, and other viruses) are responsible for hygiene-related diseases now circulating in the community. the main conclusions from this review are as follows: d id circulating in the home and community is a serious public health problem in the developed as well as the developing world. d good hygiene practice is key to reducing the burden of id in the home and community. d hand hygiene is a key component of good hygiene practice in the home and community and can produce significant benefits in terms of reducing the incidence of infection, most particularly for gastrointestinal infections but also for respiratory tract and skin infections. d decontamination of hands can be carried out either by handwashing with soap or by the use of waterless hand sanitizers, which achieve a log reduction in bacterial and viral contamination on hands by the removal of contamination or by killing the organisms in situ. the health impact of hand hygiene within a given community can be increased by using products and procedures, either alone or in sequence, that maximize the log reduction of both bacteria and viruses on hands. d the impact of hand hygiene in reducing id risks could be increased by convincing people to apply hand hygiene procedures correctly (eg, wash their hands correctly) and at the correct time. d to optimize health benefits, promotion of hand hygiene must be accompanied by hygiene education and should also involve promotion of other aspects of hygiene, for example, surface and cloth hygiene. this report highlights a number of areas in which additional data are needed: d further studies are needed to characterize the frequency of, and factors associated with, id transmission in noninstitutional settings such as the home. d further studies are needed to assess the relative efficacy of hand hygiene procedures in reducing hand contamination (handwashing with soap and use of abhs, involving different ''contact/application/rinsing'' times, and others). this includes the following: (1) in vivo panel tests to determine the reduction in bacteria and viruses on hands under controlled conditions. committee european normalisation or astm tests now provide standard test models for comparing the efficacy of handwashing with the use of waterless hand sanitizer products, under defined conditions. they provide an economic approach (relative to intervention studies) that can be used, alone or in combination with qmra, to inform hygiene policy and/or the design of intervention studies. (2) field studies to determine log reduction in counts on hands in relation to how people actually wash their hands or apply abhs in their homes. d additional data are needed to understand how, when, and why people practice hand hygiene at home and how this relates to their understanding of id transmission and risks. d intervention studies are needed to determine the health impact of hand hygiene promotion with hygiene education, compared with hygiene promotion without education. this should also include understanding how hand hygiene combines with surface hygiene to influence health outcome. d intervention studies are needed to determine the potential for an increase in health impact from promoting use of abhs in conjunction with handwashing (ie, handwashing followed by use of abhs) or as a supplement to handwashing (in situations in which access to water is limited), compared with the promotion of handwashing alone. trends in infectious disease mortality in the united states evaluating hygiene behaviour in the domestic setting and the impact of hygiene behaviour improving adherence to hygiene practice: a multidisciplinary approach talking dirty: how to save a million lives behavioural interventions to improve infection control practices behavioural considerations for hand hygiene practices: the basic building blocks the first european communicable disease epidemiological report. european centre for disease prevention and control campylobacteriosis overtakes salmonellosis as the most reported animal infection transmitted to humans in the eu european food standards agency who assesses that up to 40% of food poisoning outbreaks occur in the home. several foodborne diseases are increasing in europe. who's ''five keys to safer food'' for winter holidays a report of the study of infectious intestinal disease in england. london: the stationary office food-related illness and death in the united states infectious intestinal disease-it's not all foodborne! phls 25th annual scientific conference general outbreaks of infectious intestinal diseases linked with private residences in england and wales, 1992-1999: questionnaire study study of infectious intestinal disease in england: rates in the community, presenting to general practice and reported to national surveillance gastroenteritis in sentinel general practices in the netherlands risk factors for norovirus, sapporo-like virus and group a rotavirus gastroenteritis comparison of a waterless hand-hygiene preparation and soap-and-water hand washing to reduce coliforms on hands in animal exhibit settings are noroviruses emerging? enterically infecting viruses: pathogenicity, transmission and significance for food and waterborne infection japan: largest norovirus since 1981 increase in norovirus activity reported in europe epidemiology of hepatitis a in the united states methicillin-resistant staphylococcus aureus (mrsa), clostridium difficile, and esbl-producing escherichia coli in the home and community: assessing the problem, controlling the spread. international scientific forum on home hygiene gastroenteritis and transmission of helicobacter pylori infection in households strategies to reduce person-toperson transmission during widespread escherichia coli o157:h7 outbreak (available at: www.cdc.gov/eid) acute respiratory illness in the community: frequency of illness and the agents involved illness in the home: a study of 25,000 illnesses in a group of cleveland families the common cold at the turn of the millennium the effects of rhinovirus infections on allergic airway responses transmission of viral respiratory infections in the home the contribution of influenza to combined acute respiratory infections, hospital admissions, and death in winter mortality associated with influenza and respiratory syncytial virus in the united states warned, but not well armed: preventing viral upper respiratory infections in households transmission of influenza: implications for control in health care settings influenza season annual report respiratory infections during sars outbreak staphylococcus aureus infections familial carriage of methicillin-resistant staphylococcus aureus and subsequent infection in a premature neonate methicillin-resistant staphylococcus aureus (mrsa) in the community community-acquired methicillin-resistant staphylococcus aureus and familial transmission efficient detection and long-term persistence of the carriage of methicillin resistant staphylococcus aureus carriage and community treatment of methicillin-resistant staphylococcus aureus: what happened to colonised patients after discharge? staphylococcus aureus isolates carrying panton-valentine leucocidin genes in england and wales: frequency, characterization, and association with clinical disease is panton-valentine leukocidin the major virulence determinant in community-associated methicillin-resistant staphylococcus aureus disease? staphylococcus aureus panton valentine leukocidin causes necrotizing pneumonia. available at: www hospital transmission of panton-valentine (pvl) positive communityassociated mrsa in the midlands effect of intensive handwashing in the prevention of diarrhoeal illness among patients with aids: a randomized controlled study infections of the gastrointestinal tract helicobacter pylori infection and cancer estimated annual costs of campylobacter-associated guillain barrã© syndrome. food and consumer economics division chronic sequelae of foodborne disease opinion of the scientific committee on veterinary measures relating to public health respiratory viral infection predisposing for bacterial diseases: a review systematic risk assessment methods for the infection control professional survival of salmonella in bathrooms and toilets in domestic homes following salmonellosis cross-contamination and infection in the domestic environment and the role of chemical disinfectants preventing infection in the home the potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet causal inference: the case for hygiene and health frequency of mouthing behavior in young children microbiological and observational analysis of cross contamination risks during domestic food preparation contamination of food handlers: experiments on hepatitis a virus transfer to food and its interruption norovirus cross contamination during food-handling and interruption of virus transfer by hand antisepsis: experiments with feline calicivirus a surrogate comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive, gram-negative bacteria and phage acid sensitive enteric pathogens are protected from killing under extremely acidic conditions of ph 2.5 when they are inoculated into certain solid food sources epidemiology of campylobacter jejuni infections in the united states and other industrial nations vero cytotoxin-producing escherichia coli 0157 in beefburger linked to an outbreak of diarrhoea, haemorrhagic colitis and haemolytic uraemic syndrome in britain large outbreak of escherichia coli 0157:h7 infections in the western united states: the big picture small round structured viruses: airborne transmission and hospital control prevention of surface-to-human transmission of rotavirus by treatment with disinfectant spray efficiency of rotavirus propagation in cell culture microbiological hazards of households toilets: droplet production and the fate of residual organisms ) part a: salmonella prevalence estimates campylobacter infections-frequently asked questions escherichia coli 0157 in cattle and sheep at slaughter, on beef and lamb carcasses and in raw beef and lamb products in south yorkshire clostridium difficile in retail ground meat human zoonotic infections transmitted by dogs and cats how long do nosocomial pathogens survive on inanimate surfaces? hygienic hand antiseptics: should they not have activity and label claims against viruses? survival of human enteric viruses in the environment and food quantification and variability analysis of bacterial cross-contamination rates in common food service tasks the transmission of surrogate norwalk virus-from inanimate surfaces to gloved hands: is it a threat? the effectiveness of hygiene procedures for the prevention of cross contamination from chicken carcasses in the domestic kitchen hygiene in the home: relating bugs and behaviour transmission of viruses via contact in a household setting: experiments using bacteriophage phix174 as a model virus the effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces survival on uncommon fomites of feline calicivirus, a surrogate of noroviruses isolation of clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis the infection potential in the domestic setting and the role of hygiene practice in reducing infection the role of the home environment in the transmission of infectious diseases the significance of fomites in the spread of respiratory and enteric viral disease evidence for airborne transmission of norwalk-like virus (nlv) in a hotel restaurant a school outbreak of norwalk-like virus: evidence for airborne transmission global influenza preparedness plan world health organization. who global influenza preparedness plan world health organization writing group. nonpharmaceutical interventions for pandemic influenza mechanisms of transmission of rhinovirus infections transmission of rhinovirus colds by self-inoculation human influenza resulting from aerosol inhalation an investigation of possible transmission of rhinovirus colds through indirect contact psychological stress and the common cold transmission of experimental rhinovirus infection by contaminated surfaces possible transmission by fomites of respiratory syncytial virus modes of transmission of respiratory syncytial virus surface expression of intracellular adhesion molecule 1 on epithelial cells in the human adenoid dissemination of bacteria from the mouth during speaking, coughing and otherwise numerical study of the transport of droplets or particles generated by respiratory systems indoors medical microbiology. galveston: university of texas medical branch environmental contamination with rhinovirus and transfer to fingers of healthy individuals by daily life activity potential role of hands in the spread of respiratory viral infections ã� studies with human parainfuenza virus 3 and rhinovirus hand-to-hand transmission of rhinovirus colds role of infectious secretions in the transmission of rhinovirus comparison of cloth, paper and warm air-drying in eliminating viruses and bacteria from washed hands survival and disinfection of parainfluenza viruses on environmental surfaces survival of influenza viruses on environmental surfaces aerosol transmission of rhinovirus colds world health organization writing group. non-pharmaceutical interventions for pandemic influenza, review-national and community measures personal (non-pharmaceutical) protective measures for reducing transmission of influenza: ecdc interim recommendations transmission of avian influenza virus to and between humans an outbreak of influenza aboard a commercial airliner review of aerosol transmission of influenza a virus transmission of influenza a in human beings large sequential outbreaks caused by influenza a (h3n2) and b viruses in an institution for the mentally handicapped local infections experimental aspects active bacterial core surveillance program of the emerging infections program network. methicillin-resistant s aureus disease in three communities community-acquired mrsa: current epidemiology and management issues personal hygiene and methicillin-resistant staphylococcus aureus infection nasal carriage of staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks a us population-based survey of staphylococcus aureus colonization the population impact of mrsa in a country: the national survey of mrsa in wales methicillin-resistant staphylococcus aureus in community-acquired skin infections prevalence of methicillin-resistant and methicillin-susceptible staphylococcus aureus in the community human carriage of methicillin-resistant staphylococcus aureus linked with pet dog asymptomatic nasal carriage of mupirocin resistant, methicillin-resistant staphylococcus aureus (mrsa) in a pet dog associated with mrsa infection in household contacts panton valentine leukocidin (pvl) toxin positive mrsa strains isolated from companion animals human-to-dog transmission of methicillin-resistant staphylococcus aureus mrsa carriage in a pet therapy dog spread of staphylococcus aureus in hospitals: causes and prevention the survival of microbial contamination on worksurfaces and cloths and its transfer via cloths hands and utensils detection of mrsa in the domestic environment refractory methicillin-resistant staphylococcus aureus carriage associated with contamination of the home environment staff carriage of methicillin-resistant staphylococcus aureus (emrsa 15) and the home environment: a case report spread of methicillin-resistant staphylococcus aureus (mrsa) among household contacts of individuals with nosocomially acquired mrsa bed, bath and beyond: pitfalls in prompt eradication of methicillin-resistant staphylococcus aureus carrier status in health care workers familial carriage of methicillin-resistant staphylococcus aureus and subsequent infection in a premature neonate methicillin-resistant staphylococcus aureus (mrsa) in the community community-acquired methicillin-resistant staphylococcus aureus and familial transmission the toronto child care center study group. methicillin-resistant staphylococcus aureus carriage in a child care center following a case of disease what is the evidence for a causal link between hygiene and infections? effect of washing hands with soap on diarrhoea risk in the community: a systematic review water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis hand hygiene in the community setting: what really matters? handwashing to prevent diarrhea in day-care centers diarrheal illness among infants and toddlers in day care centers: effects of active surveillance and staff training without subsequent monitoring scheduled hand washing in an elementary school population effectiveness of a training program in reducing infections in toddlers attending day care centers effect of infection control measures on the frequency of diarrheal episodes in child care: a randomized, controlled trial selected nonvaccine interventions to prevent infectious acute respiratory disease handwashing and risk of respiratory infections: a quantitative systematic review health impact of handwashing. well fact sheet handwashing education can decrease illness absenteeism proper handwashing promotes wellness in child care effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial effect of handwashing on child health: a randomised controlled trial design of the jerusalem handwashing study: meeting the challenges of a preschool-based public health intervention trial infection prevention at day-care centres: feasibility and possible effects of intervention the effects of test variables on the efficacy of hand hygiene agents chemical disinfectants and antiseptics-hygienic handwash-test methods and requirements (phase 2/step 2) en 1499 standard test method for evaluation of healthcare personnel handwash. e1174 guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses an experimental study on the epidemiology of enteroviruses: soap and water washing of poliovirus 1-contaminated hands, its effectiveness and kinetics the effects of cleaning and disinfection in reducing salmonella contamination in a laboratory model kitchen achieving hygiene in the domestic kitchen: the effectiveness of commonly used cleaning products quantity of soap as a variable in handwashing adenovirus type 8 epidemic keratoconjunctivitis in an eye clinic: risk factors and control microbial flora of hands of homemakers physiologic and microbiologic changes in skin related to frequent handwashing distribution and transmission of pseudomonas aeruginosa and burkholderia cepacia in a hospital ward outbreak of shigella sonnei in a clinical microbiology laboratory chemical disinfectants and antiseptics-hygienic handrub-test methods and requirements (phase 2/step 2) en 1500 a close look at alcohol gel as an antimicrobial sanitizing agent effect of hand sanitizer use on elementary school absenteeism effect of alcohol hand gels and chlorhexidine hand wash in removing spores of clostridium difficile (cd) from hands pilot study to evaluate 3 hygiene protocols on the reduction of bacterial load on the hands of veterinary staff performing routine equine physical examinations in vivo protocol for testing efficacy of hand-washing agents against viruses and bacteria: experiments with rotavirus and escherichia coli inactivation of feline calicivirus, a surrogate of norovirus (formerly norwalk-like viruses), by different types of alcohol in vitro and in vivo efficacy of 3 ethanol-based handrubs against feline calicivirus, a surrogate for norovirus preliminary study of test methods to assess virucidal activity of skin disinfectants using poliovirus and bacteriophages two in-vivo protocols for testing virucidal efficacy of handwashing and hand disinfection activity of an alcohol-based hand gel against human adeno-, rhino-, and rotaviruses using the fingerpad method a test for the assessment of hygienic hand disinfection using rotavirus effect of relative humidity and air temperature on survival of hepatitis a virus on environmental surfaces virucidal efficacy of hand hygiene disinfection spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent sterilium gel an outbreak of epidemic keratoconjunctivitis in a pediatric unit due to adenovirus type 8 the impact of alcohol hand sanitizer use on infection rates in an extended care facility inactivation of caliciviruses efficacy of various disinfectants against sars coronavirus effective hand degerming in the presence of blood microbial agents and their transmission assessment of benefits from use of antimicrobial hand products: reduction in risk from handling ground beef risk factors for sporadic infection with escherichia coli o157: h7 quantitative assessment of risk reduction from hand washing with antibacterial soaps a systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children occurrence of infectious symptoms in children in day care homes evaluation of a hygienic intervention in child day-care centers an open randomized controlled trial of infection prevention in child day-care centers the effect of a comprehensive handwashing program on absenteeism in elementary schools the effect of hand hygiene on illness rate among students in university residence halls healthy hands: use of alcohol gel as an adjunct to handwashing in elementary school children a randomized controlled trial of a multifaceted hand hygiene intervention including alcohol-based hand sanitizer and hand hygiene education to reduce illness transmission in the home pandemic flu: important guidance for you and your family. uk health protection agency hygiene: how myths, monsters and mothers-in-law can promote behaviour change a multifaceted approach to changing handwashing behaviour guidelines for prevention of infection and cross infection the domestic environment recommendations for selection of suitable hygiene procedures for use in the domestic environment home hygiene-prevention of infection at home: a training resource for carers and their trainers memorandum on the threat posed by infectious diseases. need for reassessment and a new prevention strategy in germany. rudolf schulke foundation. wiesbaden: mph-verlag gmbh the authors thank dr. michele pearson, centers for disease control and prevention, atlanta, ga, for her very valuable and extensive contributions to the preparation of this review. key: cord-335141-ag3j8obh authors: higgins, g.c.; robertson, e.; horsely, c.; mclean, n.; douglas, j. title: ffp3 reusable respirators for covid-19; adequate and suitable in the healthcare setting date: 2020-06-30 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.06.002 sha: doc_id: 335141 cord_uid: ag3j8obh nan "please doctor, could you tell him that i love him?": letter from plastic surgeons at the covid-19 warfront dear sir, how many times have we heard these words in this time? too many. the covid-19 pandemic has completely disrupted our normal surgical and clinical routine. in these days, many colleagues of whatever specialty are regularly employed by their hospitals to face covid-19 emergency in italy, europe and worldwide. we are not plastic surgeons anymore. many of us feel lost, unprepared and inadequate for such an emergency. here in bergamo, the centre of the italian epidemic, we felt small and incompetent at the beginning. 1 however, we must remember that first of all we are doctors, then plastic surgeons. in these weeks we are putting our willingness at the service of our patients and colleagues. the numbers of the covid-19 pandemic in bergamo are impressive: 8664 positive patients and over official 2000 deaths in about one month. at the same time, the reaction of our hospital, papa giovanni xxiii, has been impressive too: over 400 doctors and over 900 nurses entirely dedicated to covid-19 positive patients; 88 intensive (one of the largest intensive care unit in europe) and over 400 nonintensive care beds are set aside for those patients. this huge wave of covid-19 positive patients, forced the hospital management to progressively and rapidly recruit, train and put on ward over 400 physicians of any discipline and 900 nurses from march 6th. several training programs about covid-19 infection and management have been scheduled in order to prepare the entire staff. two plastic surgeons of our team (on a total of six) have been fully dedicated on the shifting in covid medical areas coordinated by a pulmonologist and an intensivist. main activities focus on patient clinical exam, adjustment of oxygen therapy, regulation of cpap systems, hemogasanalysis implementation, blood and radiological exam monitoring and consequent therapy modulation, admission, discharge and deaths bureaucracy. despite these new clinical fields which are new for a plastic surgeon, we are learning how isolation of patients, due to public health reason, is the most devastating aspect of covid-19 pandemic. 2 , 3 every single day we phone and update the relatives of those who, because of the worsening of their respiratory condition, are unable to speak and call home. we are sometimes those who communicate the death of his or her beloved but also those who bring words of hope, words of love: "please doctor, could you tell him that i love him so much?". some of these patients die without the hug of their families. a plastic surgeon is not usually used to face death because in our surgery it is not so frequent. we would say that the death of a lonely patient also takes a part of us away. it acquires a different hint, touching some inner cord, it makes you feel impotent and lost. as plastic surgeons we often take care of the psychological side of patients and, except for some tumours and traumas, the pathologies we treat -like breast reconstruction -are not fatal diseases. if we compare the contribution of plastic surgery department in term of numbers, we are like a drop in the ocean. but as ovid wrote in epistulae ex ponto "gutta cavat lapidem" i.e. "the drop digs the rock". thanks to our support, a clinical physician is able to evaluate a larger number of patients, focusing on the most critical ones. this is why we keep going on. we want to make our part, working with commitment, dedication and professionalism and assisting all our patients to the best of our in-continueupdating knowledge. we are proud to help bergamo community to face covid-19 emergency and trying to make the difference in our wounded city. we hope this letter will help other colleagues not to consider themselves unprepared or unready. the contribute of everyone is crucial to defeat this ongoing pandemic which has not only upset our clinical routine, but it has woken us up from our everyday life. before covid-19 everything was scheduled, now there are no plans and we are not sure about our priorities. only if we behave, as long as necessary, with the awareness of being able to make a difference, we will win this terrible fight against sars-cov-2. only together we will go back to hugging, kissing and loving each other. when the critical phase of this emergency is over, it will be necessary to think deeply about the socioeconomic development strategies to discover new horizons and new opportunities for a better future. we will never give up!…and what about you? are you ready to play your part? none. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. dear sir, covid-19 is a novel coronavirus with increasing outbreaks occurring around the world. 1 , 2 during the past 4 weeks, emergence of new cases has gradually decreased in china with the help of massive efforts from society and the government. in addition to those directly working in the respiratory, infectious, cardiology, nephrology, psychology, and icu departments and covid-19 patients, all members of the general population may encounter the new coronavirus. medical staff in plastics, reconstructive, and other departments also have a responsibility to prevent the disease spreading in our community. in order to protect both patients and medical staff, selective operations and cosmetic treatments were reduced or postponed in the plastic surgery hospital, beijing, china. gloves and medical masks were saved and donated to the doctors and nurses in wuhan as the demand for protective equipment increased significantly. in addition, a standard operation procedure for covid-19 was proposed in local hos-pitals. our hospital recommended online consultations to replace face-to-face interactions. hospital websites and official social media accounts provided updated practical disease prevention information instead of plastic surgery information. other colleagues also conducted publicity campaigns on disease prevention online via their own social media accounts for relatives and friends, especially for older persons who appeared to have developed a serious illness. at the early stages of the covid-19 outbreak in certain areas, the public may not care much about the new disease. as more information about covid-19 becomes available, people without medical background may be anxious to seek diagnosis, which may result in potential risks of cross infection in the crowded fever clinics. thus, proper information and guidance can help reduce their panic and anxiety. moreover, if individuals were exhibiting relevant symptoms with epidemiologic history, they were advised to seek medical care following the directions of local health authority. in general, plastic surgeons are particularly good at introducing novel surgical methods to the public and keeping in touch with a great number of patients. as a result, they may be able to present local health authority advice in the form of straightforward images and accessible videos, as well as promote practical information via personal social media or clinic websites. in addition to local doctors and nurses from other departments helping in fever clinics and isolation wards, 3 42,600 (as of march 8, 2020) members of medical staff from other provinces rushed to help their colleagues in hubei province. 4 plastic surgeons that had completed icu training in beijing and other cities supported wuhan on their own initiative as well. 5 we suggest that measures should be taken by medical staff from all departments to help slow further spread and to protect health systems from becoming overwhelmed. dear sir, as covid-19 spreads quickly from asia via europe to the rest of the world, hospitals are evolving into hot zones for treatment and transmission of this disease. with the increasing acceptance that operating theatres are high risk areas for transmission of respiratory infections for both patients and surgeons, 1 and with our health care systems being generally well-designed to only deal with occasional high-risk cases, there is an obvious need to evolve our practice. although social media campaigns via the british association of plastic, reconstructive and aesthetic surgeons (#staysafestayhome) and british society for surgery of the hand (#playsafestaysafe) are attempting to raise awareness and reduce preventable injuries, we are still seeing a steady stream of patients present to our plastic surgery trauma service. we have had to act immediately so our systems can support essential surgical care while protecting patients and staff and conserving valuable resources. as a department we have developed a set of standard operating procedures which cover the full scope of plastic surgery from the facilitation of emergent life and limb saving surgeries, rationalised oncological management to the management of minor soft tissue and bony injuries. we have been cognisant of the need to reduce footfall to the hospital and the stratification into "dirty" and "clean" areas with attempted segregation of non-, suspected and confirmed covid cases within inpatient clinical areas. this has resulted in displacement of assessment and procedure rooms within the unit. the ward itself has been earmarked as an extended intensive care unit due to its layout and facilities. standards of practise have changed, with an emphasis on "see and treat" as operating theatre availability has been reduced due to the reduced availability of nurses and theatre staff and their conversion into intensive care areas for ventilated patients. there is also an emerging assumption that all patients are covid-19 positive until proven otherwise. 2 the combination of unfamiliar environments, lack of accessible equipment, requirement to reduce time spent with patients and adherence to social distancing has resulted in the need to provide a more mobile and flexible service. in order to support our mobile service, we have found that, as in other disaster situations where specialised bags have been deployed, 3 using a simple bag containing essential equipment and consumables has revolutionised our ability to work at the point of referral and avoid unnecessary trips to theatre. despite their simplicity, bags have been fundamental for the development of human civilization, with the word originating from the norse word baggi and comparable to the welsh baich (load, bundle)!!! 4 our portable "pandemic pack" is now being carried by the first on-call in our department. this pack contains a 10 l ultra dry adventurer tm , polymer dry bag measuring 36 cm (w) × 70 cm (l) as shown in figure 1 . the contents are shown in figure 2 . we have found this adequate for managing most common plastic surgery trauma and emergency scenarios. the bag is easily cleaned with 1000 ppm available chlorine (in accordance with public health england guidance) after each patient exposure. we have found it useful to make up two packs in advance so that one is available at handover whilst the other is replenished by the outgoing team. we are sure that this concept has been used elsewhere, but if it is not common practice in your unit, we would advocate implementing such a toolkit to facilitate management of trauma patients and reduce the amount time frontline staff need to be in a potential "dirty" environment during the covid-19 pandemic. teleconsultation-mediated nasoalveolar molding therapy for babies with cleft lip/palate during the covid-19 outbreak: implementing change at pandemic speed dear sir, cleft lip/palate is among the most common congenital anomalies, requiring multidisciplinary care from birth to adulthood. the nasolaveolar molding (nam) revolutionized the care provided to babies with a complete cleft, with proving its benefits to patients, parents, clinicians, and society. 1 this therapeutic modality requires parents' engagement with nam care at home and continuous clinicianpatient/parent encounters, commencing at the second week of life and finishing just before the lip repair. the rapidly expanding covid-19 pandemic 2 has challenged clinicians who are dealing with nam therapy to fully stop it, or adjust it to protect, both, the patient/parent and the healthcare team. based on the current who recommendation, to maintain social distancing, and the national regulation for the use of telemedicine, 2 , 3 the nam-related clinician-patient/parent relationship has timely been adjusted by implementing the non-face-to-face care model. babies with clefts are consulted individually by clinicians, proactively establishing the initial and subsequent telemedicine consultations, also providing an open communication channel for parents. based on a shared decisionmaking process, all parents have the option to completely stop nam therapy or use only lip tapping. given that each patient is at a particular stage within the continuum of nam care, numerous patient-and parent-derived issues are being addressed by video-mediated consultations. overall, this has helped explain the current covid-19-related public health recommendations and precautions to parents, while addressing patients' needs and parents' feelings, fears, expectations, and answering parents' questions. moreover, clinical support is provided to patients and parents by visual inspection (looking for potential nam-derived facial irritation), and checking parents' hand-hold maneuvers, such as feeding and placement of the lip tapping and nam device, with immediate feedback for corrections. thus, the use of an audiovisual communication tool has considerably reduced the number of in-person consultations. when a face-to-face consultation could not be resolved using the telemedicine triage, an additional video-based conversation had been implemented, focusing on the key steps, established for patient/parent visits to the facility (i.e., frequent hand-cleaning, mask usage, and keeping 1 m social distance) and on the covid-19-focused screening. 5 symptom-and exposure-screened negative parents/babies have been consulted in a time-specific scheduling with minimum waiting time to avoid crowded waiting rooms, by a clinician wearing personal protective equipment (cap, face shield, n95 mask, goggles, gloves, and gowns), and working in an environment with constant surface/object decontamination. 5 parents, who screened positive for symptoms (e.g., fever, cough, sore throat), were indicated to follow to the appropriate self-care or triage mechanism, stipulated by the who guidelines and local authorities. [2] [3] [4] [5] in the covid-19 era, the care provision should be aligned with the latest clinical evidence. 4 in response to the constantly changing needs, clinicians across the globe could adapt the telemedicine-based possibilities to their own environment of national/hospital regulatory bodies, technology accessibility, and the parents' level of technological literacy. as most of the issues addressed in the video conversations were recurrent reasons for consultations prior to the covid-19 outbreak, future investigations could assist in truly defining the key aspects of telemedicinebased clinician-patient/parent relationship in delivering nam therapy, and its impact on nam-related proxy-reported and clinician-derived outcome measures. there are no conflicts of interest to disclose. virtual clinics: need of the hour, a way forward in the future. adapting practice during a healthcare crisis the whole world is gripped by the novel coronavirus pandemic, with huge pressures on the health services globally. within the coming days, this is only going to increase the pressure on the health care services and needs robust planning and preparedness for this unprecedented situation, lest the whole system may cripple and we may see unimaginable mortalities and suffering. 1 the whole concept of social distancing 2 and keeping people in self isolation has reduced footfall to the hospitals but this is affecting delivery of routine care to patients for other illnesses in the hospital and telehealth is an upcoming way to reduce the risk of cross contamination as well as reduce close contact without affecting the quality of health care delivered. 3 at the bedford hospital nhs trust, for the past one year we have been running a virtual clinic for our skin cancer suspect patients, where in after a particular biopsy if the clinical suspicion of a malignancy was low, these patients were not given a follow up clinic appointment and instead they were informed of the biopsy result through post, sent both to their gp and themselves. most patients encouraged this model to not have to come back to an appointment and this took significant pressure off our clinics. in the event we needed to see a patient, they were informed via a telephonic conversation to attend a particular clinic appointment. from an administration standpoint, this resulted in less unnecessary follow up appointments in our skin cancer follow up clinics, which could then be offered to our regular skin cancer follow up patients as per the recommended guidelines, without having to struggle with appointments. virtual clinics have previously shown to be safe and cost effective alternatives to the out patient visits in surgical departments like urology 4 and orthopedics. 5 they improved performance as well as improved economic output. 3 , 4 we have increased the use of these virtual clinics, with the onset of the novel coronavirus pandemic, in order to reduce the patient footfall to our clinics. most patients voluntarily chose not to turn up and with the risk being highest amongst the elderly, it was logical to keep them away from hospitals as far as possible. in order to achieve this, we have started virtual clinics for nearly all patients in order to triage patients that can do without having to come to the hospital for now. the world of telemedicine is the way forward in nearly all aspects of medical practice 3 and this pandemic situation might just be the right time to establish such methods. we propose setting up of more such clinics in as many subspecialties of plastic surgery, which not only will help in the current crises situation, but will also be useful in the future to take pressure of our health care services. none declared not required funding none webinars in plastic and reconstructive surgery training -a review of the current landscape during the covid-19 pandemic dear sir, the covid-19 pandemic has resulted in cancellation of postgraduate courses and the vast majority of elective surgery. plastic surgery trainees and their trainers have therefore needed to pursue alternative means of training. in the face of cross-speciality cover and redeployment there is an additional demand for covid-19 specific education. the joint committee on surgical training (jcst) quality indicators for higher surgical training (hst) in plastic surgery state that trainees should have at least 2 h of facilitated formal teaching each week. 1 social distancing requirements have meant that innovative ways of delivering this teaching have needed to be found. a seminar is a form of academic instruction based on the socratic dialogue of asking and answering questions, with the word originating from the latin word seminarium meaning "seed plot". 2 fast and reliable internet and the ubiquitous nature of webcams has led to the evolution of the seminar into the webinar. whilst webinars have been common place for a number of years, they represent an innovative and indispensable tool for remote learning during the covid-19 pandemic, where trainees can interact and ask questions to facilitate deep and meaningful learning. speciality and trainee associations have traditionally used their websites and email lists to publicise training opportunities. however, the covid-19 pandemic has seen a shift to social media; with people seeking constant updates and information from public figures, brands and organisations alike. surgical education has mirrored this trend, and we have increasingly observed that webinars are being launched through speciality and trainee association social channels to keep up with the fast-paced demand for accessible online content. the aim of this study was to audit cumulative compliance of active publicly accessible postgraduate plastic surgery training webinar frequency and duration against jcst quality indicators. we used the social listening tool brand24 tm ( https:// brand24.com ). this tool monitors social media platforms for selected 'keywords' and provides analysis of search results. we used the search terms "plastic surgery webinar", "reconstructive surgery webinar", "royal college of surgeons", "bapras", "bssh", "british burns association", "plasta" and "bssh". there were 733 mentions of these terms from 6th may 2019 to 5th may 2020 and 727 of these were after 23rd march 2020, the date that lockdown began in the united kingdom (uk). this represents an increase of 12,017% post-lockdown. we supplemented this search strategy by searching google tm and youtube tm with "plastic and reconstructive surgery webinar". these search engines rank results in order of relevance using a relevancy algorithm, we therefore reviewed the first 100 results only. additional webinars were identified through a snowballing technique where the host webinar webpage was searched for advertised webinars at other institutions. we included any educational webinar series aimed at trainees that was free to access, mirroring weekly plastic surgery hst teaching. free webinars which required membership registration were also included. we excluded webinars aimed at patient or parent education, webinars with less than one video, any historic webinar that did not have an accessible link and webinars behind a paywall or requiring paid membership. we systematically reviewed the search results from brand24 tm , google tm and youtube tm and identified webinar series currently in progress ( table 1 ) and historic webinar series ( table 2 ) . seven active webinar series and two historic webinar series were identified respectively. all were consultant or equivalent delivered. of the active webinar series, 3 (43%) related to covid-19, 2 (29%) related to aesthetic surgery, 1 (14%) related to pan-plastic surgery and 1 (14%) related to hand surgery. the weekly total running time for active webinars amounted to 8 h 30 min, with 4 h and 30 min plastic surgery specific. this was a surplus of 2 h 30 min to jcst quality indicators. limitations of this study include us only identifying webinars advertised publicly. we are aware of training pro-grammes in the uk running in-house webinar series to supplement training and therefore the total available for training is likely to be higher than we have identified. we have also not reviewed the quality of educational content. we acknowledge there are good quality webinar series that require paid for membership such as those provided by the british association of aesthetic plastic surgeons and american society of plastic surgeons but it was not the aim of the study to present them here. innovation flourishes during times of crisis. the education of surgical trainees is of paramount importance and should be maintained, even during the difficult times we currently face. while operative skills will be difficult to develop, the use of technology can allow for the remote delivery of expert teaching to a large number of trainees at once. in this study we identify a number of freely available webinar series that provide a greater number of teaching hours than is recommended by the jcst. the training exists, it is up to trainees to make the most of it. none. none. dear sir, salisbury district hospital (sdh) is based in southwest england and provides a plastic surgery trauma service across the south coast, serving six local hospitals and the designated major trauma centre (mtc). prior to the covid-19 pandemic all patients referred to the trauma service, apart from open lower limb trauma, were reviewed in person within the trauma clinic. if surgery was required, it was usual for patients to return on a separate day for their operation and in most instances this was carried out under general anaesthetic in the main operating theatres. after discharge, patients were referred to the hand therapy and plastics dressing services and returned in person for all follow-up visits including dressing changes and therapy. patients with lower limb injuries from the mtc were transferred from southampton general hospital as inpatients to sdh for all complex reconstruction including free tissue transfer. at the start of the covid-19 crisis, it became quickly apparent that reducing patient footfall within our department was necessary to protect both patients and staff from the disease. this included reducing inpatient stays in hospital. we responded to this challenge in the following ways and hope that our experience will be of assistance to other trauma services over the course of the global pandemic. firstly, all patient protocols underwent significant redesign following which changes to the layout of our plastic surgery outpatient facility were made and patient flow through the department was altered and reduced. now, when patients are referred to our hand trauma service from peripheral hospitals, the initial patient consultations are carried out remotely using the 'attend anywhere' video platform. we are following the bssh covid-19 hand trauma guidelines 2 for patient management. all patient decisions are discussed with the trauma consultant of the day. we are managing a greater number of patients conservatively and to aid this we have designed comprehensive patient information leaflets that enable our patients to increase understanding of their own management. patients who need to be seen in person at our department are screened for symptoms of covid-19 and their temperature taken at the department entrance. level 2 ppe is worn by staff at all times. for hand trauma patients requiring surgery, this is provided on the same day to maximize efficiency and reduce the need for multiple visits. we have transformed our minor operating theatres, located adjacent to our clinic, into fully functional theatres equipped with a mini c-arm and all instruments for trauma operating. this reduces the need for our patients to be taken into the main hospital theatre suite. operations are carried out either under local anaesthetic, walant or regional block depending on complexity. all theatre staff wear level 3 ppe and staffing is kept to a minimum. all wounds are closed with dissolvable sutures. immediately post operation, our on-site hand therapists review patients. splints are made on the same day and patients are educated about their post-operative management at this time. all follow-up is subsequently carried out virtually by the hand therapy team using 'attend anywhere'. with our hub and spoke service set up for lower limb trauma patients, we have ensured that there is an on-site consultant at the mtc every day. wound coverage is being undertaken for all patients at the mtc. two plastic surgery consultants in conjunction with the orthopaedic team carry out operating for these patients. all inter-hospital transfers for this group of patients have been stopped. choice of wound coverage for these patients is being designed to minimise inpatient stay and reduce operative time. the changes that we have made to our service in a short period of time have already been beneficial for patients, streamlining their care and reducing time spent in hospital. figure 1 shows the drop in numbers of trauma patients that we have seen during the first four weeks of the uk lockdown ( n = 213 in january 2020 to n = 75 over the first 4 weeks into lockdown). this is in line with reports from other uk units. this has given us time to refine our protocols for an expected upsurge of patients as the lockdown is lifted. furthermore, during this period where we have had extra capacity, our registrars have been trained to carry out new techniques. they now undertake insertion of both mid-lines and picc lines for medical inpatients under ultrasound guidance to support and reduce the burden placed on our anaesthetic and critical care colleagues who previously would have placed these. it is our expectation that many of the changes we have implemented to our service will be continued in the longterm. we will continue to learn and adapt our protocols as this phase of work continues. whilst many of the outcomes of the covid-19 pandemic will be negative, it has also been the catalyst for significant positive change within the uk nhs. dear sir, the covid-19 pandemic has caused unprecedented disruptions in patient care globally including management of breast and other cancers. 1 however, cancer care should not be compromised unnecessarily by constraints caused by the outbreak. clinic availability and operating lists have been drastically reduced with many hospital staff members reassigned to the "frontline". furthermore, all surgical specialties have been advised to undertake emergency surgery or unavoidable procedures only with shortest possible operating times, minimal numbers of staff and leaving ventilators available for covid-19 patients. 2 in consequence, much elective surgery including immediate breast reconstruction (ibr) has been deferred in accordance with guidance issued by professional organisations such as the association of breast surgery (uk) and the american society of plastic surgeons. 3 , 4 this will inevitably lead to backlogs of women requiring delayed reconstructions and it is therefore imperative that reconstructive surgeons consider ways to mitigate this and adapt local practice in accordance with national guidelines and operative capacity. in the context of the current "crisis" or the subsequent "recovery period", time consuming and complex autologous tissue reconstruction (free or pedicled flap) should not be performed. approaches to breast reconstruction might include the following options: 1. a blanket ban on immediate reconstruction, and all forms of risk-reducing, contralateral balancing and revisional/tertiary procedures. where reconstructive delay is neither feasible nor desirable, opting for simple and expedient surgery should be considered e.g.: a) expanded use of therapeutic mammaplasty: as a unilateral procedure in selected cases instead of mastectomy and ibr. b) exploring less technically demanding (albeit "controversial") implant-based forms of ibr: i. epipectoral breast reconstruction (fixed volume implants): this adds about 30 minutes to the ablative surgery as the pre-prepared implant-adm complex is easily secured with minimal sutures. ii. "babysitter" tissue expander/implant: this acts as a scaffold to preserve the breast skin envelope for subsequent definitive reconstruction. 3. during the restrictive and early recovery phase, either a solo oncological breast surgeon or a joint ablative and reconstructive team (breast and plastic surgeon) performs surgery without the assistance of trainees or surgical practitioners. for joint procedures, the plastic surgeon acts as assistant during cancer ablation and as primary operator for the reconstruction. despite relatively high rates of complications for implant-based ibr (risking re-admission, prolonged hospital stays or repeat clinic visits), 5 avoiding all ibr will lead to long waiting lists and have a negative psychological impact, particularly among younger patients. this will also impair aesthetic outcomes due to more extensive scars and inevitable loss of nipples. whilst appreciating the restrictions imposed by covid-19, there is opportunity to offer some reconstructive options depending on local circumstances, operating capacity and the pandemic phase. we suggest that these proposals involving greater use of therapeutic mammaplasty as well as epipectoral and "babysitter" prostheses be considered in efforts to offset some of the disadvantages of covid-19 on breast cancer patients whilst ensuring that their safety and that of healthcare providers comes first. dear sir, the covid-19 pandemic has shifted clinical priorities and resources from elective and trauma hand surgery with general anaesthesia (ga) to treat the growing number of covid patients. at the time of this correspondence, the pandemic has affected over 2 million people resulting in 129045 deaths worldwide, with 12868 uk deaths, with numbers still climbing. this has particularly affected our hand trauma services which serves north london, a population of more than 2 million. we receive referrals from a network of 8 hospitals in addition to 3 emergency departments of the royal free group of hospitals and numerous gp practices and urgent care centres. in the first week following the british government lockdown, which commenced march 23rd, we experienced a 75% drop in referrals, from 25 to 6 a day. subsequently, numbers have been steadily rising to 12-14 a day by 6 th of april. the british association of plastic, reconstructive and aesthetic surgeons, the british society for surgery of the hand and the royal college of surgeons of england, have all issued guidance: both encouraging patients to avoid risky pursuits, which could result in accidental injuries and to members how to prioritise and optimise services for trauma and urgent cancer work. we have adapted our hand trauma service to a 'one stop hand trauma and therapy' clinic, where patients are assessed, definitive surgery performed and offered immediate post-operative hand therapy where therapists make splint and give specialist advice on wound care and rehabilitation including an illustrated hand therapy guide. patients are categorised based on the bssh hand injury triage app. we already have a specific 'closed fracture' hand therapy led clinic, to manage the majority of our closed injuries. we combined this clinic with the plastic surgeons' led hand trauma clinic, and improved its efficiency further by utilising the mini c-arm fluoroscope within the clinic setting. this enabled us to immediately assess fractures and perform fracture manipulation under simple local anaesthesia. we have successfully been able to perform 95% of our operations for hand trauma under wide awake local anaesthesia no tourniquet (walant). 1 prior to the pandemic, we used walant for selected elective and trauma hand surgical cases. in infected cases, where local anaesthesia is known to be less effective, we have used peripheral nerve blocks. previous data showed 50% of our trauma cases were conducted under ga, 33% under la, and 17% under brachial or peripheral nerve blocks. 2 we have specifically modified our wound care information leaflets to minimise patient hospital attendance. afterwards patients receive further therapy phone consultations and encouragement to use the hand therapy exercise app developed by the chelsea and westminster hand therapists. the patient is given details of a designated plastic surgery nhs trust email address, for direct contact with the plastic surgery team: for concerns, questions and transfers of images. we have to date received 39 emails, of which 21 have been from patients directly, and the remainder from referring healthcare providers. the majority of inquiries are followed up via a telephone consultation and only complex cases or complications, attend face-to-face follow-up. this model has successfully combined assessment, treatment and post-op therapy into a one-stop session, which has greatly limited patient exposure to other parts of the hospital, such as the radiology and therapy departments. the other benefit of such clinic is an improved outcome through combined decision making. 3 there is also a cost saving benefit compared to our traditional model of patient care. we have treated 31 patients based on this model so far, who have been suitable for remote monitoring. on average we have saved 2 plastics dressing clinic (pdc) visits for wound checks per patient, as a very minimum. we have previously calculated the cost of pdc at our centre at £155 per visit 4 and for our 31 patients this translates to an approximately saving of £9000 per month just on pdc costs. if 30 patients each month could be identified for remote monitoring, this could potentially lead to an annual saving of more than £110,000. in addition, the estimated cost-saving by converting the mode of anaesthesia from ga to walant has been shown to cause a 70% reduction. 5 the concept of a one-stop clinic has already been successfully implemented in the treatment of head & neck tumours, following introduction of nice guidelines in 2004 3 and the covid-19 pandemic has made us redesign a busy metropolitan service for hand injuries along the same lines. we believe this model is a good strategy and combining this with more widespread use of the walant technique, technology such as apps and telemedicine, as well as encouraging greater patient responsibility in their post-operative care and rehabilitation; is the way forward. we hope sharing this experience will result in improved patient care at this time of crisis. 'this is a saint patrick's day like no other' declared the irish prime minster on march 17th 2020, whilst announcing sweeping social restrictions in a response to the worsening covid-19 pandemic. this nationwide lockdown involved major restrictions on work, travel and public gatherings and signified the government's shift from the suppression to the mitigation phase of the outbreak. the national covid-19 task force produced a policy specifying the redeployment of heath care workers to essential services such as the emergency department and intensive care. 1 with the introduction of virtual outpatient clinics and the curtailment of elective operating lists, the apparent clinical commitments of a plastic surgeon during this pandemic has lessened. trauma is a continual and major component of our practice 2 ; however, a decline in emergency department presentations has fuelled anecdotal reports of a reduction in the trauma workload. with diminishing resources, the risk of staff redeployment and consequences of poor patient outcomes we aim to assess the effect of the current lockdown due to covid-19 pandemic on plastic trauma caseload. we performed a retrospective review of a prospectively maintained trauma database at a tertiary referral hospiduring the first 25 days of the lockdown, 48 patients attended plastic surgery trauma clinic, in which 41 (85.4%) underwent a surgical procedure. as seen in figure 1 , these numbers are comparable over the same time frame for the two previous years. upper limb trauma accounted for the near majority of referrals. frequency and type of surgery performed during the lockdown were similar to the previous two years, as seen in table 1 . the percentage of patients requiring general anaesthesia was 46.3% (19/41) in 2020, 44.2% (19/43) in 2019, and slightly higher in 2018 at 58.9% (23/39). we have refuted any anecdotal evidence proposing a decline in plastic trauma caseload during the covid19 nationwide lockdown. comparing the same time in previous years, the lockdown has produced an equivalent trauma volume. despite, the widespread and necessary restriction of routine elective work, somewhat surprisingly the pattern and volume of trauma remains similar to preceding years. with people confined to their household, it is the 'diy at home' associated injuries which attributes to this trend. and the exemption from regulations of certain industries such as agriculture and the food preparation chain. whilst not every trauma risk may be mitigated, the potential for these diy injuries to overwhelm the healthcare service has resulted in the british society for surgery of the hand (bssh) cautioning the general public on the safety of domestic machinery. 3 as healthcare systems are stretched further than ever before we all must recognise the need for adaptation and structural reorganisation to treat those of our patients most in need during this pandemic. staff redeployment is a necessary tool to maintain frontline services; nonetheless, we wish to highlight the outcomes of this study to the clinical directors with the challenging job of allocating resources. our trauma presentations have not reduced during the first 25 days of this pandemic, resources (staff and theatre) should still be accessible for the plastic surgery trauma team, with observance of all the appropriate risk reduction strategies as documented by british association of plastic, reconstructive and aesthetic surgeons. 4 none. none. in light of the ongoing covid-19 pandemic, the american society of plastic surgeons (asps) has released a statement urging the suspension of elective, non-essential procedures. 1 this necessary and rational suspension will result in detrimental financial effects on the plastic surgery community. given the simultaneous economic downturn inflicted by public health social-distancing protocols, there will be a bear market for elective surgery lasting well past the bans being lifted on elective surgeries. this effect will largely be due to the elimination of discretionary spending as individuals attempt to recover from weeks to months of lost earnings. as demonstrated during the 2008-2009 recession, economic decline was associated with a decrease in both elective and non-elective surgical volume. 2 private practice settings performing mostly cosmetic procedures were particularly vulnerable to these fluctuations and demonstrated a significant positive correlation with gdp. 3 the surgery community must prepare for the economic impact that this pandemic will have on current and future clinical volumes. these effects are likely to be more severe than the previous recession as surgeons are currently indefinitely unable to perform elective surgeries, coupled with the immense strain on hospital resources at this time. given this burden, elective surgery cases may be some of the last to be added back to the hospital once adequate resources are restored. while surgeons are temporarily unable to operate, they do have the potential to use telehealth in order to arrange preoperative consults and postoperative follow-up appointments. this could be accomplished in private practice settings with the use of telehealth services such as teladoc health, american well, or zoom, which allow for live consultation with patients without unnecessary exposure of patients or providers to potential infection. 4 the main limitation of these types of appointments is the lack of an inperson physical exam, so providers have found that billing based on time spent with the patient is more effective with this tool. 5 this could generate revenue and facilitate future surgical cases after the suspension of in-person elective patient care has been lifted. several strategies should be considered by the elective surgery community to minimize financial losses. many financial entities have changed their policies in order to support small businesses. examples include the small business administration offering expanded disaster impact loans and deferment of the federal income tax payments by three months to july 15. 5 another option employers may leverage is temporarily laying off of employees so that employees can apply for and collect an expanded unemployment package by federal and state governments thereby reducing the payroll burden on stagnant practices with no cash flows and providing employees with a steady source of income during the pandemic. the employer's incentive to do this may be reduced with the potential suspension of the payroll tax on employers and loan forgiveness to employers who continue to pay employees wages. 5 once elective procedures are again permitted, plastic surgeons that have retained a reconstructive practice should make a strategic business decision to increase reconstructive surgery and emergent hand surgery bookings as historically these procedures are less fluctuant with the economy. 3 other options to maintain aesthetic case volume include price reductions or temporary promotions. however, it is important that these be adopted universally in order to minimize price wars between providers. as physicians, it is principle that surgeons practice nonmaleficence and minimize non-essential patient contact for the time being. however, this time of financial standstill should be used constructively to prepare for the financial uncertainty in the months to come. none demic advise certain groups to stringently follow social distancing measures. inevitably some health care workers fall into these categories and working in a hospital places them at high risk of exposure to the virus. studies have shown human to human transmission from positive covid-19 patients to health care workers demonstrating that this threat is real 1 , 2 and as in other infectious diseases is worse in certain situations such as aerosol generating and airway procedures 3 , 4 . there is therefore a part of our workforce that has been out of action reducing available workforce at a time of great need. in our hospital a group of vulnerable surgical trainees ranging from ct2 to st8, and also consultants, have been able to keep working while socially isolating within their usual workplace. in light of covid-19 our hospital, a regional trauma centre for burns, plastic surgery and oral and maxillofacial surgery, was reorganized to increase capacity for both trauma and cancer work. as part of this a virtual hand trauma service has been set up. the primary aim of the new virtual hand trauma clinic was to allow patients to be triaged in a timely manner while adhering to social distancing guidelines by remotely accessing the clinic from home. further aims were to reduce time spent in hospital and reduced time between referral and treatment. in brief, patients referred to our virtual hand trauma clinic from across the region receive a video or telephone consultation using attend anywhere software, supported by nhs digital. following the virtual consultation patients are then triaged to theatre, further clinic, or discharged. our group of isolating doctors, plus a pharmacist and trauma coordinator, have been redeployed away from their usual face to face roles and are now working solely in the virtual trauma clinic. they are able to work to provide this service in an isolated part of the hospital named the 'virtual nest.' the nest is not accessible in a 'face to face' manner by non-isolating staff or patients. this allows a safe 'clean' environment to be maintained. the virtual team is able to participate in morning handover with other areas of the hospital via video conferencing using webex software. the nest workspace is large enough to allow social distancing between clinicians and by being on site they benefit from availability of dedicated workspaces with suitable it equipment and bandwidth. it is widely recognised that reconfiguration of hospitals and redeployment of staff has meant that training is effectively 'on hold' for many trainees. we have found that a benefit of the new virtual hand trauma clinic is that trainees can continue to engage with the intercollegiate surgical curriculum programme with work based assessments in a surgical field. while direct observation of procedural skills and procedure based assessment are not feasible, case based discussions and clinical evaluation exercises have been easily achievable due to trainees managing patients with involvement of supervising senior colleagues in decision making. this plus a varied case mix seen has enhanced development of knowledge, decision making, leadership and communication skills. as trainees are unable to attend theatre practical skills may suffer depending on how long clinicians are non patient facing. this has been acknowledged by the gmc in the skill fade review; skills have been shown to decline over 6 -18 months 5 . although it can only be postulated at the current time colleagues who are patient facing but redeployed may face a similar skill decline. the structure of the team is akin to the firm structure of days gone by with the benefits that brings in terms of support and mentorship. patients benefit from having access to a group of knowledgeable trainees, supported by consultants, and a service accessible from their own home. this minimizes footfall within our hospital, exposure to, and spread of covid-19. local assessment of our practice is ongoing but we have found that this model has enabled a cohort of vulnerable plastic surgery trainees to successfully continue to work whilst reducing the risk of exposure to covid-19 and providing gold standard care for patients. none. nothing to disclose. dear sir, a scottish sarcoma network (glasgow centre) special study day on 6th march 2019 at the school of simulation and visualisation, glasgow school of art, with representatives from sarcoma uk, beatson cancer charity and the bbc. traditional patient information leaflets inadequately convey medical information due to poor literacy levels: 16-27% of uk population have the lowest adult literacy level 1 and 40% the lowest "health literacy" level (ability to obtain, understand, act on, and communicate health information). 2 it was hypothesised that an entirely visual approach, such as ar, may obviate literacy problems by faciliating comprehension of complex 3 dimensional concepts integral to reconstructive surgery. we report the first augmented reality (ar) in patient information leaflets in plastic surgery. to our knowledge we are among the first in the world to develop, implement, and evaluate an ar patient information leaflet in any speciality. developed for sarcoma surgery, the ar patient leaflet centred around a prototypical leg sarcoma. a storyboard takes patients through tumour resection, reconstruction, and the potential post-operative outcomes. input from specialist nurses, sarcoma patients, and clinicians during a scottish sarcoma network special study day in march 2019 informed the final content ( figure 1 ). when viewed by smartphone camera (hp reveal studio, hp palo alto, california usa), photos in the ar leaflet automatically trigger additional content display without need for qr codes or internet connectivity: (1) sequential tumour resection ( a 3d alt flap model was developed using body-parts3d (research organization of information and systems database centre for life science, japan) and custom anatomical data. 4 leaflet evaluation by 14 consecutive lower limb sarcoma patients was exempted from ethics approval by greater glasgow and clyde nhs research office as part of service evaluation. ar leaflets were compared with pooled data from traditional information sources (sarcoma uk website patient leaflets (6), self-directed internet searches (5), generic sarcoma patient leaflets (5); some patients used > 1 source). the mental effort rating scale evaluated perceived difficulty of comprehension (or extrinsic cognitive load), 3 as a key outcome measure in comparison to traditional information sources. patient satisfaction was assessed by likert scale (1 was very, very satisfied and 9 very, very dissatisfied). statistical analysis performed with social science statistics, 2019. ar leaflets were rated as 1.57 (very, very low mental effort), traditional information sources as 6.36 (high mental effort) [unpaired t -test p < 0.0001]. likert-scale satisfaction was 1.43, indicating a very, very high satisfaction. when asked "do you think the ar leaflet would make you less anxious about surgery?", 12/14 (86%) patients responded 'yes'. when asked "would you think other patients would like to have a similar ar leaflet before surgery" and "would you like to see further ar leaflets to be developed in the future?", 100% responded "yes". no correlation was found between age or educational level and mental effort rating scale scores for ar patient leaflet (data not shown). subjective feedback analysis found that self-directed internet searches had too much unfocussed information: " (i) didn't want to google as may end up with all sorts" and "(there is) good and bad stuff on the internet, don't know what you're looking at". all patients felt the visual content in ar leaflets helped their understanding: "incredible…that would have made a flap easier to understand", "tremen-dous… good way of explaining things to my family", "so much better seeing the pictures, gives an idea in your head", and "helpful for others with dyslexia". traditional patient leaflets were often difficult to comprehend: "(i) didn't fully understand the sarcoma leaflets", "couldn't take information in from leaflets". feedback recommended adding simple instructions on the leaflet, however the ar leaflet is intended for use by the clinician in clinic, and to be so simple that no instructions are required once software is downloaded to the patient's smartphone (i.e., point and shoot without technical expertise, menus, or website addresses). all patients desired an actual paper leaflet for reassurance, preferring something physical show their family rather than direction to a website or video. this study demonstrates significant reduction in extraneous cognitive load (mental effort required to understand a topic) with ar patient leaflets compared to traditional information sources ( p < 0.0001). ar visualisation may make inherently difficult topics (intrinsic cognitive load), such as reconstructive surgery, easier to understand and process. significant learning advantages exist over tradi-tional leaflets or web-based videos, including facilitating patient control, interactivity, and game-based learning. all contribute to increased motivation, comprehension, and enthusiasm in the learning process. 5 ar leaflets reduced anxiety (86% patients), and scored very highly for patient satisfaction with information, which is notable given increasing evidence of strong independent determination of overall health outcomes. this study provided impetus for investment in concurrent development of other ar leaflets across the breadth of plastic surgery, and non-plastic surgery specialties. chief scientist office (cso, scotland) funding was recruited to aid development of improved, free, fully interactive 3d ar patient information leaflets and a downloadable app. ethical approval is in place for a randomised controlled trial to quantify the perceived benefits of ar in patient education. our belief is that ar leaflets will transform and redefine the future plastic surgery patient information landscape, empowering patients and bridging the health literacy gap. none. dear sir, we investigated if age has an influence on wound healing. wound healing can result in hypertrophic scars or keloids. from previous studies we know that age has an influence on the different stages of wound healing. 1-4 a general assumption seems to be that adults make better scars than children. knowledge of the influence of age on healing and scarring can give opportunities to intervene in the wound healing process to minimize scarring. it could guide patients in their decision when to revise a scar. it could also lead patients and physicians in their decision of the timing of a surgery, if the kinds of surgery allows this. this study is a retrospective cohort study at the department of plastic, reconstructive, and hand surgery of the amsterdam university medical center. all patients underwent cardiothoracic surgery through a median sternotomy incision. all patients had to be at least one year after surgery at time of investigation. hypertrophic scars were defined as raised 1 mm above skin level while remaining within the borders of the original lesion. keloid scars were defined as raised 1 mm above skin level and extending beyond the borders of the original lesion. 5 the scars were scored with the patient and observer scar assessment scale (posas) as primary outcome measure. as secondary outcome measures we looked at wound healing problems and scar measurements. in order to ensure that the results of this study are as little as possible influenced by the already known risk and protective factors for hypertrophic scarring, the patients were questioned about co-existing diseases, scar treatment, allergies, medication, length, weight, cup size (females) and smoking. their skin type was classified with the fitzpatrick scale i to vi. all calculations were performed using spss and the level of significance was set at p ≤ 0.05. 105 patients were enrolled in this study. group 1 contained 53 children and group 2 contained 52 adults. there is a significant difference between the two groups for the amount of pain in the scar scored by the patient. this item was given higher scores by adults than children ( p = 0.025). there is no significant difference between the two groups for the other posas items (itchiness, color, stiffness, thickness, and irregularity), the total score of the scar and the overall opinion of the scar scored by the patient ( table 1 ) . there is a significant difference between the two groups in pliability of the scar scored by the observer. the posas item pliability of the scars of the children was assessed higher, thus stiffer, than in adults ( p = 0.022). there is no significant difference between the two groups for the other posas items (vascularization, pigmentation, thickness, relief, and surface), the total score of the scar and the overall opinion of the scar scored by the observer ( table 1 ) . there is no significant difference between children and adults in the occurrence of wound problems post-surgery. there is no significant difference in scar measurements between children and adults. in children we found three hypertrophic scars and two keloid scars. in adults we found seven hypertrophic scars and three keloid scars. for both groups together that is a percentage of 14.3 hypertrophic and keloid scars ( table 2 ) . patients with fitzpatrick skin type i and iv-vi scored significantly higher, thus worse, in their overall opinion of the scar ( p = 0.024) than patients with skin type ii and iii. observer and patient assessed the overall opinion of the scar significantly higher (worse) in people who had gone through wound problems (respectively p = 0.020 and p = 0.007) than those who had not. we found no significant differences in the primary outcome measure between men and women, cup size a-c and d -g, smokers and non-smokers, bmi < 25 and bmi > 25, allergies and no allergies, and scar treatment and no scar treatment. age at creation of a sternotomy wound does not seem to influence the scar outcome. this is contrary to what is often the fear of a parent of a child who needs surgery early in life. comparing scars remains difficult because of the many factors that can influence scar formation. we found that scars have the tendency to change, even years after they are made. a limitation of the study is the retrospective design. the long follow-up period after surgery is a strength of the study. to our best knowledge this is the first study that compares scars of children and adults to specifically look at the clinical impact of age on scar tissue. in order to detect even more reliable and possibly significant differences between children and adults, more patients should be enrolled in future prospective studies. for now we can conclude that there is no significant difference in the actual scar outcome between children and adults in the sternotomy scar. if we extend these results to other scars, the timing of surgeries should not depend on the age of a patient. none. none. metc. reference number: w18_050 # 18.068. we published a systematic review of randomized controlled trials (rcts) on early laser intervention to reduce scar formation in wound healing by primary intention. 1 while comparing our results with two other systematic reviews on the same topic, 2 , 3 we identified various overt methodological inconsistencies in those other systematic reviews. issue 1. including duplicate data ( table 1 ) : karmisholt et al. 2 included two rcts of which both reported the identical data on five people. the inclusion of duplicate data can bias the results of a systematic review and should be prevented in the quantitative as well as the qualitative synthesis of evidence. abbreviations. id: identity; n.l.t.: no laser treatment; pcs: prospective cohort study; pmid: pubmed identifier; rct: randomized controlled trial. a) listed are rcts which were included by at least one of the three identified systematic reviews. the systematic reviews are ordered by search date from left to right. b) "search date" refers to the searching of bibliographic databases by the authors of the corresponding systematic reviews. c) "publication date" refers to the publication history status according to medline®/pubmed® data element (field) descriptions. d) "n.l.t." means that the authors of the rcts compared laser treatment with no treatment or a treatment without laser. e) "pcs" means that the authors used this term to label the corresponding rct. f) "-" indicates that an rct could not have been identified because the publication of the corresponding rct happened after the search date. g) "missing study" means that an rct could have been identified because the publication of a corresponding rct happened before the search date. h) "excluded" that the authors of the present review excluded the corresponding rct based on the exclusion criteria provided. i) "not analyzed" means that an rct was reported within an article but the corresponding data were not included in the metaanalysis. j) "other laser" means that the authors of the rcts compared various types of laser treatment. 2 attached the label "prospective cohort" to almost all considered studies including 16 rcts and seven nonrandomized studies. in rcts, subjects are allocated to different interventions by the investigator based on a random allocation mechanism. in cohort studies, subjects are not allocated by the investigator but rather allocated in the course of usual treatment decisions or peoples' choices based on a nonrandom allocation mechanism. 4 we believe that 'cohort study' is certainly not an appropriate label for rcts. furthermore, it is known for a long time that the shorthand labeling of a study using the words 'prospective' and 'retrospective' may create confusion due to the experience that these words carry contradictory and overlapping meanings. 5 issue 4. mixing data from various study designs: karmisholt et al. 2 did not clearly separate randomized from nonrandomized studies. combinations of different study design features should be expected to differ systematically, and different design features should be analyzed separately. 4 issue 5. unclear definition of outcomes and measures of treatment effect: kent et al. 3 reported, quote: "the primary outcome of the meta-analysis is the summed measure of overall efficacy provided by the pooling of overall treatment outcomes measured within individual studies." we think that the so-called "summed measure" is not defined and not understandable. the meta-analysis reported in that article included mean and standard deviation values from four rcts. these rcts applied endpoints and time periods for assessment which differed considerably among the included studies. it appears obscure to us which data were transformed in what way to finally arrive in the meta-analysis. we believe that traceability and reproducibility of data analyses are mainstays of systematic reviews. issue 6. missing an understandable risk of bias assessment: kent et al. 3 reported, quote: "the risk of bias assessment tool provided by revman indicated that all studies had 2-3 categories of bias assessed as high risk." the term "revman" is a short term for the software "review manager 5 provided by cochrane for preparing their reviews. the cochrane risk-of-bias tool for randomized trials is structured into a fixed set of domains of bias including those arising from the randomization process, due to deviations from intended interventions, due to missing outcome data, those in measurement of the outcome, and in selection of the reported result. we believe that the risk of bias assessment reported by kent et al. 3 is not readily understandable and presumably does not match standard requirements. systematic reviews of healthcare interventions aim to evaluate the quality of clinical studies, but they might have quality issues in their own right. the identification of various inconsistencies in two systematic reviews on plateletrich plasma therapy for pattern hair loss should prompt future authors to consult the cochrane handbook ( https: //training.cochrane.org/handbook ) and the equator network ( http://www.equator-network.org/ ). the latter provides information to various reporting standards such as prisma for systematic reviews, consort for rcts, and strobe for observational studies. the authors declare no conflict of interest. dear sir, journal clubs have contributed to medical education since the 19th century. 1 along the way, different models and refinements have been proposed. recently, there has been a shift towards "virtual" journal clubs, often using social media platforms. 2 our team has refined the face-to-face journal club model and successfully deployed it at two independent uk national health service (nhs) trusts in 2019. we believe there are reproducible advantages to this model. over 6 months at one nhs trust, 8 journal club events were held, with iterative changes made to increase engagement and buy-in of the surgical team. overall, tangible outputs included 3 submissions of letters to editors, of which 2 have been accepted. following this, the refined model was deployed at a second nhs trust, which had expanded academic support increasing its impact. over 4 months, 6 journal club events were held, with 4 submissions of letters to editors, 3 of which have been accepted. thus, in 10 months of 2019, the two sequential journal clubs generated 7 submissions for publication, with 16 different authors. these tangible outputs are matched by other intangible benefits, such as improving critical appraisal skills. this is assessed in uk surgical training entry selection and is also a key skill for evidence-based professional practice. therefore, we feel this helps our team members' career progression and clinical effectiveness. key aspects of the model include: 1. face-to-face meetings continue to have multiple intangible benefits there is a trend towards social media and online journal clubs. while such initiatives have considerable benefits, maintaining face-to-face contact in a department allows for an efficient discussion, and enhances teambuilding. instead of replacing face-to-face meetings with virtual ones, we use social media platforms, such as whatsapp, to support our events. this includes communications to arrange the event in advance, and for maintaining momentum on post-event activities, such as authoring letters to journals from the discussion. while some articles describing journal club models highlight the benefit of expert input in article selection, 1 we also view it as a learning opportunity. a surgical trainee is allocated to present each journal club, with one of our three academically appointed consultant surgeons chairing and overseeing. trainees are encouraged to screen the literature and identify articles beforehand and make a shared decision with the consultant. the article must be topical and have potential to impact clinical practice. doing this prior to the session allows the article to be circulated to attendees with adequate time to read it. we routinely use both reporting guidelines (e.g., prisma for systematic reviews), and also methodological quality guidance (e.g., amstar-2 for systematic reviews) to guide trainees and structure the journal club presentation. in addition to three consultants with university appointments guiding critical appraisal, a locally based information scientist also joins our meetings. during journal club discussion, emphasis is placed on relating the article to the clinical experience of team members. this provides context and aids clinical learning for trainees. while undertaking critical appraisal may be a noble endeavour, in busy schedules, it is important that it adds value for everyone involved. reviewing contemporary topics can inform clinical practice for all levels of surgeon in the team, presenting the article improves trainees' presentation skills, and publishing the appraisal generates outputs that help trainees to progress. 8. publishing summaries of journal club appraisals can impact on multiple levels journal club does not only contribute to our trainees' development and departmental clinical practice. it benefits our own research strategy and quality, and open discussion of literature in plastic surgery contributes to a global culture of improving evidence. scheduling events on a regular basis increases familiarity with reporting and quality guidance and allows for the study of complementary article types (e.g., systematic review, randomised trial, cohort study). our iterations suggest that the following structure is most effective: joint article selection one week before event, dissemination to audience, set time and location during departmental teaching, chairing by an academic consultant with information scientist and senior surgeons present, presentation led by a surgical trainee, open-floor discussion of article and its implications for our own practice, summary, drafting of letter to the editor if appropriate. as we have used variations of this model successfully at two independent nhs trusts, we believe that these tactics can be readily adapted and deployed by others as well. nil. dear sir, surgical ablation of advanced scalp malignancies requires wide local excision of the lesion, including segmental craniectomies. the free latissimus dorsi (ld) flap is a popular choice for scalp reconstruction due to its potential for mass surface area resurfacing, ability to conform to the natural convexity of the scalp, reliable vascularity and reasonable pedicle length. 1 one of the disadvantages of ld free flap use is the perceived need for harvest in in a lateral position. this necessitates a change in position of the patient intraoperatively for flap raise and can add to the overall operative time. current literature in microvascular procedures on the elderly demonstrates that a longer operative time is the only predictive factor associated with an increased frequency of post-operative medical and surgical morbidity. as most patients undergoing scalp malignancy resection are elderly it is important to reduce this surgical time in this cohort of patients. 2 , 3 we present our experience of reconstruction of composite cranial defects with ld flaps using a synchronous tumour resection and flap harvest with supine approach to reduce operative times and potential morbidity. all patients undergoing segmental craniectomies with prosthetic replacement and ld reconstruction under the care of the senior surgeons were included in the study. patients were positioned supine with a head ring to support the neck; a sandbag is placed between the scapulae and the arm on the chosen side of flap raise is free draped. a curvilinear incision is made posterior to the midaxillary line ( figure 1 ). the lateral border of the ld muscle is identified, and dissection continued in a subcutaneous plane inferiorly, superiorly and medially until the midline is approached. the muscle is divided at the inferior and medial borders, and the flap lifted towards the pedicle. once the pedicle is identified, the assistant can manipulate the position of the free draped arm to aid access into the axilla; the pedicle is clipped once adequate length has been obtained. the flap is delivered through the wound and detached ( figure 2 ). donor site closure is carried out conventionally.the flap inset is performed using a "vest over pants" technique utilising scalp over muscle by undermining the remaining scalp edges. 5 a non-meshed skin graft is used to enhance aesthetic outcome. a total of 11 patients underwent 12 free ld muscle flaps. all were muscle flaps combined with split-thickness skin grafts. the study population included ten male patients and one female. the age range was 47-74 years with a mean age of 69.5 years. the defect area ranged from 99 cm 2 -360 cm 2 . a titanium mesh was utilised for dural cover in all patients fixed with self-drilling 5 × 1.5 mm cortical screws. the primary recipient vessel used was the superficial temporal artery and vein. however, in cases where a simultaneous neck dissection and parotidectomy are necessary for regional disease, the facial artery and vein are used ( n = 1 in this series) or contralateral superficial temporal vessels. the ischaemia time ranged from 48-71 min, with a mean of 61.3 min. there were no take backs for flap re-exploration. the overall flap success rate was 100%. marginal flap necrosis with secondary infection occurred in one patient with a massive defect (at one week post-op). the area was debrided and a second ld flap was used to cover the resultant defect (30%). a further posterior transposition flap was used to cover a minor area of exposed mesh. the scalp healed completely. the total operating time ranged between 210-410 min, with a mean of 289 min. all patients were followed up at 2 and then four weeks for wound checks. the ld flap remains a popular choice due to its superior size and ability to conform to the natural convexity of the scalp compared with other flap choices. 4 also, unlike composite flaps which often require postoperative debulking procedures, the ld muscle flap atrophy's and contours favourably to the skull. 5 however, the traditional means of access to this flap requires lateral decubitus positioning of the patient, which can hinder simultaneous oncological resection. the supine position facilitates access for neck dissection, especially if bilateral access is required. our approach ensures that the tumour ablation and reconstruction is carried out in a time efficient manner in an attempt to reduce postoperative medical and surgical complications. synchronous ablation and reconstruction are key in reducing overall operative time and complication risk and is practised preferentially at our institute. it is important to maintain a degree of flexibility to achieve this -there may be situation where supine positioning overall is more favourable. likewise, there are situations relating to flap topography where a lateral approach to tumour removal and reconstruction is preferred. the resecting surgeon or reconstructive surgeon may have to compromise to achieve synchronous operating but is worthwhile to reduce overall total operative time. none. not required. once established, lymphorrhea typically persists and can present as an external lymphatic fistula. lymphorrhea occurs in limbs with severe lymphedema, as a complication after lymphatic damage, and in obese patients. some cases are refractory to conservative treatment and require surgical intervention. reconstruction of a lymphatic drainage table 1 three patients had primary lymphedema, 4 had age-related lymphedema, 3 had obesity-related lymphedema, and 2 had iatrogenic lymphorrhea. in the 2 cases of iatrogenic lymphorrhea, the lesions were located in the groin and the others in the lower leg. abbreviations: bmi, body mass index; f, female; m, male. three patients had primary lymphedema, four had agerelated lymphedema (aging of the lymphatic system and function is thought to be the cause of age-related lymphedema 1 .), three had obesity-related lymphedema, and two had iatrogenic lymphorrhea ( table 1 ) . one of 2 cases of lymphorrhea in the inguinal region was caused by lymph node biopsy and the other by revascularization after resection of malignant soft tissue sarcoma. compression therapy had been performed preoperatively in 10 cases (using cotton elastic bandages in 6 cases). four patients wore a jobst r compression garment. compression therapy was difficult to apply in 2 patients. the duration of lymphorrhea ranged from 1 to 192 months. the severity of lymphedema 2 ranged from campisi stage 2 to 4 ( table 1 ). the clinical diagnosis of lymphorrhea was confirmed by observation of fluorescent discharge from the wound on lymphography. no signs of venous insufficiency or hypertension were observed in the subcutaneous vein intraoperatively. all anastomoses were performed between distal lymphatics and proximal veins. postoperatively, lymph was observed to be flowing from the lymphatic vessels to the veins. two to 4 lvas were performed in the region distal to the lymphorrhea and 1-4 in the region proximal to the lymphorrhea in patients with lower limb involvement. six lvas were performed in patients with lymphorrhea in the inguinal region ( table 1 ) . all patients were successfully treated with lvas without perioperative complications. the volume of lymphorrhea decreased within 5 days following the lva surgery in all cases and had resolved by 2 weeks postoperatively. the compression therapy used preoperatively was continued postoperatively. there has been no recurrence of lymphorrhea or cellulitis since the lvas were performed. an 86-year-old woman had gradually developed edema in her lower limbs over a period of 2-3 years. she had also developed erosions on both lower legs ( figure 1 ). compression with cotton bandages failed to terminate the percutaneous discharge; about 400 ml of lymphatic discharge through the erosion was noted each day. ultrasonography did not suggest a venous ulcer resulting from venous thrombosis, varix, or reflux. four lvas were performed in each leg (3 distal and 1 proximal to the leak). the lymphorrhea had mostly resolved by 5 days postoperatively. the erosions healed within 3 weeks of the surgery. no recurrence of lymphorrhea was noted during 12 months of follow-up. iatrogenic lymphorrhea occurs after surgical intervention involving the lymphatic system. it is also known to occur in patients with severe lymphedema. obesity 3 and advancing age 1 are also risk factors for lymphedema. most patients with lymphorrhea respond to conservative measures but some require surgical treatment. patients with lymphorrhea are at increased risk of lymphedema. lymphorrhea that occurs after surgery or trauma is caused by damage to lymphatic vessels that are large enough to cause lymphorrhea. lymphorrhea that occurs in association with lipedema or age-related lymphedema indicates accumulation of lymph that has progressed to lymphorrhea. it is possible to treat lymphorrhea by other methods, including macroscopic ligation, compression, or negative pressure wound therapy 4 . however, it is impossible to reconstruct a lymphatic drainage route using these procedures. we hypothesized that lymphorrhea can be managed by using lva to treat the lymphedema. lva is a microsurgical technique whereby an operating microscope is used to perform microscopic anastomoses between lymphatic vessels and veins to re-establish a lymph drainage route. the primary benefits of lva are that it is minimally invasive, can be performed under local anesthesia, and through incisions measuring 2-3 cm. one anastomosis is adequate to treat lymphorrhea and serves to divert the flow of the lymphorrhea-causing lymph to the venous circulation. if operative circumstances allow, 5 or more anastomoses are recommended for the treatment of lymphorrhea complicated by lymphedema. lymphedema is a cause of delayed wound healing, and lva procedures are considered to improve wound healing in lymphedema via pathophysiologic and immunologic mechanisms 5 . lva is a promising treatment for lymphorrhea because it can treat both lymphorrhea and lymphedema simultaneously. the focus when treating lymphedema has now shifted to risk reduction and prevention, so it is important to consider the risk of lymphedema when treating lymphorrhea. none over-meshing 1:1 meshed skin graft we were curious to learn if it's feasible to mesh already meshed skin grafts. we run our skin bank at the department of plastic surgery 1 and used allograft skin that was tested microbiologically positive and thus not suitable for patient use. grafts were cut into 4 cm x 4.5 cm pieces and meshed using mesh carriers to 1:1 and over-meshed with 1:1.5. we used two kind of mesh carriers for 1:1.5 meshes. the meshed grafts were maximally expanded and measured again. the results were expressed as ratios, figure 1 . we found that, over-meshing results in 1.25-fold increase in graft area regardless of the mesh carrier used. figure 2 illustrates close-up picture of the over-meshed graft. in the close-up picture the small 1:1 incisions are still visible. in those undesirable "oh no the graft is too small"or "the graft is too large" -situations this technique has its advantages. we have used over-meshed graft in a skin graft harvest site, supplemental figure, with acceptable outcome. it seems that the tiny extra incisions in the overmeshed skin graft do not deteriorate the aesthetic outcome from the 1:1.5 mesh. what is the clinical value of the tiny incisions, we don't know, but we approximate it to be minimal if even that. to best of our knowledge, only one previous publication has addressed the over-meshing of skin grafts 2 . henderson et al. showed in porcine split thickness skin grafts that overmeshing resulted in increase of 1.5 ratio, a bit larger compared to our results. taken together, the results point to the direction that meshing of already meshed graft is feasible and does not destroy the architecture of the original or succeeding mesh. each author declares no financial conflicts of interest with regard to the data presented in this manuscript. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 048 . numerous autologous techniques for gluteal augmentation flaps have been described. in the well-known currently employed technique for gluteal augmentation, it is noticeable that added volume is unevenly distributed in the buttock. in fact, after a morphological analysis, it becomes clear that the volume is added to the upper buttock to the expense of the lower buttock. 1 according to wong's ideal buttock criteria, the most prominent posterior portion is fixed at the midpoint on the side view. 2 additionally, mendieta et al. suggest that the ideal buttock needs equal volume in the four quadrants and its point of maximum projection should be at the level of the pubic bone. 3 we describe a technique of autologous gluteal augmentation using a para-sacral artery perforator propeller flap (psap). this new technique can fill up all the quadrants vertically with a voluminous flap shaped like a gluteal anatomic implant. gluteal examination is done in a standing and prone position. patients must have a body mass index less than 30 kg/m2, an indication for a body lift contouring surgery, gluteal ptosis with platypygia and substantial steatomery on the lower back. when the pinch test is greater than 5 cm this is defined as substantial steatomery. preoperative markings: the ten steps a. standing position 1. limits of the trunk. the median limit (mlt) and the vertical lateral limit (llt) of the trunk are marked. 2. limits of the buttock. the inferior gluteal fold (igf) is drawn. the vertical lateral limit of the buttock (llb) is defined at the outer third between the mlt and the llt. 3. lateral key points. points c and c' are located on the vertical lateral limits: point c is 2 to 3 cm below the iliac crest, depending on the type of underwear. point c' is determined by an inferior strong tension pinch test performed from point c. mhz. this diagnostic tool is easy to access, non-invasive, and above all, reliable in the identification of perforating arteries, with sensitivity and a positive predictive value of almost 100%. 4 usually, one to three perforators are identified on each side and marked. 9. design of the gluteal pocket. the shape is oval, with the dimensions similar to those of the flaps. the base is truncated and suspended from the lower resection line. the width of the pocket is one to two centimeters from the lmt laterally and two centimetres from llt medially. the inferior border of the pocket is not more than two fingers'-breadth above the ifg. therefore, the pocket lies medial in the gluteal region. 10. design of the flap. the flap is shaped like a "butterfly wing" with the long axis following a horizontal line. after a 90 °medial rotation, the flap has a shape similar to an anatomical gluteal prosthesis. the medial boundary is two fingers'-breadth from the median limit of the buttock, and the width is defined by the two resection limits. the patient is placed in a prone position, arm in abduction. the flap is harvested from lateral to medial direction, first in a supra-fascial plane then sub-fascial when approaching the llb. the dissection is completed when the rotation arc of the flap is free of restriction (90 °−100 °), and viewing or dissection of the perforators is usually not required. to create the pocket, custom undermining is done in the sub-fascial plane according to the markings. the flap is then rotated and positioned into the pocket. the superficial fascial system is closed with 0 vicryl (ethicon) and the deep and superficial dermis are closed with a buried intradermal suture and running subcutaneous suture with 3.0 monocryl (ethicon). a compressive garment (medical z lipo-panty elegance coolmax h model, ec/002-h) was worn postoperatively for one month ( figure 1 ). rhinoplasty is one of the most common procedures in plastic surgery and 5-15% of the patients undergo revision. dorsal asymmetry is the leading (65%) nasal flaw in secondary patients. 1 careful management of the dorsum to achieve a smooth transition from radix to tip is necessary. camouflage techniques are well known maneuvers for correcting dorsal irregularities. cartilage, fascia, cranial bone, and acellular dermal matrix were previously used for this aim. 2 , 3 bone dust is an orthotopic option, which is easily moldable into a paste. it is especially useful in closed rhinoplasty, where our visual acuity on the dorsum is reduced. we introduce a new tool, a minimally invasive bone collector, as an effective and safe device for harvesting bone dust from the nasal bony pyramid to obtain camouflage on the dorsum and for performing ostectomy simultaneously. patients were operated for nasal deformity by the senior author (o.b.) with closed rhinoplasty between february 2018 and november 2018. in all cases, a minimally invasive bone collector was used for ostectomy and the harvest of bone dust. included patients were primary cases with standardized photos, complete medical records, and 1-year follow-up. written informed consent for operation and publishing their photographs was obtained and the study was performed in accordance with standards of declaration of helsinki. the authors have no financial disclosure or conflict of interest to declare. patient data were obtained from rhinoplasty data sheets and photographs were used for the analysis of nasal dorsum height, symmetry, and contour. physical examinations were carried out for detecting irregularities. micross (geitslich pharma north america inc., princeton, new jersey) is a bone collector, which allows easy harvest, especially in narrow areas. micross comes with a package containing 1 sterile disposable scraper. it is externally 5 mm in diameter and has a cutting blade tip. a collection chamber allows harvesting maximum of 0.25 cc graft at once. a sharp technique improves graft viability. incisions for lateral osteotomies were used to introduce micross when the planned ostectomy site was nasomaxillary buttress. infracartilaginous incision was used when the desired ostectomy site was dorsal cap or radix. bone dust was collected into a chamber with a rasping movement. the graft is mixed with blood during the harvest, this obtains an easily moldable bone paste (surgical technique is described in the video). after the completion of osteotomies and cartilaginous vault closure, the bone paste was placed on the site of bony dorsum, which is likely to show irregularities postoperatively. a nasal splint was used to maintain contour. the bone graft was not wrapped into any other graft. eighteen patients underwent primary closed rhinoplasty with 1-year follow-up. seventeen of 18 patients were female and one was male. harvesting sites were nasomaxillary buttress in 18 patients, radix in 7 patients and dorsal cap in 5 patients. the total graft volume was between 0.25 and 0.5 cc/per patient. the nasal dorsum height, symmetry, contour, and dorsal esthetic lines were evaluated using standardized preoperative and postoperative photographs. dorsal asymmetry, overcorrection of the dorsal height or residual hump were not observed in 17 of the patients ( figures 1-4 ). only 1 patient had a visible irregularity of the dorsum. physical examination revealed palpable irregularities in 3 patients. none of the patients required surgical revision for residual or iatrogenic dorsum deformity. asymmetries and irregularities of the upper one-third of the nose, lead to poor esthetic outcomes, and secondary revision surgeries. to treat open roof after hump resection; lateral osteotomies, spreader grafts, flaps and camouflage grafts are commonly used. warping, resorbtion and migration, visibility, limited volume, donor site morbidity, and the risk of infection are the main disadvantages of grafts. örero glu et al. have presented their technique of using diced cartilage combined with bone dust and blood. 4 tas have reported results with harvesting bone dust with a rasp and using this for dorsal camouflage. 5 the disadvantages of harvesting with a rasp were difficulty with collecting dust from the teeth of the rasp and losing a certain amount of graft material during the harvest. with using micross, a harvested graft is collected in the chamber, thereby the risk of losing the graft material is resolved. replacing "like with like" tissue concept is important, therefore the reconstruction of a bone gap can be achieved successfully with bone grafts. to limit the donor site morbidity, we prefer to harvest bone from the dorsal cap, which was preoperatively planned to be resected. the preference of lateral osteotomy lines as the donor site facilitates osteotomies by thinning the bone. the device allows us to effectively harvest the bone under reduced surgical exposure. simultaneous harvest and ostectomy contributes to a reduced operative time. operative cost is relatively low in comparison with alloplastic materials. in this series, we did not experience resorbtion, migration, visibility problems, or infection with bone grafts. a new practical, safe, and efficient tool for rhinoplasty was introduced. graft material was successfully used for smoothing the bony dorsum without any significant complications. none. not required. the authors have no financial disclosure or conflict of interest to declare in relation to the content of this article. no funding was received for this article. the work is attributed to ozan bitik, m.d. (private practice of plastic, reconstructive and aesthetic surgery in ankara, turkey) dear sir, early diagnosis of wound infections is crucial as they have been shown to increase patient morbidity and mortality. hence, it is important that such infections are detected early to guide decision-making and management 1 . currently, the most common methods of identifying wound infection is by clinical assessment and semi-quantitative analysis using wound swabs. bedside assessment is subjective, and it is shown that bacterial infection can often occur without any clinical features. on the other hand, swabs have the disadvantages of missing relevant bacterial infection at the periphery of the wound due to the sampling technique as well as delaying diagnostic confirmation which may lead to a change in the bioburden of the wound. although tissue biopsy is the gold standard diagnostic tool, it is seldom used as it is invasive, has a higher technical requirement and is also more expensive. a hand-held and portable point-of-care fluorescence imaging device (moleculight i:x imaging device, moleculight, toronto, canada) was introduced to address the limitations of the other diagnostic methods 2 . this device takes advantage of the fluorescent properties of certain by-products of bacterial metabolism such as porphyrin and pyoverdine. when excited by violet light (wavelength 405 nm), porphyrins will emit a red fluorescence whereas pyoverdine has a cyan/blue fluorescence. the types of bacteria that produce porphyrins include s. aureus, e. coli , coagulase-negative staphylococci, beta-hemolytic streptococci and others whereas pyoverdine which emits cyan fluorescence is specific to pseudomonas aeruginosa. this allows users to localise areas of bacterial colonisation at loads ≥10 4 amongst healthy tissue which instead emits green fluorescence 3 . the benefits of this device are that it is portable, non-contact which means minimising cross-contamination, non-invasive and it provides real-time localization of bacterial infection. all these features allow it to be a useful tool to aid diagnosis and guide further investigation and management. many previous studies that have examined the efficacy of auto fluorescent imaging in diagnosing infections in chronic wounds 3-5 . however, equally important is identifying infections in acute wounds which will help guide antimicrobial management as well as surgical debridement. often, broad-spectrum antibiotics are given where clinical assessment remains inconclusive. this, however, may lead to an increase in antimicrobial resistance. therefore, the use of moleculight i:x to identify infections in acute open wounds in hand trauma was evaluated. we collected data from patients who attended the hand trauma unit over a 4-week period prior to irrigation and/or debridement. wounds were inspected for clinical signs of infection and autofluorescence images were taken using the moleculight i:x device. wound swabs were taken, and the results of these interpreted according to the report by the microbiologist. autofluorescence images were interpreted by a clinician blinded to the microbiology results. 31 patients were included, and data collected from 35 wounds. 3 wounds (8.6%) showed positive clinical signs of infection, 3 (8.6%) were positive on autofluorescence imaging and 2 (5.7%) of wound swab samples were positive for significant infection. autofluorescence imaging correlated with clinical signs and wound swab results for 34 wounds (97.1%). in one case, the clinical assessment and autofluorescence imaging showed positive signs of infection but the wound swabs were negative. to the best of our knowledge, this is the first time the use of autofluorescence imaging in an acute scenario was investigated. in this study, out of 2 of the wound swab samples that were positive, autofluorescence imaging correctly identified both (100%) ( fig. 1 ) . one of the autofluorescence images which showed red fluorescence on the wound and which was clinically identified as infected showed growth of usual regional flora on microbiological studies. the reason behind this could be due to the method of sampling from the centre of the wound. on autofluorescence image, the areas of significant bacterial growth were on the edges of the wound ( fig. 2 ) . this example illustrates the potential of using autofluorescence imaging to guide more accurate wound sampling. this has also been shown in a non-randomised clinical trial performed by ottolino-perry et al. 4 . from a surgeon's perspective, autofluorescence imaging can guide surgical debridement by providing real-time information of the infected areas of the wound. furthermore, because of its portability, this device can also be used in intra-operative scenarios to provide evidence of sufficient debridement. although easy to use, the requirement for a dark environment causes a logistical problem. the manufacturers have realised that this is a limitation of the device and have created a single-use black polyethene drape called "darkdrape" which connects to the moleculight i:x using an adapter to provide optimal conditions for fluorescence imaging. while autofluorescence imaging can help clinicians to decide whether to start antibiotics or not, it does not provide any information on the sensitivities of the bacteria. another limitation with autofluorescence imaging we encountered in our study is the difficulty with imaging acute bleeding wounds where blood shows up as black on fluorescence and therefore may mask any underlying infection. in conclusion, autofluorescence imaging in acute open wounds may be useful to provide real-time confirmation of wound infection and therefore guide management. none declared. none received. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2020.03. 004 . when compared with the two previously published studies, publication rates have improved from 2007 and have not continued to decline. interestingly, the number of publications in jpras has fallen. this may be explained by a rise in the impact factor of the journal, increasing competitiveness for publications as well as an expansion in the number of surgical journals. we observed that journal impact factor for free paper publications was significantly greater and likely reflects the stringency of the bapras abstract vetting process. comparison with other specialties is inherently difficult, primarily due to differences in study design and inclusion criteria. exclusion of posters, inclusion of abstracts published prior to presentation and studies not referenced in pubmed affect the reported publication rates. a large meta-analysis, assessing publication of abstracts, reported rates of 44%. 3 rates from other specialties are shown in figure 2 . although our figures of close to 30% may seemingly rank low versus other specialties, including abstracts published prior to presentation would increase the publication rate to 39%, therefore making it more comparable. however, this would not be a direct comparison to the two previous bapras studies. one may debate that the academic value of a meeting should be judged upon its abstract publication ratio. however, the definition of a publication is itself clouded, with an increasing number of journals not referenced in the previous 'gold standard' of pubmed, including a number of open access journals. 4 most would still argue the importance of stringent peer review as the hallmark of a valuable publication 5 and perhaps this along with citability should remain the benchmark. in an age where publications are key components of national selection and indeed lifelong progression in many specialties, we must ensure that some element of quality control remains so as not to dilute production of meaningful data. we have been able to reassess the publication rates for the primary meeting of uk plastic surgery. the bapras meeting remains a high-quality conference providing a platform to access the latest advances in the field. significant differences in the methodology of available literature make other speciality comparisons challenging. however, when these are accounted for publication rates are similar. within a wider context, with the increase in open access journals, it has become ever more difficult to define a 'publication'. if publication rate is to be used as a surrogate for meeting quality, then only abstracts published after the date of meeting should be included. in order to continually assess the quality of papers presented at bapras meetings, the conversion to publication should be regularly re-audited. none. dear sir, global environmental impact and sustainability has been a heated topic in the recent years. plastics and singleuse items are widely, and perhaps unnecessary, used in the healthcare sector. various recent articles 1 , 2 discuss the negative impacts of this in the surgical world, but can we look at the nhs sustainability as a bigger picture? whilst it is a positive step to be considering how we can reduce the environmental impact of modern operating practice, it risks falling into the trap of being overly focused and not taking an holistic view of how the health service as a whole can become more environmentally focused and reduce costs. in fact, the operating theatre is one of the more difficult places to make change. single use medical devices seem like an obvious item to replace with a more environmentally friendly re-usable alterative, but what about patient safety? such a change would require the implementation of new workflows and supervision structures to make sure patient safety is maintained. these take time to create, will meet resistance in their design and implementation, and may not ultimately be adopted. in order to overcome these challenges, we must take a holistic view of the hospital environment -doing this reveals numerous opportunities for improvement with minimal impact on patient safety. the nhs incurs significant waste through using energy unnecessarily. some examples are readily visibly working in a hospital for a just few weeks: computers are left on standby through the night and at weekend; lights are left on throughout the night; and empty rooms are heated or cooled when left unoccupied. other sources of energy waste are less visible, but it is likely that some machinery (particularly air conditioning units) would show rapid return on investment through energy savings if they were replaced on a more regular basis. in the past, saving energy would have required a sustained campaign to educate staff and still be subject to the vagaries of human management (forgetting to switch the heating off on a friday night could lead to more than two days of wasted energy if not revisited until monday). today, solutions based on internet of things (iot) technology can use sensors to monitor the environment and take action to reduce consumption. with the use of ai and machine learning, these systems are becoming advanced such that they can even monitor and anticipate energy usage allowing rooms to be heated or cooled at times which mean that when staff arrive in the relevant room it is the ideal temperature. the nhs is starting to use such technology, with wigan hospital as the first example to install intelligent lighting. 3 adoption should not be limited to lighting, however, and the nhs needs to adopt best practice from the commercial sector. for example, sensorflow based in singapore, provide an intelligent system that optimises cooling/heating costs for hotels around south east asia, saving the operators up to 40% in energy costs. 3, 4 without doubt, these systems can also apply to hospital infrastructures and can help the nhs further reduce energy consumption. in addition to reducing energy consumption, the reduction of single use plastics has become a key focus in recent years and the nhs has started to address this issue. at least 196 million single use plastic items were purchased by the nhs last year. 5 the target to phase out plastic items used by retailers in the next 12 months is laudable, however there is also a significant amount of disposable plastic items used in staff coffee rooms and hospital canteen. getting rid of such items completely and encourage staff to use reusable coffee cups and metal cutlery can potentially compound the cost-saving and environmental benefits. the nhs has established an early leadership position tackling environmental challenges -the first european intelligent lighting installation and ambitious targets to cut disposable plastic items -but more needs to be done. to maximise impact, the nhs needs to be seen as a whole (not by department) with the most senior executives in the health service driving national level change. we read with interest the recent article 'healthcare sustainability -the bigger picture'. 1 the wider picture of the nhs environmental impact and sustainability clearly needs to be addressed. however, large-scale improvement projects to hospital buildings, such as intelligent lighting and heating systems, are likely to require huge investment in infrastructure and modernisation that the nhs in its current form is unfortunately unlikely to be able to make. we believe that the field of medical academia should similarly be contributing to environmental sustainability. firstly, the shelves of hospital libraries and offices internationally are lined with print copies of journals. we reviewed the 20 surgical journals with the highest impact factors and found that all were still offering the option of a subscription of print copies, with 19 of these printing monthly issues. 2 consumers are able to access all journals electronically through institutional subscriptions or via the nhs openathens platform, which in our view is a more time-efficient way to search for articles, read them and to reference them. as such, we commend jpras for their recent move to online-only publication. additionally, with the increasing use of social media to discuss research and the creation of visual abstracts for articles to encourage readership, this will be likely to encourage this shift further. secondly, the environmental impact of the current academic conferencing culture must be addressed. by the end of training, a uk surgical trainee spends an average of £5411 attending academic conferences, but beyond this personal expenditure, what is the environmental cost? 3 for each conference we attend, the printing of poster presentations, conference programmes and certificates all detrimentally impact our environment. furthermore, consider the conference sponsor bags we receive, filled with further printed material, plastic keyrings, stress-balls and disposable pens, all contributing to the build-up of plastic in our oceans. 4 conferences, such as the british association of plastic and reconstructive surgeons scientific meeting, have now started using electronic poster submissions, with presentations being held consecutively on large television screens -but further measures are possible. a well-designed conference smartphone app forgoes the need for printed programmes and leaflet advertising from sponsors and could include measures to reduce the carbon footprint, such as promotion of ride-share options for venue travel. the concept of virtual conferences has also been explored. organisers of an international biology meeting recently asked psychologists to assess the success of a parallel virtual meeting, with satellite groups organising local social events afterwards. more than 80% of the delegates joined online and there was an overall 10% increase those attending the conference; a full analysis of the success of this approach to conferences is awaited. 5 virtual conferences may enable delegates to sign in from multiple time zones and minimise travel, disruption of clinical commitments and time away from family. this option is being pursued by the reconstructive surgery trials network (rstn) in the uk, whereby the annual scientific meeting will be delivered using teleconferencing technology at four research active hubs across the uk, reducing delegate travel substantially and the conference's carbon footprint in turn. there is a clear but unmeasurable benefit of networking face-to-face for formation of personal connections, exchange of knowledge and opportunities for collaboration. the use of social media, instant messaging applications and modern teleconferencing technology are vital to retain this valuable aspect of academic conferencing. equally, perhaps there is a balance to be found, with societies currently holding biannual meetings moving to include one virtual, or running a parallel virtual event for those travelling long distances. the academic community must play a role in environmental sustainability by reducing the carbon footprint of our journals and conferences. jcrw is funded by the national institute for health and research (nihr) as an academic clinical fellow. none for completion of submission. none. we read with interest the study by sacher et al., who compare body mass index (bmi) and abdominal wall thickness (awt) with the diameter of the respective diea perforator and siea. 1 they found that there was a significant ( p < 0.05) positive correlation between these variables, concluding that this association may mitigate for the increased perioperative risk seen in patients with high bmi. their findings disagree with a previous smaller study by scott et al. 2 reconstruction in the high bmi patient group can be challenging, and is associated with higher complication rates. 3 despite this, satisfaction with autologous reconstruction appears similar across bmi categories. 4 as the authors discuss, perfusion, as a function of perforator diameter, is of key relevance to the safety of performing autologous breast reconstruction in patients with higher bmi. larger perforator sizes relative to total flap weight have been suggested to reduce the risk of post-operative flap skin or fat necrosis. 5 while this is likely an oversimplification, as flap survival will also depend on multiple factors including perforator row compared to abdominal zones harvested, it does suggest that if the high bmi patient group has reliably larger perforators then their risk profile may be reduced. however, we suggest caution regarding reliance on the correlation they found between bmi or awt and perforator size when planning free tissue transfer. while they demonstrate p values suggesting correlation between bmi or awt and perforator diameter, the r (correlation coefficient) values that they determined through pearson correlation analysis are low, ranging from 0.219 to 0.456. the resulting r 2 (coefficient of determination) values are therefore in the range 0.048-0.21, suggesting that only 4.8-21% of the variation in perforator diameter can be related to bmi or awt. it is therefore likely that other variables, such as height and historical abdominal wall thickness, that were not accounted for in the correlation analysis also play roles in determining perforator size, in addition to anatomical variation. in addition, their analysis and results depend on a linear relationship between the variables, which may not be the case. therefore although the authors demonstrate a correlation between abdominal wall thickness and perforator size, there is substantial variation between individual patients and so this relationship cannot be relied upon when planning autologous reconstruction. we read with interest pescarini's et al. article entitled 'the diagnostic effectiveness of dermoscopy performed by plastic surgery registrars trained in melanoma diagnosis'. 1 the article is of great interest in highlighting the potential of plastic surgery registrar training in domains such as dermoscopy, especially for those trainees looking to specialise in skin cancer. training in these experiential skill domains is essential to building a diagnostic framework, and the comparable accuracy in diagnosis to dermatologists reflects this. it would be of great benefit to understand further how diagnostic accuracy evolves along the inevitable learning curve experienced using the dermoscope. pescarini et al. comment briefly on method of training but we believe the timeline is key, as is mentorship and regular appraisal. terushkin et al. found that for the first year of dermoscopy training benign to malignant ratios in fact increased in trainee dermatologists before going on to decrease 2 potentially secondary to picking up more anomalies but not yet having the skill set to determine if these are benign or not. there is no reason to suggest that plastic surgery trainees' learning curves should differ significantly. this of course would skew the data presented in terms of accuracy at the end of the three year study period. more helpful would be a demonstration of how accuracy changes with time and experience, as one would expect, and of course how these rates are comparable to those of dermatologists. this would have implications for training programmes where specific numbers of skin lesions or defined timeframes for skin exposure during training are set as benchmarks for qualification. this is particularly pertinent for uk trainees; the nice guidelines for melanoma state that dermoscopy should be undertaken for pigmented lesions by 'healthcare professionals trained in this technique'. 3 to understand the number of lesions that trainee plastic surgeons have to assess with a dermatosope before their diagnostic accuracy improves -or the time needed to achieve that accuracymight be a key factor for placement duration and numbers required for trainees to become consciously competent dermoscopic practitioners. reproducible training programmes in this regard are therefore vital. it must be pointed out that the role of the dermascope for plastic surgeons is likely to be narrower than for our dermatological colleagues. within the uk, the role of the plastic surgeon is primarily reconstructive, with some subspeciality involvement in diagnosis of melanomas and a range of non-melanomatous skin cancers and skin lesions. the dermoscope is primarily a weapon in the diagnosis of insitu or early melanoma for plastic surgeons where diagnostic certainty is unclear following a referral for consideration for surgical removal. where doubt remains over a naevus, surgical excision is still the normal safe default. dermatologists use dermoscopes for a broad range of diagnostic purposes on a wide variety of skin conditions. the familiarity and expertise with this instrument that they garner is therefore not surprising. we must be clear in resource-limited healthcare systems about what our specific roles are as plastic surgeons and how the burden of patient assessment is shared to appropriately deploy our skills within the context of a broader multidisciplinary framework. accuracy with the dermoscope is essential to safely treating patients in a binary fashion -should the lesion be removed or monitored? comparison with dermatological expertise is helpful as a guide and dermoscopy has an important diagnostic role for plastic surgeons, but we should not strive to be equivalent in skills to dermatologists with dermascopes at the expense of the development of vital surgical reconstructive skills and excellence throughout plastic surgery training. response to the comment made on the article "the diagnostic effectiveness of dermoscopy performed by plastic surgery registrars trained in melanoma diagnosis" we strongly agree with the benefit correlated to understand the learning curve experienced by plastic surgery registrars using the dermoscope. as stated in our article, the limit of our study is its retrospective nature. moreover, the training and the level of competence differed between the three registrars. at the beginning of the data collection, two of them were at their third year of specialist training and were using dermoscope since at least one year while the other one was at his first year. all the registrars attended specific but different dermoscopy courses and all of them completed a 10 h on site training with a competent consultant. for this reason, the expertise partially differed among the three registrars. nevertheless, we believe a 3 years' period should be long enough to truly homogeneously estimate the accuracy in diagnosis of melanoma by them. in fact, townley et al. 1 demonstrate the attendance of the first international dermoscopy for plastic surgeons, oxford, improved the accuracy of diagnosing malignant skin lesions by dermoscopy rather than using naked eye examination. we believe a well-planned prospective study should be of great benefit in term of planning a reproducible dermoscopy plastic surgery-oriented training program. this could help to estimate when a clinician can be considered as competent dermoscopic practitioner. it should be underlined as learning how to use dermoscope is something is not possible to do from time to time but it need effort and self-study. we believed is important to properly plan a formal training in dermoscopy for all the plastic surgery registrars who will use this tool in their practice. vahedi et al. 2 stated, as per their survey, only one of 53% of the plastic surgery trainees that used dermoscope in their practice had formal training. as all trainees perform outpatient appointments dealing with skin lesions, especially for trainees looking to specialize in skin cancer, we believed the expertise gained through specific course and training is not at expense of the development of surgical reconstructive skills, but instead it can lead improvement in performing outpatient appointment. proper use of dermoscope will make the skin cancer specialized plastic surgeon more confident and truthful if not in detecting melanoma at least in leaving evident benign lesions. keeping always in mind a multidisciplinary approach and a close cooperation between dermatologists and plastic surgeon is of paramount importance in skin cancer treatment. there is no conflict of interest for all of the authors. dear sir, as the author mentioned in this publication, the correction of infra-orbital groove by microfat injection did increase the postoperative satisfaction of lower blepharoplasty surgery 1 . in this study, we want to explore whether this procedure can replace the previous fat pad transposition. months after the microfat injection, we have observed that fat continues to be present but its volume gradually disappears, and, with some, it totally vanishes. with fat pad transposition, the fat volume does not decrease, it seems that both have their advantages and disadvantages because the volume of transplanted fat after lower blepharoplasty might disappear gradually by time. survival of transposed fat through fat pad transposition is the best, creating a more natural look at the tear trough. however, the volume of augmentation might not be enough. it would be exceptional if we could combine both advantages; that is, to administer microfat injection after fat transposition. but prior to that, we would like to share the experience of the author. the fat pad is usually transposed to periosteum by two limits: one is the transposition of the medial fat pad to the inner groove and the other one is the transposition of the central fat pad to the center of the infra-orbital groove. as mentioned by the author, we fill the superficial layer (under the skin) and the periosteum layer (deep layer). injection into the deeper layer is not performed after lower blepharoplasty but before the musculocutaneous flap was closed. after fat pad transposition is completed, we would first cover up the musculocutaneous flap before asking the patient to sit up. then, the surgeon assesses whether a further filling of the groove with the fat is needed or not. if necessary, the musculocutaneous flap is opened and more fat is injected in-between the fat pads into the groove, but, definitely, not into the fat pads. the reason why we do the injection before the flap is closed is to accurately perform the insertion and to avoid entering into the intra-orbital fat pad, which may worsen the presence of eye bags. we inject the superficial fat only after the flap wound is closed. this procedure modifies the groove under the eye more accurately. we share with you our surgical methods with the hope that fat utilization and fat pad transposition will greatly improve surgical satisfaction. dear sir, eiben and gilbert are thanked for their comments. they may be correct in the original description of the respective flaps, but the five-flap z-plasty in our experience has always been known colloquially as the jumping man flap. indeed, extra caution is required in burns secondary reconstruction. the skin of these patients is typically thin, often scarred and unforgiving. flaps should never be undermined unless in an area of completely virgin tissue. the modification we presented does result in an apparently thinner base for the 'arm limb' flaps, but traditionally wider based flaps would have been transferred and then trimmed with the same outcome. the tiny sizes involved in paediatric eyelid surgery would not be the best forum to experiment, and certainly mustardé's original design would seem safest in that setting. we had uniquely sought to also measure precisely the geometric gain in length, and felt that the result was impressive. none letter to the editor: evaluating the effectiveness of plastic surgery simulation training for undergraduate medical students 1 we read with interest the recent correspondence regarding the effectiveness of plastic surgery simulation for training undergraduate medical students. we are in wholehearted agreement with the statement regarding medical school curricula lacking exposure to plastic surgery and commend the authors for their efforts to pique the interest of medical students in our specialty. we wish however to point out some vagueness that, unless clarified, could be misleading to your readership. the correspondence states: "the decrease in competition ratios for plastic surgery". we believe that current data supports the opposite view. taking into account published data from health education england over the last 4 years 2 , there has in fact been a 41% rise in the competition ratios from 2016 to 2019 ( fig. 1 .) suggesting an increasing interest in the specialty. highlighting this increase in demand supports the authors' desire for more undergraduate exposure to plastic surgery. this increased input in the uk curriculum would also help all medical students become aware of the support plastic surgeons can provide to other specialties as this is a particular feature of the specialty. in an increasingly specialised medical world, we feel it is important that all doctors are equipped with the knowledge to best serve their patients. no funding has been received for this work and the authors have no competing interest. dear sir/madam, in response to critical personal protective equipment (ppe) shortages during the covid-19 pandemic, medsupply-driveuk was established by ent trainee ms. jasmine ho, and medsupplydriveuk scotland by two plastic surgery trainees (ms. gillian higgins and mrs. eleanor robertson). we applied the principles of creative problem solving and multidisciplinary collaboration instilled by our specialty. since march 2020, we have recruited over 400 volunteers to mobilise over 200,000 pieces of high quality ppe donated from industry to the nhs and social care. we have partnered with academics and leaders of industry to manufacture: surgical gowns, scrubs and visors using techniques including laser cutting, injection molding, and 3d printing. we have engaged with nhs boards and trusts and politicians at local, regional and national level to advocate for healthcare worker protection in accordance with health and safety executive and coshh legislation including: engineering controls and ppe that is adequate for the hazard and suitable for task, user and environment. public health england (phe) currently advise ffp3 level of protection only in the context of a list of aerosol gener-the authors have no competing interests. ating procedures 1 . a surgical mask confers 6x (63%) protection, ffp2/n95 100x (92-98%) and ffp3 100-10,000x ( > 99%) protection ( figure 1 ). as sars-cov-2 is a novel pathogen, evidence is naïve and evolving, and since transmission occurs via aerosol, droplets and fomites from the aerodigestive tract, all 10 uk surgical associations have issued guidance to use higher levels of ppe for procedures that are not included in the phe list (2) . cbs, entuk and baoms have issued statements supporting the use of reusable respirators and power air-purifying respirators, and their use is approved by phe, health protection scotland, public health agency, public health wales, nhs and the academy of medical royal collages 1 . the first author has experienced the need to quote bapras guidance 2 in defense of their use of ppe 2 . medsupplydrive (uk and scotland) hope to empower all healthcare workers to demand provision of adequate (i.e. will protect from sars-cov-2) and suitable (for the task, user and environment) ppe by engaging with their employers directly or through unions, royal colleges and associations. as a nation we must learn from other countries who successfully protected their workforce. data suggests that staff death is avoidable with the use of occupational health measures and ffp3 grade ppe 3 , despite which at least 245 uk health care workers have died of covid-19 4 . the strain placed on systems by sars-cov-2, with reduced access to operating theatres, beds, equipment and staff has the potential for serious detrimental consequences for surgical training 5 . ppe shortages and the subsequent necessity for rationing is causing additional harm. due to global demand and supply chain failures, ffp3 disposable masks for people with small faces are in particularly short supply. the majority of these individuals are female, and they are currently provided with no solution apart from avoiding "high risk" operating if/when this resource runs out; further depriving them of training opportunities. reusable respirators provide superior respiratory protection over disposable ffp3 masks due to design characteristics. they are more likely to provide reliable fit due to increased seal surface area (half face 10mm, full face 20mm). as they are designed to be decontaminated between patients and after each shift they are both economically and ecologically advantageous whilst also reducing fit testing burden and negating reliance upon precarious supply chains. there are factories in the uk which already make reusable respirators and medsupplydrive have been contacted by uk manufacturers looking to retool to meet this demand. although some nhs trusts remain reluctant to use reusable respirators, others have already adopted them routinely, using manufacturer decontamination and filter change advice. one nhs trust has supplied every member of their workforce with a reusable respirator as a sustainable plan for ongoing pandemic waves. it is apparent that healthcare workers are unable to access sufficient quantities of high quality respiratory protection. reusable respirators provide adequate protection from sars-cov-2 as well as being eminently suitable for a wide range of users, tasks and environment. we call on those reviewing decontamination and filter policy for reusable respirators to appreciate the urgency of the situation and expedite the process to enable all health and social care workers to access the respiratory protection that they need. at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation love in the time of corona references 1. world health organization world health organization. who director-general's opening remarks at the mission briefing on covid-19 -12 plastic and reconstructive medical staffs in front line national health commission of the people's republic of china. press conference of the joint prevention and control mechanism of the state council nam therapy-evidencebased results covid-19: how doctors and healthcare systems are tackling coronavirus worldwide governmental public health powers during the covid-19 pandemic: stay-at-home orders, business closures, and travel restrictions a plastic surgery service response to covid-19 in one of the largest teaching hospitals in europe transmission routes of 2019-ncov and controls in dental practice who declares covid-19 a pandemic covid-19: uk starts social distancing after new model points to 260 000 potential deaths telehealth for global emergencies: implications for coronavirus disease 2019(covid-19) prospective evaluation of a virtual urology outpatient clinic virtual fracture clinic delivers british orthopaedic association compliance quality indicators for plastic surgery training available at url: available at url: https: //en.wikipedia.org/wiki/seminar (accessed internet resource: the telegraph. the inflexibility of our lumbering nhs is why the country has had to shut down internet resource: the british society for surgery of the hand. covid-19 resources for members caring for patients with cancer in the covid-19 era maxillofacial trauma management during covid-19: multidisciplinary recommendations asps statement on breast reconstruction in the face of covid-19 pandemic statement from the association of breast surgery 15th march 2020: confidential advice for health professionals blazeby jmbreast reconstruction research collaborative. short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (ibra): a multicentre, prospective cohort study how the wide awake tourniquet-free approach is changing hand surgery in most countries of the world. hand clin hand trauma service: efficiency and quality improvement at the royal free nhs foundation trust one -stop" clinics in the investigation and diagnosis of head and neck lumps the implications of cosmetic tourism on tertiary plastic surgery services the need for a national reporting database references 1. policy on the redeployment of staff trauma management within uk plastic surgery units president of the british society for surgery of the hand. (2020) 24th march highlights for surgeons from phe covid-19 ipc guidance american society of plastic surgery website. asps guidance regarding elective and non-essential patient care the effect of economic downturn on the volume of surgical procedures: a systematic review an analysis of leading, lagging, and coincident economic indicators in the united states and its relationship to the volume of plastic surgery procedures performed telemedicine in the era of the covid-19 pandemic: implications in facial plastic surgery united states chamber of commerce website. resources to help your small business survive the coronavirus transmission of covid-19 to health care personnel during exposures to a hospitalized patient early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia otorhinolaryngologists and coronavirus disease 2019 (covid-19) quantifying the risk of respiratory infection in healthcare workers performing high-risk procedures skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and of how skills fade may be measured or remediated ad hoc committee on health literacy for the council on scientific affairs training strategies for attaining transfer of problemsolving skill in statistics: a cognitive-load approach use of a virtual 3d anterolateral thigh model in medical education: augmentation and not replacement of traditional teaching? augmenting the learning experience in primary and secondary school education: a systematic review of recent trends in augmented reality game-based learning aging and wound healing tissue engineering and regenerative repair in wound healing duration of surgery and patient age affect wound healing in children investigating histological aspects of scars in children formation of hypertrophic scars: evolution and susceptibility early laser intervention to reduce scar formation in wound healing by primary intention: a systematic review early laser intervention to reduce scar formation -a systematic review effectiveness of early laser treatment in surgical scar minimization: a systematic review and meta-analysis cochrane handbook for systematic reviews of interventions version 6 prospective or retrospective: what's in a name? how to run an effective journal club: a systematic review the evolution of the journal club: from osler to twitter free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review the effect of age on microsurgical free flap outcomes: an analysis of 5,951 cases factors affecting outcome in free-tissue transfer in the elderly reconstruction of postinfected scalp defects using latissimus dorsi perforator and myocutaneous free flaps long-term superiority of composite versus muscle-only free flaps for skull coverage indocyanine green lymphography findings in older patients with lower limb lymphedema microsurgical technique for lymphedema treatment: derivative lymphatic-venous microsurgery lower-extremity lymphedema and elevated body-mass index lymphorrhea responds to negative pressure wound therapy lymphovenous anastomosis aids wound healing in lymphedema: relationship between lymphedema and delayed wound healing from a view of immune mechanisms evolving practice of the helsinki skin bank skin graft meshing, overmeshing and cross-meshing gluteal implants versus autologous flaps in patientswith postbariatric surgery weight loss: a prospective comparative of 3-dimensional gluteal projection after lower body lift redefining the ideal buttocks: a population analysis classification system for gluteal evaluation blondeel and others. doppler flowmetry in the planning of perforator flaps frequency of the preoperative flaws and commonly required maneuvers to correct them: a guide to reducing the revision rhinoplasty rate temporalis fascia grafts in open secondary rhinoplasty the turkish delight: a pliable graft for rhinoplasty bone dust and diced cartilage combined with blood glue: a practical technique for dorsum enhancement the use of bone dust to correct the open roof deformity in rhinoplasty wound microbiology and associated approaches to wound management moleculight _ ix _ user _ manual _ rev _ 1.0 _ english the use of the moleculight i:x in managing burns: a pilot study improved detection of clinically relevant wound bacteria using autofluorescence image-guided sampling in diabetic foot ulcers efficacy of an imaging device at identifying the presence of bacteria in wounds at a plastic surgery outpatients clinic publication rates for abstracts presented at the british association of plastic surgeons meetings: how do we compare with other specialties? are we still publishing our presented abstracts from the british association of plastic and reconstructive surgery (bapras)? full publication of results initially presented in abstracts the true cost of science publishing science for sale: the rise of predatory journals plastics in healthcare: time for a re-evaluation green theatre wigan's hospital organisation is first health trust in europe to install intelligent lighting sensorflow provides smart energy management for hotels in malaysia nhs bids to cut up to 100 million plastic straws, cups and cutlery from hospitals healthcare sustainability -the bigger picture on behalf of the council of the association of surgeons in training cross-sectional study of the financial cost of training to the surgical trainee in the uk and ireland plastic waste inputs from land into the ocean low-carbon, virtual science conference tries to recreate social buzz body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction patient body mass index and perforator quality in abdomen-based free-tissue transfer for breast reconstruction increasing body mass index increases complications but not failure rates in microvascular breast reconstruction: a retrospective cohort study are overweight and obese patients who receive autologous free-flap breast reconstruction satisfied with their postoperative outcome? a single-centre study predicting results of diep flap reconstruction: the flap viability index the diagnostic effectiveness of dermoscopy performed by pastic surgery registrars trained in melanoma diagnosis analysis of the benign to malignant ratio of lesions biopsied by a general dermatologist before and after the adoption of dermoscopy assessing suspected or diagnosed melanoma dermoscopy-time for plastic surgeons to embrace a new diagnostic tool? the use of dermatoscopy amongst plastic surgery trainees in the united kingdom modification of jumping man flap combined double z-plasty and v-y advancement for thumb web contracture plastic surgery in infancy evaluating the effectiveness of plastic surgery simulation training for undergraduate medical students united kingdom mr. b.s. dheansa queen victoria hospital recommended ppe for healthcare workers by secondary care inpatient clinical setting, nhs and independent sector personal protective equipment (ppe) for surgeons during covid-19 pandemic: a systematic review of availability, usage, and rationing covid-19: protecting worker health. annals of work exposures and health memorial of health & social care workers taken by covid-19 nursing notes2020 covid-19 robertson canniesburn plastic surgery and burns unit georope geo-technical and rope access solutions, west quarry none. the authors have no financial interests to declare in relation to the content of this article and have received no external support related to this article. no funding was received for this work. the authors would like to thank catriona graham, sarcoma specialist nurse who helped in the evaluation of this study. the authors kindly thank the beatson cancer charity, uk (grant application number 19-20-001), the jean brown bequest fund, uk, and the canniesburn research trust, uk for funding this study. the sponsors had no influence on the design, collection, analysis, write up or submission of the research. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2020.03. 011 . none. the authors declare no funding. jeremy rodrigues provided data from the two nhs trust journal clubs and invaluable advice. nil. all authors declare that there were no funding sources for this study and they approved the final article. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 029 . all authors disclose any commercial associations or financial disclosures. none. none. none. none. all authors agree to the fact there are no conflicts of interest to declare. no funding was provided for this letter. the authors have no financial or personal relationships with other people or organizations, which could inappropriately influence the work in this study. the authors have no financial disclosure or conflict of interest to declare in relation to the content of this article. no funding was received for this article. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 034 . dear sir, long has the term 'publish or perish' been considered medical doctrine and this has historically been a prerequisite for progression in research-driven specialties such as plastic surgery. national, or indeed international, presentation is pivotal to disseminating information, but also provides a stepping-stone to future publications. in the uk, bapras meetings have always represented the ideal platform for this. of significant interest is the conversion of accepted abstracts into peer-reviewed publications.previous studies 1 , 2 have assessed abstract publication for bapras meetings and have shown a declining conversion rate. we re-assessed this in order to establish whether this reported downtrend is continuing and how plastic surgery compares to other specialties.all abstracts from bapras meetings between winter 2014 and summer 2016 were analysed. later meetings were excluded to allow adequate lag time for publication. abstracts were identified retrospectively from conference programmes accessible via the bapras website ( www.bapras. org.uk ). pubmed ( https://www.ncbi.nlm.nih.gov/pubmed/ ) and google scholar ( https://scholar.google.com/ ) databases were used to search for full publications. cross-referencing of published papers with abstracts for content was completed to ensure matched studies.abstracts published prior to the conference date were excluded. two-tailed t -testing was used to assess for statistical significance between variables. none. none. dear sir, diver and lewis described a modification of the "jumping man flap". 1 in fact, what they have described is a modification of the 5-flap z-plasty. this was described by hirschowitz et al. 2 it is not a jumping man as it has no body.the true jumping man flap was described by mustarde 3 for the correction of epicanthal folds and telecanthus.we have used the 5-flap z-plasty particularly for the release of 1st web space contractures following burns, the modification of raised curved scars of the trunk and limbs following burns, and for the correction of epicanthal folds in small children.using the diver and lewis modification in burn cases results in thin and less vascular flaps. when correcting epicanthal folds in children the flaps are so small that reducing their size in any way would make it near impossible to suture the flaps correctly. no conflicts of interest. key: cord-267132-nb0j6k3h authors: loveday, h.p.; wilson, j.a.; pratt, r.j.; golsorkhi, m.; tingle, a.; bak, a.; browne, j.; prieto, j.; wilcox, m. title: epic3: national evidence-based guidelines for preventing healthcare-associated infections in nhs hospitals in england date: 2013-12-10 journal: j hosp infect doi: 10.1016/s0195-6701(13)60012-2 sha: doc_id: 267132 cord_uid: nb0j6k3h national evidence-based guidelines for preventing healthcare-associated infections (hcai) in national health service (nhs) hospitals in england were originally commissioned by the department of health and developed during 1998–2000 by a nurse-led multi-professional team of researchers and specialist clinicians. following extensive consultation, they were first published in january 2001(1) and updated in 2007.(2) a cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of hcai, incorporated into amended guidelines. periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. the department of health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. a critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. these have been clearly identified in the text. in addition, the synopses of evidence underpinning the guideline recommendations have been updated. these guidelines (epic3) provide comprehensive recommendations for preventing hcai in hospital and other acute care settings based on the best currently available evidence. national evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. clinically effective infection prevention and control practice is an essential feature of patient protection. by incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in nhs hospitals in england can be minimised. we would like to acknowledge the assistance of the infection prevention society, british infection association and the healthcare infection society for their input into the development of these guidelines; and other associations, learned societies, professional organisations, royal colleges and patient groups who took an active role in the external review of the guidelines. we would also like to acknowledge the support received from professor brian duerden cbe in chairing the guideline development advisory group, and carole fry in the chief medical ofà cer's team at the department of health (england). the department of health (england). this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. some recommendations from the previous guide lines have been revised to improve clarity; where a new recom mendation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). the recommendations are divided into à ve distinct interventions: • hospital environmental hygiene; • hand hygiene; • use of personal protective equipment (ppe); • safe use and disposal of sharps; and • principles of asepsis. these guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations. the hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff. sp2 levels of cleaning should be increased in cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection. the use of disinfectants should be considered for cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection. sp4 shared pieces of equipment used in the delivery of patient care must be cleaned and decontaminated after each use with products recommended by the manufacturer. all healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. every healthcare worker needs to know their specià c responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care. hand hygiene sp6 hands must be decontaminated: • immediately before each episode of direct patient contact or care, including clean/aseptic procedures; • immediately after each episode of direct patient contact or care; • immediately after contact with body á uids, mucous membranes and non-intact skin; • immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and • immediately after the removal of gloves. use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used: • when hands are visibly soiled or potentially contaminated with body á uids; and • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn. class a healthcare workers should ensure that their hands can be decontaminated effectively by: • removing all wrist and hand jewellery; • wearing short-sleeved clothing when delivering patient care; • making sure that à ngernails are short, clean, and free from false nails and nail polish; and • covering cuts and abrasions with waterproof dressings. effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. • preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. • washing: the handwash solution must come into contact with all of the surfaces of the hand. the hands should be rubbed together vigorously for a minimum of 10-15 s, paying particular attention to the tips of the à ngers, the thumbs and the areas between the à ngers. hands should be rinsed thoroughly. • drying: use good-quality paper towels to dry the hands thoroughly. when decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material, and: • hand rub solution must come into contact with all surfaces of the hand; and • hands should be rubbed together vigorously, paying particular attention to the tips of the à ngers, the thumbs and the areas between the à ngers, until the solution has evaporated and the hands are dry. clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation. alcohol-based hand rub should be made available at the point of care in all healthcare facilities. hand hygiene resources and healthcare worker adherence to hand hygiene guidelines should be audited at regular intervals, and the results should be fed back to healthcare workers to improve and sustain high levels of compliance. healthcare organisations must provide regular training in risk assessment, effective hand hygiene and glove use for all healthcare workers. local programmes of education, social marketing, and audit and feedback should be refreshed regularly and promoted by senior managers and clinicians to maintain focus, engage staff and produce sustainable levels of compliance. patients and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean. patients should be offered the opportunity to clean their hands before meals; after using the toilet, commode or bedpan/urinal; and at other times as appropriate. products available should be tailored to patient needs and may include alcohol-based hand rub, hand wipes and access to handwash basins. selection of personal protective equipment must be based on an assessment of the: • risk of transmission of microorganisms to the patient or carer; • risk of contamination of healthcare practitioners' clothing and skin by patients' blood or body á uids; and • suitability of the equipment for proposed use. healthcare workers should be educated and their competence assessed in the: • assessment of risk; • selection and use of personal protective equipment; and • use of standard precautions. supplies of personal protective equipment should be made available wherever care is delivered and risk assessment indicates a requirement. gloves must be worn for: • invasive procedures; • contact with sterile sites and nonintact skin or mucous membranes; • all activities that have been assessed as carrying a risk of exposure to blood or body á uids; and • when handling sharps or contaminated devices. gloves must be: • worn as single-use items; • put on immediately before an episode of patient contact or treatment; • removed as soon as the episode is completed; • changed between caring for different patients; and • disposed of into the appropriate waste stream in accordance with local policies for waste management. hands must be decontaminated immediately after gloves have been removed. a range of ce-marked medical and protective gloves that are acceptable to healthcare personnel and suitable for the task must be available in all clinical areas. sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented, and alternatives to natural rubber latex gloves must be available. disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body á uids. full-body á uid-repellent gowns must be worn where there is a risk of extensive splashing of blood or body á uids on to the skin or clothing of healthcare workers. plastic aprons/á uid-repellent gowns should be worn as single-use items for one procedure or episode of patient care, and disposed of into the appropriate waste stream in accordance with local policies for waste management. when used, nondisposable protective clothing should be sent for laundering. sp29 fluid-repellent surgical face masks and eye protection must be worn where there is a risk of blood or body á uids splashing into the face and eyes. appropriate respiratory protective equipment should be selected according to a risk assessment that takes account of the infective microorganism, the anticipated activity and the duration of exposure. respiratory protective equipment must à t the user correctly and they must be trained in how to use and adjust it in accordance with health and safety regulations. personal protective equipment should be removed in the following sequence to minimise the risk of cross/self-contamination: • gloves; • apron; • eye protection (when worn); and • mask/respirator (when worn). hands must be decontaminated following the removal of personal protective equipment. sharps must not be passed directly from hand to hand, and handling should be kept to a minimum. sp34 needles must not be recapped, bent or disassembled after use. used sharps must be discarded at the point of use by the person generating the waste. all sharps containers must: • conform to current national and international standards; • be positioned safely, away from public areas and out of the reach of children, and at a height that enables safe disposal by all members of staff; • be secured to avoid spillage; • be temporarily closed when not in use; • not be à lled above the à ll line; and • be disposed of when the à ll line is reached. all clinical and non-clinical staff must be educated about the safe use and disposal of sharps and the action to be taken in the event of an injury. sp38 use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers. organisations should involve end-users in evaluating safer sharps devices to determine their effectiveness, acceptability to practitioners, impact on patient care and cost benefi t prior to widespread introduction. organisations should provide education to ensure that healthcare workers are trained and competent in performing the aseptic technique. the aseptic technique should be used for any procedure that breaches the body's natural defences, including: • insertion and maintenance of invasive devices; • infusion of sterile fl uids and medication; and • care of wounds and surgical incisions. this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. some recommendations from the previous guidelines have been revised to improve clarity; where a new recommen dation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. these guidelines apply to adults and children aged ≥1 year who require a short-term indwelling urethral catheter (≤28 days), and should be read in conjunction with the guidance on standard principles. the recommendations are divided into six distinct interventions: • assessing the need for catheterisation; • selection of catheter type and system; • catheter insertion; • catheter maintenance; • education of patients, relatives and healthcare workers; and • system interventions for reducing the risk of infection. only use a short-term indwelling urethral catheter in patients for whom it is clinically indicated, following assessment of alternative methods and discussion with the patient. class d/gpp uc2 document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal. uc3 assess and record the reasons for catheterisation every day. remove the catheter when no longer clinically indicated. assess patient's needs prior to catheterisation in terms of: • latex allergy; • length of catheter (standard, female, paediatric); • type of sterile drainage bag and sampling port (urometer, 2-l bag, leg bag) or catheter valve; and • comfort and dignity. select a catheter that minimises urethral trauma, irritation and patient discomfort, and is appropriate for the anticipated duration of catheterisation. uc6 select the smallest gauge catheter that will allow urinary outfl ow and use a 10-ml retention balloon in adults (follow manufacturer's instructions for paediatric catheters). urological patients may require larger gauge sizes and balloons. uc22 ensure patients, relatives and carers are given information regarding the reason for the catheter and the plan for review and removal. if discharged with a catheter, the patient should be given written information and shown how to: • manage the catheter and drainage system; • minimise the risk of urinary tract infection; and • obtain additional supplies suitable for individual needs. uc23 use quality improvement systems to support the appropriate use and management of short-term urethral catheters and ensure their timely removal. these may include: • protocols for catheter insertion; • use of bladder ultrasound scanners to assess and manage urinary retention; • reminders to review the continuing use or prompt the removal of catheters; • audit and feedback of compliance with practice guidelines; and • continuing professional education this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. ivad1 healthcare workers caring for patients with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infection. ivad2 healthcare workers should be aware of the manufacturer's advice relating to individual catheters, connection and administration set dwell time, and compatibility with antiseptics and other á uids to ensure the safe use of devices. ivad3 before discharge from hospital, patients with intravascular catheters and their carers should be taught any techniques they may need to use to prevent infection and manage their device. ivad4 hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body á uids, before and after any contact with the intravascular catheter or insertion site. ivad5 use the aseptic technique for the insertion and care of an intravascular access device and when administering intravenous medication. ivad6 use a catheter with the minimum number of ports or lumens essential for management of the patient. ivad7 preferably use a designated singlelumen catheter to administer lipidcontaining parenteral nutrition or other lipid-based solutions. ivad8 use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required. ivad9 use a peripherally inserted central catheter for patients in whom mediumterm intermittent access is required. ivad10 use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for >5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection. ivad11 in selecting an appropriate intravascular insertion site, assess the risks for infection against the risks of mechanical complications and patient comfort. ivad12 use the upper extremity for nontunnelled catheter placement unless medically contraindicated. ivad13 use maximal sterile barrier precautions for the insertion of central venous access devices. ivad36 when safer sharps devices are used, healthcare workers should ensure that all components of the system are compatible and secured to minimise leaks and breaks in the system. ivad37 administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-specià c recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced. ivad38 administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 h (whichever is sooner). ivad39 administration sets used for lipidcontaining parenteral nutrition should be changed every 24 h. ivad40 use quality improvement interventions to support the appropriate use and management of intravascular access devices (central and peripheral venous catheters) and ensure their timely removal. these may include: • protocols for device insertion and maintenance; • reminders to review the continuing use or prompt the removal of intravascular devices; • audit and feedback of compliance with practice guidelines; and • continuing professional education. these are systematically developed broad statements (principles) of good practice. they are driven by practice need, based on evidence and subject to multi-professional debate, timely and frequent review, and modià cation. national guidelines are intended to inform the development of detailed operational protocols at local level, and can be used to ensure that these incorporate the most important principles for preventing hcai in the nhs and other acute healthcare settings. during the past two decades, hcai have become a signià cant threat to patient safety. the technological advances made in the treatment of many diseases and disorders are often undermined by the transmission of infections within healthcare settings, particularly those caused by antimicrobial-resistant strains of disease-causing microorganisms that are now endemic in many healthcare environments. the à nancial and personal costs of these infections, in terms of the economic consequences to the nhs and the physical, social and psychological costs to patients and their relatives, have increased both government and public awareness of the risks associated with healthcare interventions, especially the risk of acquiring a new infection. many, although not all, hcai can be prevented. clinical effectiveness (i.e. using prevention measures that are based on reliable evidence of efà cacy) is a core component of an effective strategy designed to protect patients from the risk of infection, and when combined with quality improvement methods can account for signià cant reductions in hcai such as meticillin-resistant staphylococcus aureus (mrsa) and clostridium difà cile. these guidelines describe clinically effective measures that are used by healthcare workers for preventing infections in hospital and other acute healthcare settings. three sets of guidelines were developed originally and have now been updated. they include: • standard infection control principles: including best practice recommendations for hospital environmental hygiene, effective hand hygiene, the appropriate use of ppe, the safe use and disposal of sharps, and the principles of asepsis; • guidelines for preventing infections associated with the use of short-term indwelling urethral catheters; and • guidelines for preventing infections associated with the use of intravascular access devices. the evidence for these guidelines was identià ed by multiple systematic reviews of peer-reviewed research. in addition, evidence from expert opinion as reá ected in systematically identià ed professional, national and international guidelines was considered following formal assessment using a validated appraisal tool. 3 all evidence was critically appraised for its methodological rigour and clinical practice applicability, and the best-available evidence iná uenced the guideline recommendations. a team of specialist infection prevention and control researchers and clinical specialists and a guideline development advisory group, comprising lay members and specialist clinical practitioners, developed the epic3 guidelines (see sections 1.1 and 1.2). these guidelines can be appropriately adapted and used by all hospital practitioners. this will inform the development of more detailed local protocols and ensure that important standard principles for infection prevention are incorporated. consequently, they are aimed at hospital managers, members of hospital infection prevention and control teams, and individual healthcare practitioners. at an individual level, they are intended to iná uence the quality and clinical effectiveness of infection prevention decision-making. the dissemination of these guidelines will also help patients and carers/relatives to understand the standard infection prevention precautions they can expect all healthcare workers to implement to protect them from hcai. each set of guidelines follows an identical format, which consists of: • a brief introduction; • the intervention heading; • a headline statement describing the key issues being addressed; • a synthesis of the related evidence; and • guideline recommendation(s) classià ed according to the strength of the underpinning evidence. a cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identià ed, appraised and, if shown to be effective for the prevention of hcai, incorporated into amended guidelines. the evidence base for these guidelines will be reviewed in 2 years (2015) and the guidelines will be considered for updating approximately 4 years after publication (2017). following publication the dh will ask the advisory group on antimicrobial resistance and healthcare associated infection to advise whether the s12 h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 evidence base has progressed signià cantly to alter the guideline recommendations and warrant an update. in addition to informing the development of detailed local operational protocols, these guidelines can be used as a benchmark for determining appropriate infection prevention decisions and, as part of reá ective practice, to assess clinical effectiveness. they also provide a baseline for clinical audit, evaluation and education, and facilitate on-going quality improvements. there are a number of audit tools available locally, nationally and internationally that can be used to audit compliance with guidance including high-impact intervention tools for auditing care bundles. signià cant additional costs are not anticipated in implement ing these guidelines. however, where current equipment or resources do not facilitate the implementation of the guidelines or where staff levels of adherence to current guidance are poor, there may be an associated increase in costs. given the social and economic costs of hcai, the consequences associated with not implementing these guidelines would be unacceptable to both patients and healthcare professionals. the guidelines were developed using a systematic review process (appendix a.1). in each set of guidelines, a summary of the relevant guideline development methodology is provided. electronic databases were searched for national and international guidelines and research studies published during the periods identià ed for each search question. a two-stage search process was used. for each set of epic guidelines, an electronic search was conducted for systematic reviews of randomised controlled trials (rcts) and current national and international guidelines. international and national guidelines were retrieved and subjected to critical appraisal using the agree ii instrument, 3 an evaluation method used internationally for assessing the methodological quality of clinical guidelines. following appraisal, accepted guidelines were included as part of the evidence base supporting guideline development and, where appropriate, for delineating search limits. they were also used to verify professional consensus and, in some instances, as the primary source of evidence. review questions for the systematic reviews of the literature were developed for each set of epic guideline topics following recommendations from scientià c advisors and the guideline development advisory group. searches were constructed using relevant mesh (medical subject headings) and free-text terms. the following databases were searched: • medline; • cumulated index of nursing and allied health literature; • embase; • the cochrane library; and • psycinfo (only searched for hand hygiene). search results were downloaded into a refworks™ database, and titles and abstracts were printed for review. titles and abstracts were assessed independently by two reviewers, and studies were retrieved where the title or abstract: addressed one or more of the review questions; identià ed primary research or systematically conducted secondary research; or indicated a theoretical/clinical/in-use study. where no abstract was available and the title indicated one or more of the above criteria, the study was retrieved. due to the limited resources available for this review, foreign language studies were not identià ed for retrieval. full-text studies were retrieved and read in detail by two experienced reviewers; those meeting the study inclusion criteria were independently quality assessed for inclusion in the systematic review. included studies were appraised using tools based on systems developed by the scottish intercollegiate guideline network (sign) for study quality assessment. 4 studies were appraised independently by two reviewers and data were extracted by one experienced reviewer. any disagreement between reviewers was resolved through discussion. evidence tables were constructed from the quality assessments, and the studies were summarised in adapted considered judgement forms. the evidence was classià ed using methods from sign, and adapted to include interrupted time series design and controlled before-after studies using criteria developed by the cochrane effective practice and organisation of care (epoc) group (table 1) . 4, 5 this system is similar that used in the previous epic guidelines. 2 the evidence tables and considered judgement reports were presented to the guideline development advisory group for discussion. the guidelines were drafted after extensive discussion. factors iná uencing the guideline recommendations included: • the nature of the evidence; • the applicability of the evidence to practice; • patient preference and acceptability; and • costs and knowledge of healthcare systems. the classià cation scheme adopted by sign was used to deà ne the strength of recommendation ( these guidelines have been subject to extensive external consultation with key stakeholders, including royal colleges, professional societies and organisations, patients and trade unions (appendix a.2). comments were requested on: • format; • content; • practice applicability of the guidelines; • patient preference and acceptability; and • specià c sections or recommendations. all the comments were collated and sent to the scientià c advisors and the guideline development advisory group for consideration prior to virtual meetings for discussion and agreement on any changes in the light of comments. final agreement was sought from the scientià c advisors and the guideline development advisory group following revision. high-quality meta-analyses, systematic reviews of rcts or rcts with a very low risk of bias 1+ well-conducted meta-analyses, systematic reviews or rcts with a low risk of bias 1-meta-analyses, systematic reviews or rcts with a high risk of bias* 2++ high-quality systematic reviews of case-control or cohort studies. high-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal. interrupted time series with a control group: (i) there is a clearly deà ned point in time when the intervention occurred; and (ii) at least three data points before and three data points after the intervention 2+ well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal. controlled before-after studies with two or more intervention and control sites 2-case-control or cohort studies with a high risk of confounding or bias and a signià cant risk that the relationship is not causal. interrupted time series without a parallel control group: (i) there is a clearly deà ned point in time when the intervention occurred; and (ii) at least three data points before and three data points after the intervention. controlled before-after studies with one intervention and one control site 3 non-analytic studies (e.g. uncontrolled before-after studies, case reports, case series) 4 expert opinion. legislation *studies with an evidence level of '1-' and '2-' should not be used as a basis for making a recommendation. rct, randomised controlled trial. this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). the recommendations are divided into à ve distinct interventions: • hospital environmental hygiene; • hand hygiene; • use of ppe; • safe use and disposal of sharps; and • principles of asepsis. these guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations. this section discusses the evidence upon which recommendations for hospital environmental hygiene are based. the evidence identià ed in the previous systematic review was used as the basis for updating the searches, and searches were conducted for new evidence published since 2006. 2 hospital environmental hygiene encompasses a wide range of routine activities. guidelines are provided here for: • cleaning the general hospital environment; • cleaning items of shared equipment; and • education and training of staff. current legislation, regulatory frameworks and quality standards emphasise the importance of the healthcare environment and shared clinical equipment being clean and properly decontaminated to minimise the risk of transmission of hcai and to maintain public conà dence. [6] [7] [8] [9] [10] patients and their relatives expect the healthcare environment to be clean and infection hazards to be controlled adequately. 9 the term 'cleaning' is used to describe the physical removal of soil, dirt or dust from surfaces. conventionally, this is achieved in healthcare settings using cloths and mops. dust may be removed using dry dust-control mops/cloths. detergent and water is used for cleaning of soiled or contaminated surfaces, although microà bre cloths and water can also be used for surface cleaning. 9 enhanced cleaning describes the use of methods in addition to standard cleaning specià cations. these may include increased cleaning frequency for all or some surfaces, or the use of additional cleaning equipment. enhanced cleaning may be applied to all areas of the healthcare environment or in specià c circumstances, such as cleaning of rooms or bed spaces following the transfer or discharge of patients who are colonised or infected with a pathogenic microorganism. this is sometimes referred to as 'terminal cleaning'. disinfection is the use of chemical or physical methods to reduce the number of pathogenic microorganisms on surfaces. these methods need to be used in combination with cleaning as they have limited ability to penetrate organic material. the term 'decontamination' is used for the process that results in the removal of hazardous substances (e.g. microorganisms, chemicals) and therefore may apply to cleaning or disinfection. research evidence in this à eld remains largely limited to ecological studies and weak quasi-experimental and observational study designs. there is evidence from outbreak reports and observational research which demonstrates that the hospital environment becomes contaminated with microorganisms responsible for hcai. pathogens may be recovered from a variety of surfaces in clinical environments, including those near to the patient that are touched frequently by healthcare workers. [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] however, no studies have provided high-quality evidence of direct transmission of the same strain of microorganisms found in the environment to those found in colonised or infected patients. we identià ed one prospective cohort study that found a signià cant independent association between acquisition of two multi-drug-resistant pathogens and a prior room occupant with the same organism [multi-drug-resistant pseudomonas aeruginosa odds ratio (or) 2.3, 95% conà dence interval (ci) 1.2-4.3, p=0.012; multi-drug-resistant acinetobacter baumanii or 4.2, 95% ci 1.1-1.3, p=0.04] after adjustment for severity of underlying illness, comorbidities, antimicrobial exposure and some other risk factors. 21 a further study reported an association between mrsa and vancomycin-resistant enterococcus (vre), 22 but conclusions that can be drawn from the à ndings are limited by the retrospective study design and lack of adjustment for severity of underlying illness, colonisation pressure and antibiotic exposure. similarly, another retrospective cohort study found an association between acquisition of c. difà cile and prior room occupant with the same infection; however, this was based solely on clinical diagnosis rather than active surveillance. 23 many microorganisms recovered from the hospital environment do not cause hcai. cleaning will not completely eliminate microorganisms from environmental surfaces, and reductions in their numbers will be transient. 15 there is some evidence that enhanced cleaning regimens are associated with the control of outbreaks of hcai; 24 however, these study designs do not provide robust evidence of cause and effect. enhanced cleaning has been recommended, particularly 'terminal cleaning', after a bed area has been used by a patient colonised or infected with an hcai. we searched for robust evidence from studies conducted in the healthcare environment which demonstrated cleaning interventions that were associated with reductions in both environmental contamination and hcai. a randomised crossover study of daily enhanced cleaning of high-touch surfaces in an intensive care unit (icu) demonstrated a reduction in the daily number of s15 sites in a bed area contaminated with mrsa (or 0.59, 95% ci 0.4-0.86, p=0.006), and the aerobic colony count in communal areas (or 0.65, 95% ci 0.47-0.92, p=0.013). although the reduction in mrsa in the environment was associated with a large reduction in mrsa contaminating doctors' hands (or 0.26, 95% ci 0.07-0.95, p=0.025), there was no effect on the incidence of mrsa acquisition by patients (or 0.98, 95% ci 0.58-1.65, p=0.93). 25 disinfectants have been recommended for cleaning the hospital environment; 1,2 however, a systematic review failed to conà rm a link between disinfection and the prevention of hcai, although contamination of detergent and inadequate disinfection strength could have been an important confounder. 26 whilst subsequent studies may have demonstrated a link between disinfection and reduced environmental contamination, and sometimes the acquisition of hcai, the study designs are weak with no control groups or randomisation of intervention, and/or the introduction of multiple interventions at the same time. this makes it difà cult to draw deà nitive conclusions about the specià c effect of disinfection or cleaning. new technologies for cleaning and decontaminating the healthcare environment have become available over the past 10 years, including hydrogen peroxide, and others are in the early stages of development. whilst hydrogen peroxide has been used for decontamination of selected rooms in a us hospital following use by patients with a multi-drug-resistant organism or c. difà cile, this study found that it was not possible to use hydrogen peroxide routinely for this purpose. 27 the effectiveness, cost-effectiveness and practicality of this and other new technologies in terms of reducing hcai and routine use in the variety of facilities in uk hospitals has yet to be demonstrated. we identià ed three studies conducted in patient care environments that provided evidence for the effectiveness of different products, containing chemical or other disinfection agents, on environmental contamination but not reductions in hcai. a prospective randomised crossover study provided evidence for the effectiveness of daily cleaning of high-touch surfaces with microà bre/copper-impregnated cloths on the reduction of mrsa, as discussed above. 25 an rct demonstrated the efà cacy of daily high-touch surface cleaning with peracetic acid on mrsa and c. difà cile contamination of the environment, with a signià cant reduction in mrsa and c. difà cile isolated from samples taken from surfaces with gloved hands (p<0.001) and the hands of healthcare workers (3/27 in peractic acid group vs 15/38 in standard cleaning group, p=0.13). 28 a nonrandomised controlled trial (nrct) in two wards at a single hospital provided evidence that an additional cleaner was associated with a 32.5% reduction in environmental microbial contamination of hand-touch sites (95% ci 20.2-42.9, p<0.0001) and 26.6% reduction in acquisition of mrsa infection (95% ci 7.7-92.3, p=0.032), although the infection types were not specià ed. 29 hydrogen peroxide has been used as a method of decontamination of the environment in situations where wards/ beds can be closed or left unused for the required period of time [30] [31] [32] we identià ed a prospective, randomised beforeafter study that compared the efà cacy of hypochlorite and a hydrogen peroxide decontamination system for terminal cleaning of rooms used by a patient with c. difà cile infection in reducing environmental contamination with c. difà cile. although both methods reduced environmental contamination signià cantly compared with cleaning alone, hydrogen peroxide achieved a signià cantly greater reduction (91% vs 30% decrease in proportion of samples with c. difà cile, p<0.005). 33 a prospective cohort study provided evidence for the efà cacy of hydrogen peroxide when used for terminal decontamination after standard cleaning in signià cantly reducing the acquisition of multi-drug-resistant organisms in patients subsequently admitted to the rooms (adjusted incidence rate ratio 0.36, 95% ci 0.19-0.7). however, the effect was mainly driven by reduction in acquisition of vre, and the results could have been confounded by the concurrent implementation of chlorhexidine baths, incomplete surveillance data and nonrandom assignment of rooms to the intervention. 34 the efà cacy of antimicrobial surfaces in the clinical environment in reducing surface contamination and hcai is an area of emerging research. four non-randomised, experimental studies, conducted in clinical environments, demonstrated signià cant reductions in microbial burden of between 80% and 90% on high-touch surfaces coated with metallic copper and/or its alloys compared with similar noncopper surfaces. [35] [36] [37] [38] one rct conducted in three icus reported a signià cantly lower acquisition of hcai in patients allocated to rooms with six high-touch copper-coated surfaces (3.4% vs 8.1%, p=0.013). a multi-variate analysis suggested that both severity of underlying illness and room assignment were independently associated with the acquisition of hcai or colonisation. however, these à ndings may have been biased by poor discrimination of patients colonised on admission because of limited surveillance cultures, poor agreement in deà ning cases of hcai, and incomplete adjustment for confounders in the multi-variate analysis. 39 evidence of the effectiveness and cost-effectiveness of these technologies and their contribution to reductions in hcai is therefore not currently available. indicators of cleanliness based on levels of microbial or adenosine triphosphate (atp) contamination have been recommended; however, relationships between atp and aerobic colony counts are not consistent, and neither method distinguishes normal environmental á ora and pathogens responsible for hcai. 40, 41 benchmark values of between 250 and 500 relative light units have been proposed as a more objective measure of assessing the efà cacy of cleaning than visual assessment, although these are based on arbitrary standards of acceptable contamination that have not been shown to be associated with reductions in hcai. [42] [43] [44] we identià ed a number of uncontrolled before-after studies that used atp in various forms to highlight the extent of contamination of the healthcare environment. in addition, some studies described the use of atp monitoring as an intervention to improve cleaning, but the lack of a control group in the study design precluded their inclusion in this review. as cleaning will only have a transient effect on the numbers of microorganisms, regular cleaning or disinfection of hospital surfaces will not guarantee a pathogenfree environment. preventing the transfer of pathogens from the environment to patients therefore still depends on ensuring that hands are decontaminated prior to patient contact. the hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff. sp2 levels of cleaning should be increased in cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection. the use of disinfectants should be considered for cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection. shared clinical equipment used to deliver care in the clinical environment comes into contact with intact skin and is therefore unlikely to introduce infection directly. however, it can act as a vehicle by which microorganisms are transferred between patients, which may subsequently result in infection. equipment should therefore be cleaned and decontaminated after each use with cleaning agents compatible with the piece of equipment being cleaned. in some outbreak situations, the use of chlorine-releasing agents and detergent should be considered. [6] [7] [8] [9] sp4 shared pieces of equipment used in the delivery of patient care must be cleaned and decontaminated after each use with products recommended by the manufacturer. in a systematic review of healthcare workers' knowledge about mrsa and/or frequency of cleaning practices, three studies indicated that staff were not using appropriate cleaning practices with sufà cient frequency to ensure minimisation of mrsa contamination of personal equipment. 13 staff education was lacking on optimal cleaning practices in the clinical areas. the à nding of the review is reinforced by a later observational study, which noted that lapses in adherence to the cleaning protocol were linked with an increase in environmental contamination with isolates of a. baumannii. 15 a second systematic review of four cohort studies that compared the use of detergents and disinfectants on microbial-contaminated hospital environmental surfaces suggested that a lack of effectiveness was, in many instances, due to inadequate strengths of disinfectants, probably resulting from a lack of knowledge. 26 we identià ed no new, robust research studies of education or system interventions for this review. however, creating a culture of responsibility for maintaining a clean environment and increasing knowledge about how to decontaminate equipment and high-touch surfaces effectively requires education and training of both healthcare cleaning professionals and clinical staff. all healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. every healthcare worker needs to know their specià c responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care. total number of articles located = 5944 abstract indicates that the article: relates to infections associated with hospital hygiene; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = 164 full text conà rms that the article: relates to infections associated with hospital hygiene; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental, experimental studies answering specià c questions), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 26 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. total number of studies accepted after critical appraisal = 12 total number of studies rejected after critical appraisal = 14 this section discusses the evidence for recommendations concerning hand hygiene practice. designing and conducting robust, ethical rcts in the à eld of hand hygiene is challenging, meaning that recommendations are based on evidence from nrcts, quasi-experimental studies, observational studies and laboratory studies with volunteers. in addition, expert opinion derived from systematically retrieved and appraised professional, national and international guidelines is used. the areas discussed in this section include: • assessment of the need to decontaminate hands; • efà cacy of hand decontamination agents and preparations; • rationale for choice of hand decontamination practice; • technique for hand decontamination; • care required to protect hands from the adverse effects of hand decontamination practice; • promoting adherence to hand hygiene guidelines; and • involving patients and carers in hand hygiene. the transfer of organisms between humans can occur directly via hands, or indirectly via an environmental source (e.g. commode or wash basin). epidemiological evidence indicates that hand-mediated transmission is a major contributing factor in the acquisition and spread of infection in hospitals. 1, 2, 45 the hands are colonised by two categories of microbial á ora. the resident á ora are found on the surface, just below the uppermost layer of skin, are adapted to survive in the local conditions and are generally of low pathogenicity, although some, such as stapylococcus epidermidis, may cause infection if transferred on to a susceptible site such as an invasive device. the transient á ora are made up of microorganisms acquired by touching contaminated surfaces such as the environment, patients or other people, and are readily transferred to the next person or object touched. they may include a range of antimicrobial-resistant pathogens such as mrsa, acinetobacter or other multi-resistant gram-negative bacteria. 1 if transferred into susceptible sites such as invasive devices or wounds, these microorganisms can cause life-threatening infections. transmission to non-vulnerable sites may leave a patient colonised with pathogenic and antibiotic-resistant organisms, which may result in an hcai at some point in the future. outbreak reports and observational studies of the dynamics of bacterial hand contamination have demonstrated an association between patient care activities that involve direct patient contact and hand contamination. 2, [45] [46] [47] [48] the association between hand decontamination, using liquid soap and water and waterless alcohol-base hand rub (abhr), and reductions in infection have been conà rmed by clinically-based nonrandomised trials 49, 50 and observational studies. 51, 52 current national and international guidance has consistently identià ed that effective hand decontamination results in signià cant reductions in the carriage of potential pathogens on the hands, and therefore it is logical that the incidence of preventable hcai is decreased, leading to a reduction in patient morbidity and mortality. 2 patients are put at risk of developing an hcai when informal carers or healthcare workers caring for them have contaminated hands. decontamination refers to a process for the physical removal of dirt, blood and body á uids, and the removal or destruction of microorganisms from the hands. 45 the world health organization's (who) 'five moments for hand hygiene' 53 provides a framework for training healthcare workers, audit and feedback of hand hygiene practice, and has been adopted without modià cation in many countries and adapted in others (e.g. canada). 54 hands must be decontaminated at critical points before, during and after patient care activity to prevent crosstransmission of microorganisms. 1, 2, 45, 55 evidence considered by the national institute for health and clinical excellence (nice) 56 indicated increases in hand decontamination compliance before and after patient contact associated with implementation of the who 'five moments' and us centers for disease control and prevention 2002 guidelines, but no difference in compliance after contact with patient surroundings. the following recommendations are derived from the who framework and nice guidelines, 56 and include additional points of emphasis. hands must be decontaminated: • immediately before each episode of direct patient contact or care, including clean/aseptic procedures; • immediately after each episode of direct patient contact or care; • immediately after contact with body á uids, mucous membranes and non-intact skin; • immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and • immediately after the removal of gloves. current national and international guidelines 2,45,53 consider the efà cacy of various preparations for the decontamination of hands using liquid soap and water, antiseptic handwash agents and abhr in laboratory studies and their effectiveness in clinical use. overall, there is no compelling evidence to favour the general use of antiseptic handwashing agents over liquid soap or one antiseptic agent over another. 2, 45, 53, 57 all hand hygiene products for use in clinical care must comply with current british standards. 58 many studies have been conducted during the past 15 years to compare hand hygiene preparations, including abhr and gels, antiseptic handwash and liquid soap. 45 rcts and other quasiexperimental studies have generally demonstrated alcoholbased preparations to be more effective hand hygiene agents than non-medicated soap and antiseptic handwashing agents, although a small number of studies reported no statistically signià cant difference. [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] many of these studies involved the use of abhr as part of a number of interventions, or multimodal campaigns, to improve hand hygiene practice, and had methodological á aws that weaken the causal relationship between the introduction of abhr and reductions in hcai. 77 we identià ed one multi-variate, interrupted time series which suggested that the amount of abhr used per patientday was the only factor associated with a reduction in mrsa incidence density (p=0.011) in a neonatal icu in japan. 78 incidence density fell over a 4-year period from an average of 15 per 1000 patient-days, with a peak of 20 per 1000 patientdays in august 2006, to 0 per 1000 patient-days in october 2008 and was sustained to july 2009 (average incidence density 7.5 per 1000 patient-days). the supporting evidence from laboratory studies of the efà cacy of abhr indicates that these products are highly effective at reducing hand carriage, whilst overcoming some of the recognised barriers to handwashing; most importantly, the ease of use at the point of patient care. these studies underpin a continuing trend to adopt abhr for routine use in clinical practice. however, some studies highlight the need for continued evaluation of the use of abhr within the clinical environment to ensure staff adherence to guidelines and effective hand decontamination technique. 75, 76 choosing the method of hand decontamination will depend upon the assessment of what is appropriate for the episode of care, the availability of resources at or near the point of care, what is practically possible and, to some degree, personal preferences based on the acceptability of preparations or materials. in general, effective handwashing with liquid soap and water or the effective use of abhr will remove transient microorganisms and render the hands socially clean. the effective use of abhr will also substantially reduce resident microorganisms. this level of decontamination is sufà cient for general social contact and most clinical care activities. 2, 45, 53 liquid soap preparations that contain an antiseptic affect both transient microorganisms and resident á ora, and some exert a residual effect. the use of preparations containing an antiseptic is required in situations where prolonged reduction in microbial á ora on the skin is necessary (e.g. surgery, some invasive procedures or in outbreak situations). 2, 45, 53 abhr is not effective against all microorganisms (e.g. some viruses such as norovirus and spore-forming microorganisms such as c. difà cile). it will not remove dirt and organic material, and may not be effective in some outbreak situations. 52, 79 we identià ed two laboratory studies which demonstrated that abhr was not effective in removing c. difà cile spores from hands. 80, 81 in the à rst study, a comparison of liquid soap and water, chlorhexidine gluconate (chg) soap and water, antiseptic hand wipes and abhr resulted in all the soap and water protocols yielding greater mean colony-forming unit (cfu) reductions, followed by the antiseptic hand wipes, than abhr. abhr was equivalent to no intervention (0.06 log 10 cfu/ml, 95% ci -0.34 to 0.45 log 10 cfu/ml). 80 in the second study, three abhr preparations with a minimum 60% alcohol s19 concentration were compared with antiseptic (chg) soap and water. antiseptic soap and water reduced spore counts signià cantly compared with each of the abhrs (chg vs isagel, p=0.005; chg vs endure, p=0.010; chg vs purell, p=0.005). in addition, 30% of the residual spores were readily transferred by handshake following the use of abhr. 81 recent evidence from a laboratory study that compared the efà cacy of liquid soap and water and abhr with and without chg against h1n1 iná uenza virus demonstrated that all the hand hygiene protocols were effective in reducing virus copies. 82 a further study that compared the use of liquid soap and water and 65% ethanol hand sanitisers for the removal of rhinovirus indicated that the hand sanitisers were more effective than soap and water. 83 two economic evaluations from the usa, included in recent nice primary care guidelines, suggest that non-compliance with hand hygiene guidelines results in increased infection-related costs. 56 although compliance increases procurement costs of hand hygiene products, even a small increase in compliance is likely to result in reduced infection costs. we identià ed a further economic analysis of a hand hygiene programme based on the introduction of point-of-use abhr and associated implementation materials. this demonstrated a reduction in episodes of hcai and a saving of $23.7 for every $1 spent on the programme when future costs were considered. sensitivity analyses showed that the programme remained cost saving in all alternative scenarios. 84 abhr is likely to be less costly and result in greater compliance. national and international guidelines suggest that the acceptability of agents and techniques is an essential criterion for the selection of preparations for hand hygiene. 2, 45, 53 acceptability of preparations is dependent upon the ease with which the preparation can be used in terms of time and access, together with their dermatological effects. 58 abhr is preferable for routine use due to its efà cacy, availability at the point of care and acceptability to healthcare workers. 45 however, abhr does not remove organic matter and is ineffective against some microorganisms; therefore, handwashing is required. use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used: • when hands are visibly soiled or potentially contaminated with body á uids; and • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn. investigations of technique for hand decontamination are limited and generally laboratory-based or small-scale observational designs. hand hygiene technique involves both the preparation and the physical process of decontamination. 2, 45, 53 hands and wrists need to be fully exposed to the hand hygiene product and therefore should be free from jewellery and long-sleeved clothing. a number of small-scale observational studies have demonstrated that wearing rings and false nails is associated with increased carriage of microorganisms and, in some cases, linked to the carriage of outbreak strains. department of health guidance on uniforms and work wear and nice guidelines indicate that healthcare workers should remove rings and wrist jewellery, and wear short-sleeved clothing whilst delivering patient care. 56, 85 evidence for the duration of hand decontamination has been considered in previous systematic reviews underpinning guidelines, and suggests that different durations of handwashing and hand rubbing do not signià cantly affect the reduction of bacteria. 59, 76 the who guidelines indicate that decontamination using abhr should take 20-30 s for a seven-step process, and that handwashing should take 40-60 s for a nine-step process. 45 we identià ed one recent rct in a single hospital which demonstrated that allowing staff to decontaminate their hands 'in no particular order' took less time and was as effective as using the who seven-step technique using abhr or liquid antimicrobial soap and water (p=0.04 and p<0.001, respectively). all three of the protocols tested in this study were effective in reducing hand bacterial load (p<0.01). 86 a similar result was reported by authors of a laboratory study that tested the en1500 six-step technique against a range of other protocols. they reported that allowing volunteers to use their own 'responsible application' or a new à ve-step technique resulted in better coverage of the hands during hand decontamination. 87 a number of laboratory-based studies that investigated methods of hand drying suggested that there is no signià cant difference in the efà cacy of different methods of drying hands, but that good-quality paper towels dry hands efà ciently and remove bacteria effectively. 88, 89 current guidance on infection control in the built environment suggests that air and jet driers are not appropriate for use in clinical areas. 90 we identià ed one systematic review of studies on hand drying that failed to meet the quality criteria for inclusion. 91 due to the methodological limitations of studies, evidence recommendations are based on national and international guidelines which state that the duration of hand decontamination, the exposure of all aspects of the hands and wrists to the preparation being used, the use of vigorous rubbing to create friction, thorough rinsing in the case of handwashing, and ensuring that hands are completely dry are key factors in effective hand hygiene and the maintenance of skin integrity. healthcare workers should ensure that their hands can be decontaminated effectively by: • removing all wrist and hand jewellery; • wearing short-sleeved clothing when delivering patient care; • making sure that à ngernails are short, clean, and free from false nails and nail polish; and • covering cuts and abrasions with waterproof dressings. effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. • preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. • washing: the handwash solution must come into contact with all of the surfaces of the hand. the hands should be rubbed together vigorously for a minimum of 10-15 s, paying particular attention to the tips of the à ngers, the thumbs and the areas between the à ngers. hands should be rinsed thoroughly. • drying: use good-quality paper towels to dry the hands thoroughly. when decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material and: • hand rub solution must come into contact with all surfaces of the hand; and • hands should be rubbed together vigorously, paying particular attention to the tips of the à ngers, the thumbs and the areas between the à ngers, until the solution has evaporated and the hands are dry. expert opinion suggests that skin damage is generally associated with the detergent base of the preparation and/or poor handwashing technique. 1, 2, 45, 53 in addition, the frequent use of some hand hygiene agents may cause damage to the skin and alter normal hand á ora. sore hands are associated with increased colonisation by potentially pathogenic microorganisms and increase the risk of transmission. 1, 2, 45, 53 the irritant and drying effects of liquid soap and antiseptic soap preparations have been identià ed as one of the reasons why healthcare practitioners fail to adhere to hand hygiene guidelines. 1, 2, 45, 53, 92 in addition, washing hands regularly with liquid soap and water before or after the use of abhr is associated with dermatitis and is not necessary. 45 systematic reviews conducted to underpin national guidelines 1,2,45,53,57 have identià ed a range of studies that compared the use of alcohol-based preparations with liquid soap and water using self-assessment of skin condition by nurses. these studies found that abhr was associated with less skin irritation than liquid soap and water. 60, 61, 64, 67, [93] [94] [95] in addition, a longitudinal study of the introduction and subsequent use of abhr over a 7-year period observed no reports of irritant and contact dermatitis associated with the use of abhr. 51 we identià ed a recent study which suggested that two abhr preparations containing a glycerol emollient were more acceptable to staff (p<0.001). 96 hand moisturisers/ emollients that are for shared use are more likely to become contaminated, and have been associated with an outbreak of infection in a neonatal unit. 97 current national and international guidance suggests that skin care, through the appropriate use of hand lotion or moisturisers added to hand hygiene preparations, is an important factor in maintaining skin integrity, encouraging adherence to hand decontamination practices and assuring the health and safety of healthcare practitioners. 2, 45, 53 clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation. national and international guidelines emphasise the importance of adherence to hand hygiene guidance, and provide an overview of the barriers and factors that iná uence hand hygiene compliance. 1, 2, 45, 53 the use of multi-modal approaches to improving hand hygiene practice and behaviour has been advocated for over 10 years. observational studies have consistently reported an association between multi-modal interventions involving the introduction of near-patient abhr, audit and feedback, reminders and education, and greater compliance by healthcare staff. 51, [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] an early systematic review of 21 studies involving interventions to improve hand hygiene compliance concludes that: • single interventions have a short-term iná uence on hand hygiene; • reminders have a modest but sustained effect; • feedback increases rates of hand hygiene but must be regular; • near-patient alcohol-based preparations improve the frequency with which healthcare workers clean their hands; and • multi-faceted approaches have a more marked effect on hand hygiene and rates of hcai. 110 h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 national hand hygiene campaigns have been modelled on the multi-modal approach and implemented across the world. 45, 51, 111, 112 in england and wales, the national patient safety agency's 'cleanyourhands campaign' was piloted and implemented between 2004 and 2008 with the aim of creating sustainable change in hand hygiene compliance. the campaign comprised the use of near-patient abhr, national poster materials, audit and feedback, and materials for patient engagement. recent cochrane reviews of randomised and controlled clinical trials, interrupted time series and controlled before-after studies have suggested that the majority of studies conducted in this à eld have methodological biases that exclude them from this review. 77, 113 we identià ed four systematic reviews of interventions to improve hand hygiene compliance. 77, [114] [115] [116] the most recent cochrane review identià ed 84 studies published after 2006 for potential inclusion, but only four studies (one rct, two interrupted time series and one controlled before-after study) were included following detailed quality assessment. 77 the heterogeneity of interventions and methods precluded the pooling and meta-analysis of results, and it was concluded that multi-faceted campaigns that include social marketing or staff engagement may be more effective than campaigns without these components, and that education or product substitution alone were less effective. an integrative systematic review of 35 studies that reported a wide range of interventions, including multi-modal interventions and hand hygiene product changes, only scored nine of the included studies as having limited or no fatal á aws. 114 the authors concluded that design limitations made it difà cult to generalise the study results or isolate the specià c effects of hand hygiene (or other interventions) on reductions in hcai. an earlier systematic review of 'bundled' behavioural intervention studies that reported hcai or rates of colonisation as the primary outcome identià ed 33 potential studies for inclusion; of these, only four had quality scores >80%. again, due to the heterogeneity of study interventions and outcomes, the results were narratively synthesised. 115 the authors concluded that the formation of multi-disciplinary quality improvement teams and educational interventions might be effective strategies to improve hand hygiene and reduce rates of hcai. the à nal systematic review focused specià cally on educational interventions to improve hand hygiene compliance and competence in hospital settings, and included all study designs that reported at least one outcome measure of hand hygiene competence and had a follow-up of at least 6 months. 116 thirty studies met the inclusion criteria for the review, but it was not possible to separate competence from compliance. educational interventions taught or re-taught the correct methods for hand hygiene and then assessed compliance. the authors concluded that educational interventions had a greater impact if compliance with hand hygiene was low. multiple interventions were better than single interventions in sustaining behaviour change, as were continuous, rather than one-off, interventions. however, it was not possible to determine the duration or sustainability of behaviour change in these studies. we identià ed six new studies in our systematic review: one cluster rct and process evaluation, 117,118 one step-wedge cluster rct, 119 two interrupted time series studies 84,120 and one controlled before-after study 121 that evaluated multi-modal interventions with varying components. in a cluster rct that also included a process evaluation, the authors tested a set of core elements in a 'state-of-the-art strategy' (sas) against a team-leader-directed strategy (tds) at baseline (t1), immediately following the intervention (t2) and 6 months later (t3) to ascertain the additional beneà ts of leadership and staff engagement components. 117, 118 in the intention-to-treat analysis (itt), an or of 1.64 (95% ci 1.33-2.02, p<0.001) in favour of the tds between t2 and t3 suggested that engaging ward leadership and the involvement of teams in setting norms and targets resulted in greater compliance with hand hygiene. however, there was no signià cant difference between the groups' compliance at t3 in the itt (p=0.187), with the sas also having a sustained effect. 117 the process evaluation examined the extent to which the content, dosage and coverage of the intervention had been delivered. 118 an as-treated analysis demonstrated a greater effect size for the tds at t3 with a signià cant difference in hand hygiene compliance (p<0.01). the process evaluation also suggested that feedback about individual hand hygiene performance at t2 and t3 (p<0.05 and p<0.01, respectively), challenging colleagues on undesirable hand hygiene practice (p<0.01), and support from colleagues in performing hand hygiene (p<0.01) were positively correlated with changes in nurses' hand hygiene compliance. 118 the second cluster rct used a step-wedge design to assess a behavioural feedback intervention in intensive therapy units (itus) and acute care of the elderly (ace) wards at sites participating in the 'cleanyourhands campaign'. 119 the primary and secondary outcome measures were hand hygiene compliance measured by covert direct observation for 1 h every 6 weeks, and soap and abhr procurement, respectively. sixty wards were recruited, of which 33 implemented the intervention. the itt analysis (60 wards) showed a signià cant effect of the intervention in the itus but not the ace wards, equating to a 7-9% increase in compliance, with estimated or of 1.44 (95% ci 1.018-1.76, p=<0.001) in itus and estimated or of 1.06 (95% ci 0.87-1.25, p=0.5) in ace wards. the perprotocol analysis (33 wards) showed a signià cant increase in compliance in both ace wards and itus of 10-13% and 13-18%, respectively, with estimated or of 1.67 (95% ci 1.26-2.22, p0.001) in ace wards and estimated or of 2.09 (95% ci 1.55-2.81, p0.001) in itus. the authors concluded that individual feedback and team action planning resulted in moderate but sustained improvements in hand hygiene adherence. the difà culties in implementing this intervention point to the problems that might be faced in a non-trial context. two interrupted time series studies of the 4-year national 'cleanyourhands campaign' in england and a 4-year hospitalwide programme in taiwan demonstrated increased hand hygiene compliance (measured by procurement of abhr and liquid soap) and reductions in hcai [mrsa and c. difà cile, and mrsa and extensively-drug-resistant acinetobacter (xdrab)]. 84, 120 in the national study, increased procurement of soap was independently associated with reductions in c. difà cile infection (adjusted incidence rate ratio for 1-ml increase per patient-bed-day 0.993, 95% ci 0.990-0.996, p<0.0001) and mrsa in the last four quarters of the study (adjusted incidence rate ratio for 1-ml increase per patient-bed-day 0.990, 95% ci 0.985-0.995, p<0.0001). 120 the 'cleanyourhands campaign' was not independent of other national programmes to reduce analysis also identià ed that the publication of the health act and the department of health improvement team visits were associated with reductions in mrsa and c.difà cile. in the hospital-wide study, 84 the authors demonstrated a decrease in the cumulative incidence of hcai caused by mrsa (change in level, p=0.03; change in trend, p=0.04) and xdrab (change in level, p=0.78; change in trend, p<0.001) during the intervention period. hand hygiene compliance was signià cantly correlated with increased consumption of abhr, and improved overall from 43.3% in 2004 to 95.6% in 2007 (p<0.001). hand hygiene compliance was also signià cantly correlated with professional categories of healthcare workers (p<0.001) in both general wards and icus (p<0.001). the controlled before-after study 121 of a range of patient safety interventions in england, including hand hygiene, as measured by abhr and soap consumption in non-specialist acute hospitals, reported no signià cant differences in the rate of increase in consumption of abhr (p=0.760 favouring controls and p=0.889 favouring intervention) and non-signià cant decreases in c. difà cile (p=0.652) and mrsa (p=0.693). alcohol-based hand rub should be made available at the point of care in all healthcare facilities. hand hygiene resources and healthcare worker adherence to hand hygiene guidelines should be audited at regular intervals, and the results should be fed back to healthcare workers to improve and sustain high levels of compliance. healthcare organisations must provide regular training in risk assessment, effective hand hygiene and glove use for all healthcare workers. local programmes of education, social marketing, and audit and feedback should be refreshed regularly and promoted by senior managers and clinicians to maintain focus, engage staff and produce sustainable levels of compliance. patient involvement in multi-modal strategies to improve hand hygiene among healthcare workers is established, and includes making it acceptable for patients and carers to request that healthcare workers clean their hands. 45 however, research suggests that many patients and carers do not feel empowered to challenge staff, particularly doctors. 108, 109, 122, 123 many nhs trusts have promoted hand hygiene among visitors by placing abhr at the entrances to wards and patient rooms, but there is no evidence that this reduces hcai. despite being highlighted as an important gap in research, the role of patients' hands in the cross-transmission of microorganisms has not been investigated systematically, other than in ecologic studies that describe hand or skin contamination [124] [125] [126] or observations of non-use of hand hygiene products. 127 studies of effective interventions to enable patients to clean their hands remain small scale and descriptive in nature. [128] [129] [130] [131] we identià ed three studies that described interventions to improve patient hand hygiene: one in an outbreak situation, one uncontrolled before-after study of parent education in a single paediatric icu, and one as part of a prospective observational study in a community hospital. none of these studies met the quality criteria for inclusion in this systematic review. [132] [133] [134] however, all of these studies suggested that improving patient/carer hand hygiene had some effect on crosstransmission of microorganisms and hand hygiene technique. national guidelines indicate that it is important to educate patients and carers about the importance of hand hygiene, and inform them about the availability of hand hygiene facilities and their role in maintaining standards of healthcare workers' hand hygiene. 56 patients and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean. patients should be offered the opportunity to clean their hands before meals; after using the toilet, commode or bedpan/urinal; and at other times as appropriate. products available should be tailored to patient needs and may include alcohol-based hand rub, hand wipes and access to handwash basins. total number of articles located = 8223 abstract indicates that the article: relates to infections associated with hand hygiene; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = 255 full text conà rms that the article: relates to infections associated with hand hygiene; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental, experimental studies answering specià c questions), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 78 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. total number of studies accepted after critical appraisal = 17 total number of studies rejected after critical appraisal = 61 this section discusses the evidence and associated recommendations for the use of ppe by healthcare workers in acute care settings and includes the use of aprons, gowns, gloves, eye protection and face masks/respirators to prevent potential transmission of pathogenic microorganisms to staff, patients and the healthcare environment. the use of gloves for other purposes does not form part of these guidelines. where health and safety legislation underpins a recommendation, this is indicated by 'health & safety (h&s)' in addition to the classià cation of any clinical evidence underpinning the recommendations. the primary roles of ppe are to protect staff and reduce opportunities for cross-transmission of microorganisms in hospitals. 1, 2, 135 there is no evidence that uniforms or work clothing are associated with hcai. however, there is a public expectation that healthcare workers will wear work and protective clothing to minimise any potential risk to patients and themselves. 85, 136 the decision to use or wear ppe must be based upon an assessment of the level of risk associated with a specià c patient care activity or intervention, and take account of current health and safety legislation. [137] [138] [139] [140] there is evidence that both a lack of knowledge of guidelines and non-adherence to guideline recommendations are common, and that regular in-service education and training is required. 106, [141] [142] [143] [144] selection of personal protective equipment must be based on an assessment of the: • risk of transmission of microorganisms to the patient or carer; • risk of contamination of healthcare practitioners' clothing and skin by patients' blood or body á uids; and • suitability of the equipment for proposed use. healthcare workers should be educated and their competence assessed in the: • assessment of risk; • selection and use of personal protective equipment; and • use of standard precautions. supplies of personal protective equipment should be made available wherever care is delivered and risk assessment indicates a requirement. the use of gloves as an element of ppe and contact precautions is an everyday part of clinical practice for healthcare workers. 1, 2, 135 there are other indications unrelated to preventing the cross-transmission of infection that require gloves to be worn (e.g. the use of some chemicals or medications). the two main indications for the use of gloves in the prevention of hcai 1 are: • to protect hands from contamination with organic matter and microorganisms; and • to reduce the risk of cross-transmission of microorganisms to staff and patients. gloves should be selected on the basis of a risk assessment, and should be suitable for the proposed task and the materials being handled. [138] [139] [140] gloves are categorised as medical gloves (examination and surgical) and protective gloves. 145 examination gloves are available as sterile or non-sterile for use by healthcare workers during clinical care to prevent contamination with microorganisms, blood and body á uids. surgical gloves are available as sterile for use by healthcare workers during surgical and other invasive procedures. protective gloves are used to protect healthcare workers from chemical hazards. 145 gloves should not be worn as a substitute for hand hygiene. their prolonged and unnecessary use may cause adverse reactions and skin sensitivity, and may lead to crosscontamination of the patient environment. 1, 2 the need to wear gloves and the selection of appropriate glove materials requires careful assessment of the task to be performed and its related risks to patients and healthcare workers. 1, 2, 135, 146, 147 risk assessment should include consideration of: • who is at risk (patient or healthcare worker) and whether sterile or non-sterile gloves are required; • potential for exposure to blood, body á uids, secretions and excretions; • contact with non-intact skin or mucous membranes during care and invasive procedures; and • healthcare worker and patient sensitivity to glove materials. we identià ed four observational studies which suggested that clinical gloves are not used in line with current guidance, and that glove use impacts negatively on hand hygiene. [148] [149] [150] [151] in addition, a cluster rct of screening and enhanced contact precautions for patients colonised with mrsa or vre found no reduction in transmission, but also found that adherence to contact precautions was less than ideal. 152 gloves must be removed immediately following each care activity for which they have been worn, and hands must be decontaminated in order to prevent the cross-transmission of microorganisms to other susceptible sites in that individual or to other patients. gloves should not be washed or decontaminated with abhr as a substitute for changing gloves between care activities. 45 there is evidence that hands become contaminated when clinical gloves are worn, even when the integrity of the glove appears undamaged. 1, 2, 135 in terms of leakage, gloves made from natural rubber latex (nrl) perform better than vinyl gloves in laboratory test conditions. 1,2 standards for the manufacture of medical gloves for single use require gloves to perform to european standards. [153] [154] [155] [156] [157] however, the integrity of gloves cannot be guaranteed, and hands may become contaminated during the removal of gloves. 1, 2, 149, 156 the appropriate use of medical gloves provides barrier protection and reduces the risk of hand contamination from blood, body á uids, secretions and excretions, but does not eliminate the risk. hands cannot be considered to be clean because gloves have been worn, and should be decontaminated following the removal of gloves. used gloves must be disposed of in accordance with the requirements of current legislation and local policy for waste management. 157 gloves must be worn for: • invasive procedures; • contact with sterile sites and nonintact skin or mucous membranes; • all activities that have been assessed as carrying a risk of exposure to blood or body á uids; and • when handling sharps or contaminated devices. gloves must be: • worn as single-use items; • put on immediately before an episode of patient contact or treatment; • removed as soon as the episode is completed; • changed between caring for different patients; and • disposed of into the appropriate waste stream in accordance with local policies for waste management. hands must be decontaminated immediately after gloves have been removed. clinical gloves should be used by healthcare workers to prevent the risk of hand contamination with blood, body á uids, secretions and excretions, and to protect patients from potential cross-contamination of susceptible body sites or invasive devices. 1 having decided that gloves should be used for a healthcare activity, the healthcare worker must make a choice between the use of: • sterile or non-sterile gloves, based on contact with susceptible sites or clinical devices; and • surgical or examination gloves, based on the aspect of care or treatment to be undertaken. healthcare organisations must provide gloves that conform to european standards (en455-1, 455-2, 455-3), and which are acceptable to healthcare practitioners. [153] [154] [155] medical gloves are available in a range of materials, the most common being nrl, which remains the material of choice due to its efà cacy in protecting against bloodborne viruses and properties that enable the wearer to maintain dexterity. 1, 158 patient or healthcare practitioner sensitivity to nrl proteins must also be taken into account when deciding on glove materials. 146 synthetic gloves are generally more expensive than nrl gloves and may not be suitable for all purposes. 1 nitrile gloves have the same chemical range as nrl gloves and may also lead to sensitivity problems in healthcare workers and patients. polythene gloves are not suitable for clinical use due to their permeability and tendency to damage easily. 1 a study that compared the performance of nitrile, latex, copolymer and vinyl gloves under stressed and unstressed conditions found that nitrile gloves had the lowest failure rate, suggesting that nitrile gloves are a suitable alternative to nrl gloves, provided that there are no sensitivity issues. importantly, the study noted variation in performance of the same type of glove produced by different manufacturers. 158 the health and safety executive (hse) also provide a guide-to-glove selection for employers. 147 a range of ce-marked medical and protective gloves that are acceptable to healthcare personnel and suitable for the task must be available in all clinical areas. sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented, and alternatives to natural rubber latex gloves must be available. national and international guidelines recommend that ppe should be worn by all healthcare workers when close contact with the patient, materials or equipment may lead to contamination of uniforms or other clothing with microorganisms, or when there is a risk of contamination with blood or body á uids. 2, 138, 159 disposable plastic aprons are recommended for general clinical use. 2 full-body gowns need only be used where there is the possibility of extensive splashing of blood or body á uids, and should be á uid repellent. 2, 159 we identià ed a systematic review of the evidence that microbial contaminants found on the work clothing of healthcare practitioners are a signià cant factor in cases of hcai. 136 the reviewers identià ed seven small-scale studies that described the progressive contamination of work clothing during clinical care, and a further three studies that suggested a link with microbial contamination and infection. 17, [160] [161] [162] [163] [164] [165] [166] [167] [168] [169] one of the three studies was conducted in a simulated scenario and demonstrated that it was possible to transfer s. aureus from nurses' gowns to patients' bed sheets, but this was not associated with clinical infection. 167 a further pair of linked studies, associated with an outbreak of bacillus cereus, showed an epidemiological link between contaminated clothing and hcai, but this occurred when surgical scrub suits became highly contaminated in an industrial laundry, rather than as a result of clinical care. 168, 169 a further study demonstrated high levels of contamination of gowns, gloves and stethoscopes with vre following examination of patients known to be infected. 170 a systematic review of eight studies that assessed the effects of gowning by attendants and visitors found no evidence to suggest that over-gowns are effective in reducing mortality, clinical infection or bacterial colonisation in infants admitted to newborn nurseries. 171 one quasi-experimental study investigated the use of gowns and gloves as opposed to gloves alone for prevention of acquisition of vre in a medical icu setting. 172 a further prospective observational study investigated the use of a similar intervention in a medical icu. 173 these studies suggested that the use of gloves and gowns may minimise the transmission of vre when colonisation pressure is high. disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body á uids. full-body á uid-repellent gowns must be worn where there is a risk of extensive splashing of blood or body á uids on to the skin or clothing of healthcare workers. plastic aprons/á uid-repellent gowns should worn as single-use items for one procedure or episode of patient care, and disposed of into the appropriate waste stream in accordance with local policies for waste management. when used, non-disposable protective clothing should be sent for laundering. healthcare workers (and sometimes patients) may use standard, á uid-repellent surgical face masks to prevent respiratory droplets from the mouth and nose being expelled into the environment. face masks are also used, often in conjunction with eye protection, to protect the mucous membranes of the wearer from exposure to blood and/or body á uids when splashing may occur. our previous systematic reviews failed to reveal any robust experimental studies that demonstrated that healthcare workers wearing surgical face masks protected patients from hcai during routine ward procedures, such as wound dressing or invasive medical procedures. 1, 2 face masks are also used to protect the wearer from inhaling aerosolised droplet nuclei expelled from the respiratory tract. as surgical face masks are not effective at à ltering out such particles, specialised respiratory protective equipment (respirators) may be recommended for the care of patients with certain respiratory diseases [e.g. active multiple drugresistant pulmonary tuberculosis, 174 severe acute respiratory syndrome (sars) and pandemic iná uenza]. 175 the à ltration efà ciency of these respirators will protect the wearer from inhaling small respiratory particles, but to be effective, they must à t closely to the face to minimise leakage around the mask. 1, 2, 176 the selection of the most appropriate respiratory protective equipment (rpe) should be based on a suitable risk assessment that includes the task being undertaken, the characteristics of the biological agent to which there is a risk of exposure, as well as the duration of the task and the local environment. where the activity involves procedures likely to generate aerosols of biological agents transmitted by an airborne route (e.g. intubation), rpe with an assigned protection factor (apf) of 20 (equivalent to ffp3) should be used. in other circumstances, such as where the agent is transmitted via droplet rather than aerosol or where the level of aerosol exposure is low, the risk assessment may conclude that other forms of rpe (e.g. apf10/ ffp2) or a physical barrier (e.g. surgical face mask) may be appropriate, such as when caring for patients with iná uenza. where rpe is required, it must à t the user properly and the user must be fully trained in how to wear and adjust it. 177 we identià ed four systematic reviews of the use of facial protection, all of which had been undertaken in the aftermath of the sars outbreak and in response to the h1n1 iná uenza pandemic. a range of study designs were considered in each of the reviews, including cluster rcts, rcts, cohort studies and descriptive before-after studies. overall, many studies were poorly controlled, with no accounting for confounders, such as poor compliance in the weaker studies. the authors of each of the reviews concluded that there was no strong evidence that masks/respirators alone are effective for the prevention of respiratory viral infections. masks/respirators should be used together with other protective measures to reduce transmission. [178] [179] [180] [181] our previous systematic review indicated that different protective eyewear offered protection against physical splashing of infected substances into the eyes (although not on all occasions), but that compliance was poor. 1 expert opinion recommends that face and eye protection reduce the risk of occupational exposure of healthcare workers to splashes of blood or body á uids. 1, 2, 159, 182 sp29 fluid-repellent surgical face masks and eye protection must be worn where there is a risk of blood or body á uids splashing into the face and eyes. appropriate respiratory protective equipment should be selected according to a risk assessment that takes account of the infective microorganism, the anticipated activity and the duration of exposure. respiratory protective equipment must à t the user correctly and they must be trained in how to use and adjust it in accordance with health and safety regulations. personal protective equipment should be removed in the following sequence to minimise the risk of cross/self-contamination: • gloves; • apron; • eye protection (when worn); and • mask/respirator (when worn). hands must be decontaminated following the removal of personal protective equipment. total number of articles located = ag (867), fp (8160) abstract indicates that the article: relates to infections associated with protective clothing; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = ag (32), fp (25) full text conà rms that the article: relates to infections associated with protective clothing; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = ag (6), fp (6) all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. total number of studies accepted after critical appraisal = ag (6), fp (4) total number of studies rejected after critical appraisal = ag (0), fp (2) this section discusses the evidence and associated recommendations for the safe use and disposal of sharps in general care settings. this includes minimising the potential infection risks associated with sharps use and disposal, and the use of needle protection devices. the use and disposal of sharps is subject to the health and safety at work act 1974 183 and several elements of health and safety legislation including: 188 where health and safety legislation underpins a recommendation, this is indicated by 'h&s' in addition to the classià cation of any clinical evidence underpinning the recommendations. the hse deà ne a sharp as a needle, blade or other medical instrument capable of cutting or piercing the skin. 184 similarly, a sharps injury is an incident that causes a needle, blade or other medical instrument to penetrate the skin (percutaneous injury). the safe handling and disposal of needles and other sharp instruments forms part of an overall strategy of clinical waste disposal to protect staff, patients and visitors from exposure to bloodborne pathogens. 159 the national audit ofà ce identià ed that needlestick and sharps injuries ranked alongside moving and handling, falls, trips and exposure to hazardous substances as the main types of accidents experienced by nhs staff. 189 a later royal college of nursing survey of 4407 nurses found that almost half (48%) had, at some point in their career, sustained a sharps injury from a device that had previously been used on a patient. a similar number (52%) reported fearing sharps injuries, and nearly half (45%) reported that they had not received training from their employer on safe needle use. 190 the 2012 'eye of the needle' report from the health protection agency conà rms that healthcare workers continue to be exposed to bloodborne virus infections, even though such exposures are largely preventable. 191 the average risk of transmission of bloodborne viruses following a single percutaneous exposure from an infected person, in the absence of appropriate post-exposure prophylaxis, has been estimated to be: 135, 191, 192 • hepatitis b virus, one in three; • hepatitis c virus, one in 30; and • human immunodeà ciency virus, one in 300. national and international guidelines are consistent in their recommendations for the safe use and disposal of sharp instruments and needles, and the management of healthcare workers who are exposed to potential infection from bloodborne viruses. 135, [193] [194] [195] as with many infection prevention and control policies, the assessment and management of the risks associated with the use of sharps is paramount, and safe systems of work and engineering controls must be in place to minimise any identià ed risks. 139 national 184 and european union 196 legislation requires the uk and all eu member states to provide protection for all healthcare workers exposed to the risk of sharps injuries. in summary, the health and safety (sharp instruments in healthcare) regulations 2013 require all employers, under existing health and safety law, to: • conduct risk assessments; • avoid unnecessary use of sharps and, where this is not possible, use safer sharps that incorporate protection mechanisms; • prevent the recapping of needles; • ensure safe disposal by placing secure sharps containers close to the point of use; • provide employees with adequate information and training on the safe use and disposal of sharps, what to do in the event of a sharps injury and the arrangements for testing, immunisation and post-exposure prophylaxis, where appropriate; • record and investigate sharps incidents; and • provide employees who have been injured with access to medical advice, and offer testing, immunisation, post-exposure prophylaxis and counselling, where appropriate. 184, 193 legislation also includes a duty for employees who receive a sharps injury whilst undertaking their work to inform their employer as soon as is practicable. 184, 193 all healthcare workers must be aware of their responsibility in avoiding sharps injuries. we identià ed a systematic review which included studies that focused on education and training interventions to minimise the incidence of occupational injuries involving sharps devices. 197 the authors identià ed à ve primary beforeafter studies that demonstrated a consistent reduction in the incidence of percutaneous injuries when other safety initiatives (e.g. training) were implemented before and during the introduction of safer sharps devices. [198] [199] [200] [201] [202] these studies used a range of interventions in one setting and are not generalisable. however, education is essential in ensuring that staff understand safe ways of working and how to use safer sharps devices. this should form a part of induction programmes for new staff and on-going in-service education. the introduction of new devices should include an appropriate training programme as part of staff introduction. sharps must not be passed directly from hand to hand, and handling should be kept to a minimum. needles must not be recapped, bent or disassembled after use. used sharps must be discarded at the point of use by the person generating the waste. all sharps containers must: • conform to current national and international standards; • be positioned safely, away from public areas and out of the reach of children, and at a height that enables safe disposal by all members of staff; • be secured to avoid spillage; • be temporarily closed when not in use; • not be à lled above the à ll line; and • be disposed of when the à ll line is reached. all clinical and non-clinical staff must be educated about the safe use and disposal of sharps and the action to be taken in the event of an injury. to improve patient and staff safety, legislation and the department of health require healthcare providers and their employees to pursue safer methods of working through risk assessment to eliminate the use of sharps and, where this is not possible, the use of safer sharps. 184, 203, 204 the incidence of sharps injuries has led to the development of safety devices in many different product groups. 205 they are designed to minimise the risk of operator injury during sharps use, as well as 'downstream' injuries that occur after disposal, often involving the housekeeping or portering staff responsible for the collection of sharps disposal units. the lack of well-designed, controlled intervention studies means that evidence to show whether or not safety devices are effective in reducing rates of infection is limited. however, a small number of studies have shown signià cant reductions in injuries associated with the use of safety devices 2 in cannulation, 206,207 phlebotomy 208-210 and injections. 211 it is logical that where needle-free or other safety devices are used, there is a resulting reduction in sharps injuries. a review of needlestick injuries in scotland suggested that 56% of injuries would 'probably' or 'deà nitely' have been prevented if a safety device had been used. 212 however, some studies have identià ed a range of barriers to the expected reduction in injuries, including staff resistance to using new devices, complexity of device operation or improper use, and poor training. 2 a comprehensive report and product review s29 conducted in the usa provides background information and guidance on the need for and use of needlestick-prevention devices, but also gives advice on establishing and evaluating a sharps injury prevention programme. 205 it reported that all devices have limitations in relation to cost, applicability and/or effectiveness. some of the devices available are more expensive than standard devices, may not be compatible with existing equipment, and may be associated with an increase in bloodstream infection rates if used incorrectly. 213 nice identià ed three rcts that compared safety cannulae with standard cannulae. the studies were all in hospital settings and of low/very-low quality. the quality of evidence for safety needle devices was low, with no rcts identià ed and the à ve before-after implementation studies being of very-low quality. the quality of evidence for training was similarly low, with the type of training varying across the à ve observational studies identià ed. 56 we identià ed a systematic review undertaken by the hse which reviewed 41 studies that provided evidence for reductions in the incidence of occupational sharps injuries associated with use of sharps safety devices, education and training, and the acceptability of sharps safety devices. 197 thirteen studies, predominantly with observational designs, demonstrated that safer sharps devices were associated with a signià cant reduction in the incidence of healthcare worker needlestick injury. 199, 201, [208] [209] [210] [214] [215] [216] [217] [218] [219] [220] [221] however, safety devices were not the total solution to reducing occupational injury. the beneà cial outcome of consulting with end-users of safer sharps devices before they are introduced was demonstrated in à ve studies identià ed in this review. 208, 211, [222] [223] [224] [225] in the usa, the occupational safety health administration and the national institute for occupational safety and health suggest that a thorough evaluation of any device is essential before purchasing decisions are made. 195, 226 similarly, the hse suggests that the end-users of any safer sharps device should be involved in the assessment of user acceptability and clinical applicability of any needle safety devices. 184 the evaluation should ensure that the safety feature works effectively and reliably, that the device is acceptable to healthcare practitioners and that it does not have an adverse effect on patient care. use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers. organisations should involve end-users in evaluating safer sharps devices to determine their effectiveness, acceptability to practitioners, impact on patient care and cost beneà t prior to widespread introduction. systematic review questions total number of articles located = 3989 abstract indicates that the article: relates to infections associated with sharps; is written in english, is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = 18 full text conà rms that the article: relates to infections associated with sharps; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 2 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. the term 'asepsis' means the absence of potentially pathogenic microorganisms. 227 asepsis applies to both medical and surgical procedures. medical asepsis aims to minimise the risk of contamination by microorganisms, and prevent their transmission by applying standard principles of infection prevention, including decontaminating hands, use of ppe, maintaining an aseptic area, and not touching susceptible sites or the surface of invasive devices. 56 surgical asepsis is a more complex process, including procedures to eliminate microorganisms from an area (thus creating an aseptic environment), and is practised in operating theatres and for invasive procedures, such as the insertion of a central venous catheter (cvc). 56 'aseptic technique' is a term applied to a set of specifi c practices and procedures used to assure asepsis and prevent the transfer of potentially pathogenic microorganisms to a susceptible site on the body (e.g. an open wound or insertion site for an invasive medical device) or to sterile equipment/devices. it involves ensuring that susceptible body sites and the sterile parts of devices in contact with a susceptible site are not contaminated during the procedure. the aseptic technique is an essential element of the prevention of hcai, particularly when the body's natural defence mechanisms are compromised. however, similar to nice, 56 we identifi ed no clinical or economic evidence that any one approach to the aseptic technique is more clinically or cost-effective than another. thus, all recommendations here are class d/gpp. no studies that met the inclusion criteria and compared education interventions for improving the aseptic technique generally were identifi ed. we identifi ed one systematic review that assessed education interventions to improve competence in the aseptic insertion and maintenance of cvcs. 228 the review included 47 studies of educational interventions that were designed to change staff behaviour related to: general asepsis, maximal sterile barrier (msb) precautions during insertion, cutaneous antisepsis, and other aspects of insertion and maintenance practice. the studies all described multi-modal education approaches alone or combined with demonstration, simulation, video and self-study. only one of these studies reported improvements in competence with performing the aseptic technique as a discrete outcome, and nine studies measured overall compliance with the total insertion bundle. variations in terminology are used in the literature to describe the aseptic technique. inconsistencies in the use of terms and application of the principles of asepsis in clinical practice have been addressed in a framework referred to as 'aseptic non-touch technique'. 229 this provides a practice structure and educational materials aimed at minimising variation and developing competence in practice. 229 however, no comparative evidence indicating the effi cacy of this approach was identifi ed. organisations should provide education to ensure that healthcare workers are trained and competent in performing the aseptic technique. the aseptic technique should be used for any procedure that breaches the body's natural defences, including the: • insertion and maintenance of invasive devices; • infusion of sterile fl uids and medication; and • care of wounds and surgical incisions. abstract indicates that the article: relates to infections associated with asepsis; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. full text conà rms that the article: relates to infections associated with asepsis; is written in english; is primary research (randomised controlled trialsrct), prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 1 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. total number of studies accepted after critical appraisal = 0 total number of studies rejected after critical appraisal = 1 this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. evidence identià ed in the healthcare infection control practices advisory committee (hicpac) systematic review was used to support the recommendations in these guidelines. 230 some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. these guidelines apply to adults and children aged 1 year who require a short-term indwelling urethral catheter (28 days), and should be read in conjunction with the guidance on standard principles. the recommendations are divided into six distinct interventions: • assessing the need for catheterisation; • selection of catheter type and system; • catheter insertion; • catheter maintenance; • education of patients, relatives and healthcare workers; and • system interventions for reducing the risk of infection. urinary tract infection (uti) is the most common infection acquired as a result of health care, accounting for 19% of hcai, with between 43% and 56% of utis associated with a urethral catheter. 231, 232 catheters predispose to infection because microorganisms are able to bypass natural host mechanisms, such as the urethra and micturition, and gain entry to the bladder. 233 most microorganisms causing catheterassociated uti (cauti) gain access to the urinary tract either extraluminally or intraluminally. extraluminal contamination may occur as the catheter is inserted, by contamination of the catheter from healthcare workers' hands or from the patient's own perineal á ora. extraluminal contamination is also thought to occur from microorganisms ascending from the perineum. intraluminal contamination occurs by reá ux of microorganisms from a contaminated urine drainage bag. 234 the bladder is normally sterile; in the non-catheterised patient, a uti is usually identià ed from the symptoms of dysuria and frequency of urination. patients who develop a uti with a short-term indwelling urethral catheter in place may not experience these symptoms, and diagnosis may be based on other signs, such as fever or suprapubic or loin tenderness. 235 after a few days of catheterisation, microorganisms may be isolated from urine and, in the absence of any symptoms of uti, this is called 'bacteriuria'. 236 the duration of catheterisation is the dominant risk factor for cauti, and virtually all catheterised patients develop bacteriuria within 1 month. 230 for the purpose of these guidelines, a duration of catheterisation of 28 days is considered to be a short-term catheterisation. 234 several factors contribute to the potential development of cauti, including the formation of bioà lms and encrustation of the catheter. bacteria on the catheter surface and drainage bag multiply rapidly, adhering to the surface by excreting extracellular polysaccharides and forming a layer known as a 'bioà lm'. bacteria within the bioà lm are morphologically and physiologically different from free-living planktonic bacteria in the urine, and have considerable survival advantages as they are protected from the action of antibiotic therapy. 234 whilst bioà lms commonly form on devices inserted into the body, they can cause additional problems on urethral catheters if the bacteria produce the enzyme urease, such as proteus mirabilis. 234 this enzyme causes the urine to become alkaline, inducing crystallisation of calcium and magnesium phosphate within the urine. these crystals are incorporated into the bioà lm and, over time, result in encrustation of the catheter. encrustation is generally associated with long-term catheterisation, as it has a direct relationship with the length of catheterisation. 234 urinary catheterisation is a frequent intervention during clinical care in hospital, affecting a signià cant number of patients. it has been estimated that 15-25% of hospitalised patients have a urinary catheter inserted during their stay. [237] [238] [239] [240] this number is much higher in icus. 241 the risk of infection is associated with the method and duration of catheterisation, the quality of catheter care and patient susceptibility. 242 bacteriuria develops in approximately 30% of catheterised patients after 2-10 days, and 24% (95% ci 23-29%) of these will develop symptoms of cauti. 242 approximately 3.6% (95% ci 3.4-3.8%) of those with cauti develop life-threatening secondary infections, such as bacteraemia or sepsis, where mortality rates range from 10% to 33%. 243, 244 cauti is associated with prolonged hospitalisation, re-admission and increased mortality. 245 patients at particular risk are those who are immunocompromised, the elderly and patients with diabetes. 246 physical and psychological discomfort associated with insertion, removal and the catheter in situ are common. 247 complications such as iná ammation, urethral strictures, mechanical trauma, bladder calculi and other infections of the renal system also occur. 237, [248] [249] [250] urine retention after catheter removal is also a frequent occurrence. 251 in some instances, especially in older people, cauti may contribute to falls and delirium. 252 the treatment of both cauti and other infection sequelae contribute to the emerging problem of antibiotic resistance in hospitals, and uropathogens are a major source of infections caused by antimicrobial-resistant organisms. 253 cauti also increases the cost of health care due to delayed discharge from hospital, antimicrobial treatment and staff resources. the à nancial burden of cauti on the nhs has been estimated as £99 million per year, with an estimated cost per episode of £1968. 254, 255 however, there are no robust economic assessments of the cost of cauti. there is a strong association between the duration of catheterisation and the risk of infection (i.e. the longer the catheter is in place, the higher the incidence of uti). 242, 256, 257 in acute care facilities, the risk of developing bacteriuria increases 5% for each day of catheterisation. approximately 24% of bacteriuric patients will develop cauti, and of these, up to 4% develop a severe secondary infection such as bloodstream infection. 242 current best practice emphasises the importance of documenting all procedures involving the catheter or drainage system in the patient's records, 255 and providing patients with adequate information in relation to the need for catheterisation, details of the insertion, catheter and drainage system, maintenance procedures and plan for removal of the catheter. 255, 258 there is some evidence to suggest that computer management systems improve documentation and are associated with reduced duration of catheterisation. 259 using a short-term indwelling urethral catheter only when necessary after considering alternatives and ensuring the catheter is removed as soon as possible are simple and effective methods to prevent cauti. the use of a short-term indwelling urethral catheter may be appropriate in patients with acute urinary retention or obstruction, those who require precise urine output measures to monitor an underlying condition, and patients undergoing certain surgical procedures (especially urological procedures and those of prolonged duration). a short-term indwelling urethral catheter may also be appropriate to minimise discomfort or distress (e.g. during end-of-life care or in the management of open sacral or perineal wounds when the patient is incontinent). 230 however, short-term indwelling urethral catheterisation should not be used as a method of managing urinary incontinence. while the use of a short-term indwelling urethral catheter is sometimes unavoidable, there is evidence that catheters are inserted without a clear clinical indication, clinicians are not always aware they are in situ, and they are not removed promptly when no longer required. 238, 260 interventions that prompt or facilitate the removal of unnecessary catheters may, therefore, reduce the risk of cauti. these interventions have been categorised as reminder systems which prompt clinicians that the catheter is in place and removal should be considered, or stop orders, which indicate that catheters should be removed after a set period of time or when deà ned clinical criteria have been met. 259, [261] [262] [263] a systematic review of 14 studies (one rct, one nrct, three controlled before-after studies and nine uncontrolled beforeafter studies) on reminder and stop order systems found that these interventions signià cantly decreased the rate of cauti and did not increase the need for re-catheterisation, although, as some of the studies were not controlled, they were susceptible to bias in favour of the intervention. 261 a second systematic review identià ed a number of uncontrolled before-after studies that used ultrasound bladder scanners to assess for urinary retention and support appropriate catheterisation. 264 when used in combination with guidelines, 265 insertion checklist/kit, education, audit and feedback, 266 and reminder/stop orders, 267 ultrasound bladder scanners were found to decrease the use of urethral catheters by 5-15%. 264 only use a short-term indwelling urethral catheter in patients for whom it is clinically indicated, following assessment of alternative methods and discussion with the patient. uc2 document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal. assess and record the reasons for catheterisation every day. remove the catheter when no longer clinically indicated. evidence from best practice indicates that the incidence of cauti in patients catheterised for a short time (up to 1 week) is not iná uenced by any particular type of catheter material. 268, 269 however, many practitioners have strong preferences for one type of catheter over another. this preference is often based on clinical experience, patient assessment and materials that induce the least allergic response. smaller gauge catheters with a 10-ml balloon minimise urethral trauma, mucosal irritation and residual urine in the bladder; all factors that predispose to cauti. 270, 271 there is also a risk of urethral trauma associated with using a female length catheter in a male patient, and systems should be in place to ensure that this does not occur. 272 however, in adults that have recently undergone urological surgery, larger gauge catheters may be indicated to allow for the passage of blood clots. our previous evidence-based guidelines 1 identià ed three experimental studies that compared the use of latex with silicone catheters, which found no signià cant difference in the incidence of bacteriuria. 249, 273, 274 we identià ed one new systematic review which included three trials that compared different types of standard (nonantiseptic-/non-antimicrobial-impregnated) catheters. these studies did not provide sufà cient evidence to suggest that one type of catheter may be more effective than another for the prevention of bacteriuria. [274] [275] [276] [277] in our previous systematic review, 278 we found evidence related to the efà cacy of using short-term indwelling urethral catheters coated or impregnated with antiseptic or antimicrobial agents from four systematic reviews and one meta-analysis. in general, all of these à ve studies suggested that antiseptic-impregnated or antimicrobial-coated shortterm indwelling urethral catheters can signià cantly prevent or delay the onset of cauti compared with standard untreated urinary catheters. 235, [279] [280] [281] [282] the consensus in these à ve reviews of evidence, however, is that the individual studies reviewed are generally of poor quality; for instance, in one case, only eight studies out of 117 met the inclusion criteria, 280 and in another, of the six reports describing seven trials included, only one scored à ve in the quality assessment. the other à ve reports only scored one. 282 the studies included in these reviews investigated a wide range of coated or impregnated catheters, including catheters coated or impregnated with: silver alloy, 279, 280, [282] [283] [284] [285] [286] [287] [288] [289] silver oxide, 280 gendine, 290 gentamicin, 291 silverhydrogel, 292-294 minocycline, 294 rifampicin, 295 chlorhexidinesilver-sulfadiazine, 294 chlorhexideine-sulfadiazine-triclosan, 294 nitrofurazone 294 and nitrofuroxone. 296 four studies compared the use of silver-coated (silver alloy or silver oxide) catheters with silicone, hydrogel or teá on ® latex. 297-300 a systematic review and meta-analysis of these and other studies found that silver-alloy-coated (but not silver-oxide-coated) catheters were associated with a lower incidence of bacteriuria. 256, 280 despite their unit cost, these devices may provide a costeffective option if overall numbers of infections are reduced signià cantly through their use. however, the few studies that have explored the cost-beneà t/cost-effectiveness of using these devices have been inconclusive. 285, 287, 289, 291 we identià ed two new systematic reviews of the efà cacy of silver-coated or antimicrobial-impregnated catheters for the prevention of cauti. 235, 275 the à rst systematic review included 22 rcts, as well as one nrct, and concluded that silver-coated (alloy or oxide) short-term indwelling urethral catheters reduced the risk of bacteriuria but did not demonstrate an effect on cauti. 275 catheters impregnated with antimicrobial agents (minocycline, rifampicin or nitrofurazone) were found to reduce the rate of bacteriuria during the à rst week of catheterisation, but not for catheter durations exceeding 1 week. although antimicrobial-impregnated catheters reduced the risk of cauti, the number of cases was too small to demonstrate a signià cant effect. the second systematic review, which included nine rcts and three quasi-experimental studies, concluded that, compared with standard catheters, both nitrofurazone-impregnated and silver-alloy-coated catheters can prevent and delay the onset of bacteriuria during short-term use. however, there were no data on the risk of cauti. 235 we identià ed one multi-centre rct that compared silveralloy-coated and nitrofurazone-impregnated catheters with standard teá on-coated latex for short-term catheterisation. 301 although the nitrofurazone-impregnated and silver-alloycoated catheters were associated with a reduced risk of cauti compared with the teá on-coated latex, the effect was not considered to be clinically effective (adjusted or 0.81, 95% ci 0.66-1.01 and adjusted or 0.96, 95% ci 0.78-1.19, respectively). the nitrofurazone-impregnated catheter, but not the silver-alloy-coated catheter, was associated with a signià cantly lower incidence of bacteriuria (or 0.68, 95% ci 0.48-0.99, p=0.017). however, the nitrofurazone-impregnated catheter was associated with increased discomfort during the period the catheter was in place. a major limitation of this study was that the median duration of catheterisation was 2 s34 h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 days (range 1-3 days) and the risk of cauti associated with this short period is correspondingly low. also, utis developing up to 6 weeks post randomisation were included in the outcome measurement, even though they may not have been directly associated with catheterisation. the economic analysis suggested that nitrofurazone-impregnated catheters, but not silver-alloy-coated catheters, may be cost-effective, but the measures of cost were associated with a large amount of uncertainty. overall, the evidence suggests that silver-coated urethral catheters reduce the risk of bacteriuria, but there is insufà cient evidence to indicate whether they reduce the risk of cauti in short-term catheterised patients. assess patient's needs prior to catheterisation in terms of: • latex allergy; • length of catheter (standard, female, paediatric); • type of sterile drainage bag and sampling port (urometer, 2-l bag, leg bag) or catheter valve; and • comfort and dignity. select a catheter that minimises urethral trauma, irritation and patient discomfort, and is appropriate for the anticipated duration of catheterisation. uc6 select the smallest gauge catheter that will allow urinary outá ow and use a 10-ml retention balloon in adults (follow manufacturer's instructions for paediatric catheters). urological patients may require larger gauge sizes and balloons. in our previous review, 2 we found evidence from one systematic review which suggested that the use of the aseptic technique has not demonstrated a reduction in the rate of cauti. 281 however, principles of good practice, clinical guidance 258, 302 and expert opinion, 269, 270, [303] [304] [305] [306] [307] together with à ndings from another systematic review, 256 agree that shortterm indwelling urethral catheters must be inserted using sterile equipment and the aseptic technique. expert opinion indicates that there is no advantage in using antiseptic preparations for cleansing the urethral meatus prior to catheter insertion. 230, 258, 269, 270 whilst there is low-quality evidence to suggest that pre-lubrication of the catheter decreases the risk of bacteriuria, it is also important to use lubricant or anaesthetic gel in order to minimise urethral trauma and discomfort. 230 there is no evidence suggesting a general beneà t of securing the catheter in terms of preventing the risk of cauti, but it is important in order to minimise patient discomfort. 230 ensuring healthcare practitioners are trained and competent in the insertion of short-term indwelling urethral catheters will minimise trauma, discomfort and the potential for cauti. 270, 302, 306, 307 neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic review. 230 catheterisation is an aseptic procedure and should only be undertaken by healthcare workers trained and competent in this procedure. uc8 clean the urethral meatus with sterile, normal saline prior to the insertion of the catheter. uc9 use lubricant from a sterile singleuse container to minimise urethral discomfort, trauma and the risk of infection. ensure the catheter is secured comfortably. maintaining a sterile, continuously closed urinary drainage system is central to the prevention of cauti. 258, 270, 302, 306, 308, 309 the risk of infection reduces from 97% with an open system to 8-15% when a sterile closed system is employed. 269, 307, 310 breaches in the closed system, such as unnecessary emptying, changing of the urinary drainage bag or taking a urine sample, will increase the risk of cauti and therefore should be avoided. 269, 302, 311 hands must be decontaminated, and clean and non-sterile gloves should be worn before manipulation of the catheter or the closed system, including drainage taps. a systematic review has suggested that sealed (e.g. taped, pre-sealed) drainage systems contribute to preventing bacteriuria. 281 however, there is limited evidence regarding how often catheter bags should be changed. one study showed that higher rates of symptomatic and asymptomatic cauti were associated with a 3-day urinary drainage bag change regimen compared with no routine change regimen. 312 best practice suggests that drainage bags should only be changed when necessary (i.e. according either to the manufacturer's recommendations or the patient's clinical need). 258, 302 reá ux of urine is associated with infection and, consequently, drainage bags should be positioned in a way that ensures the free á ow of urine and prevents back-á ow. 270, 302 it is also recommended that urinary drainage bags should be hung on an appropriate stand that prevents contact with the á oor. 269 a number of studies have investigated the addition of disinfectants and antimicrobials to drainage bags as a way of preventing cauti. 256 three acceptable studies 313-315 from our original systematic review 1 demonstrated no reduction in the incidence of bacteriuria following the addition of hydrogen peroxide or chlorhexidine to urinary drainage bags. these à ndings are supported by a further systematic review, which suggested that adding bacterial solutions to drainage bags had no effect on catheter-associated infection. 281 neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic review. 230 uc10 connect a short-term indwelling urethral catheter to a sterile closed urinary drainage system with a sampling port. uc11 do not break the connection between the catheter and the urinary drainage system unless clinically indicated. uc12 change short-term indwelling urethral catheters and/or drainage bags when clinically indicated and in line with the manufacturer's recommendations. uc13 decontaminate hands and wear a new pair of clean non-sterile gloves before manipulating each patient's catheter. decontaminate hands immediately following the removal of gloves. uc14 use the sampling port and the aseptic technique to obtain a catheter sample of urine. uc15 position the urinary drainage bag below the level of the bladder on a stand that prevents contact with the á oor. uc16 do not allow the urinary drainage bag to à ll beyond three-quarters full. uc17 use a separate, clean container for each patient and avoid contact between the urinary drainage tap and the container when emptying the drainage bag. uc18 do not add antiseptic or antimicrobial solutions to urinary drainage bags. our previous systematic reviews 1,2 found eight acceptable studies that compared meatal cleansing with a variety of antiseptic/antimicrobial agents or soap and water. no reduction in bacteriuria was demonstrated when using any of these preparations for meatal/peri-urethral hygiene compared with routine bathing or showering. 281, [316] [317] [318] [319] [320] [321] [322] expert opinion and other systematic reviews support the view that active meatal cleansing is not necessary and may increase the risk of infection. 56, 230, 256, 258, 269, 270 daily routine bathing or showering is all that is needed in order to maintain patient comfort. neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic review. 230 uc19 routine daily personal hygiene is all that is required for meatal cleansing. evidence from our previous systematic review did not demonstrate any beneà cial effect of bladder irrigation, instillation or washout with a variety of antiseptic or antimicrobial agents for the prevention of cauti. 1, 2, [323] [324] [325] [326] [327] [328] [329] [330] [331] evidence from best practice supports these à ndings of no beneà cial effect, and indicates that the introduction of such bladder maintenance solutions may have local toxic effects and contribute to the development of resistant microorganisms. however, continuous or intermittent bladder irrigation may be required for other urological or catheter management indications. 256 given the frequency of urinary catheterisation in hospital patients and the associated risk of uti, it is important that patients, their relatives and healthcare workers responsible for catheter insertion and management are educated about infection prevention. all those involved must be aware of the signs and symptoms of uti and how to access expert help when difà culties arise. healthcare professionals must be conà dent and proà cient in associated procedures. we identià ed two systematic reviews that reported evidence of the efà cacy of healthcare workers' education in reducing the risk of cauti within other system interventions. 264, 332 most of the studies included in these reviews provided lowgrade evidence from uncontrolled before-after studies where a combination of different system interventions focusing on reducing the use of urethral catheters and risk of cauti were introduced. the à rst systematic review 264 identià ed one small controlled before-after study 263 of an educational intervention with guideline change and posters that was associated with a reduction in use of urethral catheters [relative risk (rr) 0.86, 95% ci 0.68-1.10]. another systematic review included one controlled before-after study that demonstrated a signià cant (p<0.01) increase in adherence to a clinical guideline on the insertion and maintenance of urethral catheters in association with an education programme. 332, 333 a further study reported a reduction in cauti and an increase in adherence to protocols for hand hygiene and catheter care in association with an education programme. however, this study did not include a control group. 100 uc21 healthcare workers should be trained and competent in the appropriate use, selection, insertion, maintenance and removal of short-term indwelling urethral catheters. uc22 ensure patients, relatives and carers are given information regarding the reason for the catheter and the plan for review and removal. if discharged with a catheter, the patient should be given written information and shown how to: • manage the catheter and drainage system; • minimise the risk of urinary tract infection; and • obtain additional supplies suitable for individual needs. a number of studies have reported the effect of quality improvement programmes on the risk of cauti. 230 the components of these programmes include various combinations of clinical guidelines for catheter insertion and maintenance, education, audit and feedback of compliance with policy, physician/nurse reminder systems (to prompt removal if no longer necessary), automated or nurse-driven removal protocols [where the catheter is removed after a specià ed period (e.g. 48-72 h) unless countermanded by the physician] and the use of bladder scanners to assess urinary retention and support appropriate catheterisation. 230 we identià ed three systematic reviews relevant to this question. 261, 264, 332 the à rst was a review of interventions to remind physicians/nurses to remove unnecessary catheters and the outcome on cauti, short-term indwelling urethral catheter use and catheter replacement. it included 14 studies (one rct, one nrct, three controlled before-after studies and nine uncontrolled before-after studies). 261 interventions included prewritten or computer-generated stop orders, nurse-generated daily bedside reminders to remove catheters, and daily use of a checklist or protocol to review need for the catheter. some studies also implemented catheter placement restrictions and education. the meta-analysis suggested that the use of reminder or stop order systems reduced the rate of cauti by 52% (p<0.001) and the mean duration of catheterisation by 37%, with 2.61 fewer days of catheterisation in the intervention group compared with the control group, and no difference in re-catheterisation rates. the second systematic review was a review of interventions to minimise the placement of urethral catheters in acute care patients. 264 it included one rct, one nrct and six uncontrolled before-after studies. interventions included various combinations of clinician reminders, stop orders and indication checklists, use of bladder scanners and education. the authors concluded that the studies were too small and heterogeneous to draw a deà nitive conclusion about efà cacy in terms of reducing inappropriate catheter placement. the third systematic review included three controlled before-after studies and seven uncontrolled before-after studies measuring interventions that increased adherence to catheter care protocols or reduced unnecessary catheter use. 332 interventions included reminders, stop orders, use of bladder scanners, education and catheterisation protocols with audit and feedback on performance. physician/nurse reminders, particularly automatic stop orders, were found to reduce the duration of catheterisation, although there were insufà cient data to determine their effect on cauti. many studies in this area are uncontrolled before-after designs and therefore susceptible to bias in favour of the intervention. however, these interventions constitute best practice, and this evidence supports the use of systems to minimise the insertion of catheters and promote timely removal to reduce both the duration of catheterisation and the risk of cauti. s37 uc23 use quality improvement systems to support the appropriate use and management of short-term urethral catheters and ensure their timely removal. these may include: • protocols for catheter insertion; • use of bladder ultrasound scanners to assess and manage urinary retention; • reminders to review the continuing use or prompt the removal of catheters; • audit and feedback of compliance with practice guidelines; and • continuing professional education. uc24 no patient should be discharged or transferred with a short-term indwelling urethral catheter without a plan documenting the: • reason for the catheter; • clinical indications for continuing catheterisation; and • date for removal or review by an appropriate clinician overseeing their care. systematic review questions 1. what are the clinical indications for the use of short-term urinary catheters?(*b) 2. what is the risk associated with short-term catheterisation in terms of bacteriuria, cauti, other morbidities and mortality? (b) 3. what is the effectiveness (in terms of patient acceptability and reduced risk of bacteriuria, cauti, other morbidities and mortality) and the cost-effectiveness of different types of short-term indwelling urinary catheters (material, coatings and design)? 4. what is the most effective catheter insertion technique in terms of patient acceptability and minimisation of urethral trauma, bacteriuria, cauti and other morbidities? 5. what is the most effective and cost-effective means of maintaining meatal hygiene and a closed drainage system? 6. what is the effectiveness of system interventions in reducing the use and duration of short-term urinary catheterisation to minimise the risk of bacteriuria, cauti, other morbidities and mortality? 7. what is the effectiveness of system interventions in improving healthcare workers' knowledge and behaviour relating to the insertion, maintenance and timely removal of indwelling urinary catheters to minimise the risk of bacteriuria, cauti, other morbidities and mortality? total number of articles located = 7073 abstract indicates that the article: relates to infections associated with short-term indwelling urethral catheters; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = 54 full text conà rms that the article: relates to infections associated with short-term indwelling urethral catheters; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasiexperimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 16 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. this guidance is based on the best critically appraised evidence currently available. the type and class of supporting evidence explicitly linked to each recommendation is described. evidence identià ed in the hicpac systematic review was used to support the recommendations in these guidelines. 334 some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. these recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. none are regarded as optional. intravascular access devices, including peripheral, central venous and arterial catheters, are commonly used in the management of patients in acute and chronic care settings. cvcs are frequently used during clinical care and include peripherally inserted, non-tunnelled and tunnelled, and totally implantable cvcs (table 3) . 334 the use of any of these catheters can result in bloodstream infection. catheter-related bloodstream infections (cr-bsi) associated with the insertion and maintenance of cvcs are potentially among the most dangerous complications associated with health care. 231, 232, 335 in the most recent national prevalence survey, the health protection agency reported that the prevalence of bsi was 0.5%, accounting for 7.3% of the hcai detected; 64% of bsi occurred in patients with a vascular access device. 231 a previous point prevalence survey reported that the prevalence of bsi was 0.85%, accounting for 7% of the hcai detected; of these, 70% were primary cr-bsi. 232 peripheral venous catheters (pvcs) cause phlebitis in some patients, with studies indicating mean rates of 7-27%, [336] [337] [338] [339] but evidence suggests that these devices are less frequently associated with cr-bsi. 334, [336] [337] [338] [339] [340] cr-bsi involves the presence of systemic infection and evidence implicating the intravascular catheter as its source (i.e. the isolation of the same microorganism from blood cultures as that shown to be signià cantly colonising the intravascular catheter). 334, 335 catheter colonisation refers to the growth of microorganisms on either the endoluminal or the external catheter surface beneath the skin in the absence of systemic infection. 334, 335 the microorganisms that colonise catheter hubs and the skin adjacent to the insertion site are the source of most cr-bsi. coagulase-negative staphylococci, particularly staphylococcus epidermidis, are the microorganisms most frequently implicated in cr-bsi. other microorganisms commonly involved include s. aureus, candida species and enterococci. [341] [342] [343] cr-bsi is generally caused either by skin microorganisms at the insertion site, which contaminate the catheter during insertion and migrate along the cutaneous catheter track after insertion, [344] [345] [346] or microorganisms from the hands of healthcare workers that contaminate and colonise the catheter hub during care interventions. 347 less commonly, infusate contamination or seeding from a different site of infection in the body via the bloodstream is identià ed as a cause of cr-bsi. 348,349 these guidelines are based upon evidence-based guidelines for preventing intravascular device (ivd)-related infections, developed at the us centers for disease control and prevention by hicpac and published in 2011. 334 the agree ii collaboration appraisal instrument was used by four appraisers to review the guidelines independently. 3 the appraisal process resulted in the decision that the guideline development processes were valid and that the guidelines were evidence based, categorised to the strength of the evidence examined, reá ective of current concepts of best practice. the guideline development advisory group considered that they were the most authoritative reference guidelines currently available. following the agree process, we systematically searched, retrieved and appraised additional evidence published since the search period identià ed in the hicpac technical report. 334 our search period for additional evidence spanned from 2009 to 2012. these guidelines apply to caring for all adults and children over the age of 1 year in nhs acute care settings with a cvc or pvc that is being used for the administration of á uids, medications, blood components and/or parenteral nutrition. they should be used in conjunction with the recommendations for standard principles for preventing hcai, previously described in these guidelines. these recommendations describe general principles of best practice that apply to all patients in hospital in whom an intravascular catheter is being used during an acute episode of treatment/care. they do not specià cally address the more detailed, technical aspects of the care of infants under 1 year of age, or those children or adults receiving haemodialysis or chemotherapy who will generally have long-term intravascular catheters managed in renal dialysis or outpatient settings. the recommendations are divided into nine distinct interventions: • education of healthcare workers and patients; • general asepsis; • selection of type of intravascular catheter; • selection of intravascular catheter insertion site; • msb precautions during insertion; • cutaneous antisepsis; • catheter and catheter site care; • replacement strategies; and • general principles for catheter management. to improve patient outcomes and reduce healthcare costs, it is essential that everyone involved in caring for patients with intravascular catheters is educated about infection prevention. healthcare workers in hospitals need to be conà dent and proà cient in infection prevention practices, and to be aware of the signs and symptoms of clinical infection. structured educational programmes that enable healthcare workers to provide, monitor and evaluate care and continually increase their competence are critical to the success of any strategy designed to reduce the risk of infection. evidence reviewed by hicpac demonstrates that the risk of infection declines following standardisation of the aseptic technique, [350] [351] [352] [353] [354] [355] [356] and increases when the maintenance of intravascular catheters is undertaken by inexperienced healthcare workers. 353, 357 h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 we identià ed two recent systematic reviews that assessed the effectiveness of education interventions in reducing cr-bsi. 228, 358 the à rst concluded that current evidence comes predominantly from uncontrolled before-after studies that do not convincingly distinguish intervention effectiveness from secular trends. clinical practices are addressed by a wide variety of educational strategies that do not draw upon pedagogic, theoretical or conceptual frameworks and consequently do not provide generalisable conclusions about the most effective approaches to education to improve practice. 358 the second systematic review concluded à rst that educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit and feedback, and when availability of clinical equipment is consistent with the content of the education provided. second, that educational interventions will have a greater impact if baseline compliance with best practice is low. third, that repeated educational sessions, fed into daily practice, using practical participation, appear to have a small, additional effect on practice change compared with education alone. 228 healthcare workers should be aware of the manufacturers' advice relating to the compatibility of individual devices with antiseptic solutions, dwell time and connections to ensure safe use. with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infection. ivad2 healthcare workers should be aware of the manufacturer's advice relating to individual catheters, connection and administration set dwell time and compatibility with antiseptics and other á uids to ensure the safe use of devices. ivad3 before discharge from hospital, patients with intravascular catheters and their carers should be taught any techniques they may need to use to prevent infection and manage their device. hand decontamination and meticulous attention to the aseptic technique are essential during catheter insertion, manipulation, changing catheter site dressings and for accessing the system. hands should be decontaminated using abhr or liquid soap and water when hands are visibly soiled or potentially contaminated with organic material, such as blood and other body á uids. 45, 53 the aseptic technique should be used for the insertion and management of ivds. structured education should be provided to ensure that healthcare workers are trained and assessed as competent in performing the aseptic technique. gloves should be worn for procedures involving contact with blood or body á uids. sterile gloves must be worn for the insertion and dressing of cvcs. 334 ivad4 hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body á uids, before and after any contact with the intravascular catheter or insertion site. ivad5 use the aseptic technique for the insertion and care of an intravascular access device and when administering intravenous medication. the selection of the most appropriate intravascular catheter for each individual patient can reduce the risk of subsequent catheter-related infection. intravascular catheter material may be an important determinant in the development of catheter-related infection. polytetraá uroethylene (teá on) and polyurethane catheters have been associated with fewer infections than catheters made of polyvinyl chloride or polyethylene. [359] [360] [361] multi-lumen intravascular access devices may be used because they permit the concurrent administration of á uids and medications, parenteral nutrition and haemodynamic monitoring among critically ill patients. several rcts and other studies suggest that multi-lumen catheters are associated with a higher risk of infection than single-lumen catheters. 334, [362] [363] [364] [365] [366] [367] however, other studies examined by hicpac failed to demonstrate a difference in the rates of cr-bsi. 368, 369 multi-lumen catheter insertion sites may be particularly prone to infection because of increased trauma at the insertion site or because multiple ports increase the frequency of cvc manipulation. 364, 365 patients with multi-lumen catheters tend to be more severely ill, although the increased risk of cr-bsi appears to be independent of underlying illness. 366 a prospective epidemiological study in patients receiving parenteral nutrition concluded that either using a singlelumen catheter or a dedicated port in a multi-lumen catheter for parenteral nutrition would reduce the risk of cr-bsi. 359 neither we nor hicpac identià ed any additional evidence for this recommendation whilst updating our systematic review, and hicpac considered this to be a unresolved issue. 334 in a systematic review and quantitative meta-analysis focused on determining the risk of cr-bsi and catheter colonisation in multi-lumen catheters compared with single-lumen catheters, the reviewers reported that, although cr-bsi was more common in patients with multi-lumen catheters, when conà ned to highquality studies that control for patient differences, there is no signià cant difference in rates of cr-bsi for the two types of catheter. this analysis suggests that multi-lumen catheters are not a signià cant risk factor for increased cr-bsi or local catheter colonisation compared with single-lumen cvcs. 370 a later systematic review and quantitative meta-analysis tested whether single-vs multi-lumen cvcs had an impact on catheter colonisation and cr-bsi. the study authors concluded that there is some evidence from à ve rcts with data on 530 cvcs that for every 20 single-lumen catheters inserted, one cr-bsi (which would have occurred had multi-lumen catheters been used) would be avoided. 371 neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic reviews. 334 ivad6 use a catheter with the minimum number of ports or lumens essential for management of the patient. ivad7 preferably use a designated singlelumen catheter to administer lipidcontaining parenteral nutrition or other lipid-based solutions. surgically implanted (tunnelled) devices (e.g. hickman ® catheters) are commonly used to provide vascular access to patients requiring long-term intravenous therapy. alternatively, totally implantable intravascular access devices (e.g. port-a-cath ® ) are also tunnelled under the skin, but have a subcutaneous port or reservoir with a self-sealing septum that is accessible by needle puncture through intact skin. multiple studies comparing the incidence of infection associated with long-term tunnelled cvcs and/or totally implantable ivds with that from percutaneously (non-tunnelled) inserted catheters have been assessed by hicpac. 372 although most studies reported a lower rate of infection in patients with tunnelled cvcs, [373] [374] [375] [376] [377] [378] [379] [380] [381] some studies found no signià cant difference in the rate of infection between tunnelled and nontunnelled catheters. 382, 383 additionally, most studies concluded that totally implantable devices had the lowest reported rates of cr-bsi compared with either tunnelled or non-tunnelled cvcs. [384] [385] [386] [387] [388] [389] [390] [391] [392] [393] [394] however, although these devices are less disruptive for patients in terms of daily living, they have a number of disadvantages including the need for needle insertion resulting in increased discomfort. 395 additional evidence was obtained from studies of efà cacy of tunnelling to reduce catheter-related infections in patients with short-term cvcs. one rct demonstrated that subcutaneous tunnelling of short-term cvcs inserted into the internal jugular vein reduced the risk for cr-bsi. 396 in a later rct, the same investigators failed to show a statistically signià cant difference in the risk for cr-bsi for subcutaneously tunnelled femoral vein catheters. 397 an additional meta-analysis of rcts was focused on the efà cacy of tunnelling short-term cvcs to prevent catheterrelated infections. 398 data synthesis demonstrated that tunnelling decreased catheter colonisation by 39% and decreased cr-bsi by 44% in comparison with non-tunnelled placement. the majority of the beneà t in the decreased rate of catheter sepsis came from one trial of cvcs inserted at the internal jugular site. the reduction in risk was not signià cant when pooled with data from à ve subclavian catheter trials. tunnelling was not associated with increased risk of mechanical complications from placement or technical difà culties during placement. this meta-analysis concluded that tunnelling decreased catheterrelated infections; however, a synthesis of the evidence in this meta-analysis does not support routine subcutaneous tunnelling of short-term subclavian venous catheters, and this cannot be recommended unless efà cacy is evaluated at different placement sites and relative to other interventions. peripherally inserted central catheters (piccs) are increasingly used for medium term (6 weeks to 6 months) 395 intravascular access, particularly in adults and children requiring antimicrobial treatment, chemotherapy and parenteral nutrition. evidence examined by hicpac suggested that piccs are associated with a lower rate of infection than that associated with other non-tunnelled cvcs. 382, 398 retrospective studies in outpatient settings indicate that rates of picc-related bloodstream infection range from 0.4 to 0.8 per 1000 catheter-days. [399] [400] [401] [402] [403] [404] however, there is little recent robust evidence regarding comparison of rates of cr-bsi in piccs vs other long-term central venous access devices. a prospective study 405 that compared the use of inpatient piccs indicated a similar rate of cr-bsi to non-tunnelled catheters placed in the internal jugular or subclavian veins and a higher rate than cuffed and tunnelled (ct) catheters (picc 3.5 cr-bsi per 1000 catheter-days vs nontunnelled 2.7 cr-bsi per 1000 catheter-days vs cuffed and tunnelled 1.6 cr-bsi per 1000 catheter-days). a systematic review of 200 studies indicated that when used in inpatients, piccs pose a slightly lower risk of cr-bsi than standard noncuffed and non-medicated cvcs placed in the subclavian or internal jugular vein (2.1 cr-bsi per 1000 catheter-days vs 2.7 cr-bsi per 1000 catheter-days). 340 neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic review. 334 ivad8 use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required. ivad9 use a peripherally inserted central catheter for patients in whom mediumterm intermittent access is required. some catheters and cuffs are marketed as anti-infective and are coated or impregnated with antimicrobial or antiseptic agents, e.g. chlorhexidine/silver sulfadiazine, minocycline/ rifampicin, platinum/silver, and ionic silver in subcutaneous collagen cuffs attached to cvc. evidence reviewed by hicpac [406] [407] [408] [409] [410] [411] [412] [413] [414] [415] [416] indicated that the use of antimicrobial or antisepticimpregnated cvc in adults whose catheter is expected to remain in place for more than à ve days could decrease the risk for cr-bsi. this may be cost-effective in high-risk patients (intensive care, burn and neutropenic patients) and in other patient populations in whom the rate of cr-bsi exceeds 3.3 per 1,000 catheter days even when there is a comprehensive strategy to reduce rates of cr-bsi. 406 a meta-analysis of 23 rcts published between 1988-1999 included data on 4,660 catheters (2,319 anti-infective and 2,341 control). 417 eleven of the trials in this meta-analysis were conducted in intensive care unit (icu) settings; four among oncology patients, two among surgical patients; two among patients receiving total parenteral nutrition (tpn) and four among other patient populations. study authors concluded that antibiotic and chlorhexidine-silver sulfadiazine coatings are anti-infective for short (approximately one week) insertion time. for longer insertion times, there was no data on antibiotic coating, and there is evidence of lack of effect for à rst generation chlorhexidine-silver sulfadiazine coating. for silver-impregnated collagen cuffs, there is evidence of lack of effect for both short-and long-term insertion. second generation chlorhexidine/silver sulfadiazine catheters with chlorhexidine coating on both the internal and external luminal surfaces are now available. the external surface of these catheters have three times the amount of chlorhexidine and extended release of the surface bound antiseptics than that in the à rst generation catheters (which are coated with chlorhexidine/silver sulfadiazine only on the external luminal surface). early studies indicated that the prolonged anti-infective activity associated with the second generation catheters improved efà cacy in preventing infections. 418 a systematic review and economic evaluation in 2006 concluded that rates of cr-bsi were statistically signià cantly reduced when an antimicrobial cvc was used. studies in this review report the best effect when catheters were treated with minocycline/rifampin, or internally and externally treated with silver or chlorhexidine/silver sulfadiazine. a trend to statistical signià cance was seen in catheters only extraluminally coated. investigation of other antibiotic treated catheters is limited to single studies with non-signià cant results. 419 we identià ed two additional systematic reviews and one rct in our updated search. a recent cochrane review of studies using impregnation, coating or bonding for reducing central venous catheter-related infections in adults included 56, predominantly unblinded studies, with low or unclear risk of bias. patients with impregnated catheters had lower rates of cr-bsi (actual risk reduction of 2% (95% ci, 3% to 1%)), and catheter colonisation (actual risk reduction 10% (95% ci, 13% to 7%)). in terms of catheter colonisation sub-group analysis showed that impregnated catheters were more beneà cial in studies conducted in intensive care units (rr 0.68 (95% ci, 0.59 to 0.78)) than in studies conducted in haemo-oncology (rr 0.75 (95% ci, 0.51 to 1.11)) or in patients requiring long-term parenteral nutrition rr 0.99 (95% ci, 0.74 to 1.34)). however, sub-group analysis did not identify the same beneà t in terms of cr-bsi. there were no statistically signià cant differences in the overall rates of bloodstream infections or mortality, although these outcomes were less often assessed than cr-bsi and catheter colonisation. 420 a collaborative network metaanalysis of cvc use in adults indicated that rifampicin-based impregnated cvc was the only type of impregnated/coated cvc that reduced catheter colonisation and cr-bsi compared with standard cvc. 421 in a single blind non-inferiority trial, authors concluded that cvc coated with 5-á uorouracil were non-inferior to chlorhexidine and silver sulfadiazine coated cvcs with respect to the incidence of catheter colonisation (2.9% vs. 5.3%, respectively). 422 chlorhexidine is a potential allergenic antiseptic that is present in many products and is widely used in health care for skin antisepsis, insertion of urinary catheters or coating cvcs. 406 in susceptible individuals, initial contact will cause a minor hypersensitivity reaction that, although not severe, should not go undocumented as subsequent exposures to chlorhexidine may lead to anaphylaxis. 423, 424 the medicines and healthcare products regulatory agency has alerted all healthcare providers in the uk to the risk of chlorhexidine allergy 425 and requires them to have systems in place that ensure: • awareness of the potential for an anaphylactic reaction to chlorhexidine; • known allergies are recorded in patient notes; • labels and instructions for use are checked to establish if products contain chlorhexidine prior to use on patients with a known allergy; • if a patient experiences an unexplained reaction, checks are carried out to identify whether chlorhexidine was used or was impregnated in a medical device that was used; and • reporting of allergic reactions to products containing chlorhexidine to the medicines and healthcare products regulatory agency. ivad10 use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for >5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection. the site at which a vascular access catheter is placed can iná uence the subsequent risk of cr-bsi because of variation in both the density of local skin á ora and the risk of thrombophlebitis. cvcs are generally inserted in the subclavian, jugular or femoral veins, or peripherally inserted into the superior vena cava by way of the major veins of the upper arm (i.e. the cephalic and basilar veins of the antecubital space). pvcs are normally inserted in the upper extremity, although alternatives, such as the foot and scalp, may be used in children and babies. hicpac examined a number of studies that compared insertion sites and concluded that cvcs inserted into subclavian veins had a lower risk for catheter-related infection than those inserted into either jugular or femoral veins. 345, 408, [426] [427] [428] [429] [430] [431] [432] [433] [434] guideline developers suggested that internal jugular insertion sites may pose a greater risk for infection because of their proximity to oropharyngeal secretions and because cvcs at this site are difà cult to immobilise. 334 however, mechanical complications associated with catheterisation might be less common with internal jugular than with subclavian vein insertion. femoral catheters have been demonstrated to have relatively high colonisation rates compared with subclavian and internal jugular sites when used in adults, and current guidelines suggest that the femoral site should be avoided because it is associated with both a higher risk of deep vein thrombosis and catheter-related infection than internal jugular or subclavian catheters. 428, [432] [433] [434] [435] [436] [437] one study also found that the risk of infection associated with catheters placed in the femoral vein is accentuated in obese patients. 409 thus, in adult patients, a subclavian site is preferred for preventing infection, although other factors (e.g. the potential for mechanical complications, risk for subclavian vein stenosis and catheter-operator skill) should be considered when deciding where to place the catheter. we identià ed a systematic review and meta-analysis 438 in which investigators reviewed two rcts, eight cohort studies and data from a national hcai programme. these provided evidence that the selection of device insertion site is not a signià cant factor for the prevention of cr-bsi. the metaanalysis demonstrated no difference in the risk of cr-bsi between the femoral, subclavian and internal jugular sites, s43 having removed two studies that were statistical outliers. the authors concluded that a pragmatic approach to site selection for central venous access, taking into account underlying disease (e.g. renal disease), the expertise and skill of the operator and the risks associated with placement, should be used. 438 two meta-analyses 439, 440 indicate that the use of real-time two-dimensional ultrasound for the placement of cvcs substantially reduced mechanical complications compared with the standard landmark placement technique. consequently, the use of ultrasound may indirectly reduce the risk of infection by facilitating mechanically uncomplicated subclavian placement. in the uk, nice guidelines provide recommendations for two-dimensional ultrasound placement of cvcs. 441 piccs may be used as an alternative to subclavian or jugular vein catheterisation. these are inserted into the superior vena cava via the major veins of the upper arm above the antecubital fossa. hicpac indicated that they are less expensive, associated with fewer mechanical complications (e.g. haemothorax, inà ltration and phlebitis) and easier to maintain than short peripheral venous catheters. 334 in a prospective cohort study using data from two randomised trials and a systematic review to estimate rates of picc-related bloodstream infection in hospitalised patients, the author concluded that piccs used in high-risk hospitalised patients are associated with a rate of cr-bsi similar to conventional cvcs placed in the internal jugular or subclavian veins (two to à ve per 1000 catheter-days). 441 to reduce the risk of cr-bsi and phlebitis, it is preferable to use an upper extremity site for inserting a pvc in adults and to replace a device inserted in a lower extremity to a site in the upper extremity as soon as possible. 334 in paediatric patients, the upper or lower extremity and the scalp (in young infants) can be used for siting a pvc. 405, 442 ivad11 in selecting an appropriate intravascular insertion site, assess the risks for infection against the risks of mechanical complications and patient comfort. ivad12 use the upper extremity for nontunnelled catheter placement unless medically contraindicated. the importance of strict adherence to hand decontamination and the aseptic technique as the cornerstone for preventing catheter-related infection is widely accepted. although this is considered adequate for preventing infections associated with the insertion of short peripheral venous catheters, it is recognised that central venous catheterisation carries a signià cantly greater risk of infection. studies examined by hicpac concluded that if msb precautions were used consistently during cvc insertion, catheter contamination and subsequent catheter-related infections could be reduced signià cantly. 345, 352, 443, 444 a prospective randomised trial that tested the efà cacy of msb precautions to reduce infections associated with long-term, non-tunnelled subclavian silicone catheters, compared with routine procedures, found that they decreased the risk of cr-bsi signià cantly. 443 msb precautions involve wearing sterile gloves and gown, cap and mask, and using a full-body sterile drape during insertion of the catheter. 334 it has been generally assumed that cvcs inserted in the operating theatre pose a lower risk of infection than those inserted on inpatient wards or other patient care areas. 372 however, data examined by hicpac from two prospective studies suggest that the difference in risk of infection depended largely on the magnitude of barrier protection used during catheter insertion, rather than the surrounding environment (i.e. ward vs operating theatre). 345, 443 a systematic review of the value of msb precautions to prevent cr-bsi deà ned the components as: the person inserting the catheter should wear a head cap, face mask, sterile body gown and sterile gloves, and use a full-size sterile drape. their search identià ed 95 papers discussing the prevention of cr-bsi. the majority of these were narrative reviews or consensus statements. three primary research studies, differing in design, patient population and clinical settings, that compared infection outcomes using msb precautions with less stringent barrier techniques, concluded that the use of msb precautions resulted in a reduction in catheter-related infections. the authors concluded that using msb precautions appears to decrease transmission of microorganisms, delay colonisation and reduce the rate of hcai. they also suggested that biological plausibility and the available evidence support using msb precautions during routine insertion of a cvc to minimise the risk of infection. they recommended that, given the lack of adverse patient reactions, the relatively low cost of msb precautions and the high cost of cr-bsi, it is probable that msb precautions will prove to be a cost-effective, or even a cost-saving, intervention. 445 neither we nor hicpac identià ed any additional evidence of acceptable quality whilst updating our systematic review. 334 ivad13 use maximal sterile barrier precautions for the insertion of central venous access devices. microorganisms that colonise catheter hubs and the skin surrounding the vascular catheter insertion site are the cause of most cr-bsi. 416, 446 as the risk of infection increases with the density of microorganisms around the insertion site, skin cleansing/antisepsis of the insertion site is one of the most important measures for preventing catheter-related infections. 334 since the early 1990s, research has focused on identifying the most effective antiseptic agent for skin preparation prior to the insertion of ivds in order to prevent catheter-related infections, especially cr-bsi. in the uk, clinicians principally use alcohol, or either povidone iodine (pvi) or chg, in various strengths, and the latter two as either aqueous or alcohol-based solutions. a prospective randomised trial of agents used for cutaneous antisepsis demonstrated that 2% aqueous chg was superior to either 10% pvi or 70% alcohol for the prevention of central venous and arterial catheter-related infections. 447 a further prospective, randomised trial demonstrated that a 4% alcoholbased solution of 0.25% chg and 0.025% benzalkonium chloride was more effective for the prevention of central venous or arterial catheter colonisation and infection than 10% pvi. 448 the use of 5% pvi solution in 70% ethanol has been shown to be associated with a substantial reduction in catheter-related colonisation and infection compared with 10% aqueous pvi. 449 clinicians may à nd this useful for those patients for whom alcoholic chg is contraindicated. a meta-analysis 450 of studies that compared the risk for cr-bsi following insertion-site skin care with any type of chg solution vs pvi solution indicated that the use of chg rather than pvi can reduce the risk for cr-bsi by approximately 49% (rr 0.51, 95% ci 0.27-0.97) in hospitalised patients who require short-term catheterisation (i.e. for every 1000 catheter sites disinfected with chg rather than pvi, 71 episodes of catheter colonisation and 11 episodes of cr-bsi would be prevented). in this analysis, several types of chg solution were used in the individual trials, including 0.5% or 1% chg alcohol solution and 0.5% or 2% chg aqueous solution. all of these solutions provided a concentration of chg that is higher than the minimal inhibitory concentration (mic) for most nosocomial bacteria and yeasts. subset analysis of aqueous and non-aqueous solutions showed similar effect sizes, but only the subset analysis of the à ve studies that used alcoholic chg solution produced a signià cant reduction in cr-bsi. as few studies used chg aqueous solution, the lack of a signià cant difference seen for this solution compared with pvi solution may be a result of inadequate statistical power. additionally, an economic decision analysis based on available evidence from the same authors suggested that the use of chg, rather than pvi, for skin care would result in a 1.6% decrease in the incidence of cr-bsi, a 0.23% decrease in mortality, and à nancial savings per catheter used. 451 several studies were examined that focused on the application of antimicrobial ointments to the catheter site at the time of catheter insertion, or during routine dressing changes, to reduce microbial contamination of catheter insertion sites. 448 reported efà cacy of this practice for the prevention of catheter-related infections yielded contradictory à ndings. [449] [450] [451] [452] [453] [454] [455] [456] [457] there was also concern that the use of polyantibiotic ointments that were not fungicidal could signià cantly increase the rate of colonisation of the catheter by candida species. 458, 459 nice 56 identià ed three rcts that compared the effectiveness of different antiseptic solutions for the insertion of pvcs in hospitalised patients. the evidence from these studies was considered to be of very low quality, and no conclusion could be drawn about the beneà ts of one particular antiseptic solution over another. however, while there is no evidence comparing different concentrations of chg, the reviewers indicated that the trend in the evidence suggests that chg in alcohol may be more effective than pvi in alcohol. we identià ed one recent systematic review of the clinical efà cacy and perceived role of chg in skin antisepsis that included studies about intravascular access. 460 the authors suggested a potential source of bias, as many studies have overlooked the importance of alcohol when assessing the efà cacy of chg. the authors assessed the attribution of chg in each study as correct, incorrect or intermediate. studies were scored and analysis was performed separately to assess chg efà ciency. the authors concluded that chg is more efà cient than pvi or any other technique alone, but that the presence of alcohol provides additional beneà t. the authors suggested that vascular catheters require the immediate antiseptic activity provided by alcohol prior to insertion. they also require a long-lasting antiseptic, as they stay in place for prolonged periods of time. ivad14 decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry prior to the insertion of a central venous access device. ivad15 decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry before inserting a peripheral vascular access device. ivad16 do not apply antimicrobial ointment routinely to the catheter placement site prior to insertion to prevent catheter-related bloodstream infection. the safe maintenance of an intravascular catheter and appropriate care of the insertion site are essential components of a comprehensive strategy for preventing catheter-related infections. this includes good practice in caring for the patient's catheter hub and connection port, the use of an appropriate intravascular catheter site dressing regimen, and using á ush solutions to maintain the patency of the catheter. following placement of a pvc or cvc, a dressing is used to protect the insertion site. as occlusive dressings trap moisture on the skin and provide an ideal environment for the rapid growth of local microá ora, dressings for insertion sites must be permeable to water vapour. 446 the two most common types of dressings used for insertion sites are sterile, transparent, semi-permeable polyurethane dressings coated with a layer of an acrylic adhesive ('transparent dressings') and gauze and tape dressings. transparent dressings are permeable to water vapour and oxygen, and impermeable to microorganisms. hicpac reviewed the evidence related to which type of dressing provided the greatest protection against infection, including the largest controlled trial of dressing regimens on pvcs, 361 a meta-analysis comparing the risk of cr-bsi using transparent vs gauze dressings 461 and a cochrane review. 462 all concluded that the choice of dressing can be a matter of preference, but if blood is leaking from the catheter insertion site, a gauze dressing might be preferred to absorb the á uid. we identià ed an updated cochrane review which concluded that bloodstream infection was higher in the transparent polyurethane group compared with the gauze and tape group. 463 the included trials were graded low quality due to the small sample size and risk of bias. there was additional low-quality evidence that demonstrated no difference between highly permeable polyurethane dressings and other polyurethane dressings in the prevention of cr-bsi. hicpac reviewed the evidence related to impregnated sponge dressings compared with standard dressings and found two rcts in adults which demonstrated that chlorhexidineimpregnated sponge dressings were associated with a signià cant reduction in cr-bsi. however, a meta-analysis that included eight rcts found a reduction in exit site colonisation but no signià cant reduction in cr-bsi. in paediatric patients, two small rcts found a reduction in catheter colonisation but not cr-bsi, and evidence of localised contact dermatitis when used for infants of very low birth weight. 334 we identià ed one systematic review and meta-analysis, undertaken as part of a quality improvement collaborative, that synthesised the effects of the routine use of chgimpregnated sponge dressings in reducing centrally inserted cr-bsi. 464 five studies were included in the analysis; two of the à ve studies were in patients in haemo/oncological icus, and the remaining three studies were in surgical and medical icus. four of the à ve studies were sponsored by the manufacturer of the product. the reviewers concluded that chg-impregnated sponge dressings are effective for the prevention of cr-bsi (or 0.43, 95% ci 0.29-0.64) and catheter colonisation (or 0.43, 95% ci 0.36-0.51). we identià ed an economic evaluation of the use of chg sponge dressings and the non-inferiority of dressing changes at 3 and 7 days. 465 the authors concluded that the major cost avoided by the use of chg sponge dressings and 7-day dressing changes rather than 3-day dressing changes was the increased length of stay of 11 days associated with cr-bsi. chlorhexidineimpregnated sponge dressings remained cost saving for any value where the cost per cr-bsi was >$4400 and the baseline rate of cr-bsi was >0.35%. 465 we identià ed a further rct of chg dressings compared with highly adhesive semi-permeable dressings or standard semi-permeable dressings for the prevention of cr-bsi in 1879 patients. 466 in the chg group, the major catheterrelated infection rate was 67% lower (0.7 vs 2.1 per 1000 catheter-days, hr 0.328, 95% ci 0.174-0.619, p=0.0006) and the cr-bsi rate was 60% lower (0.5 vs 1.3 per 1000 catheterdays, hr 0.402, 95% cl 0.186-0.868, p=0.02) than with nonchlorhexidine dressings. decreases were also noted in catheter colonisation and skin colonisation rates at catheter removal. highly adhesive dressings decreased the detachment rate to 64.3% vs 71.9% (p<0.0001) and the number of dressings per catheter to two (one to four) vs three (one to à ve) (p<0.0001), but increased skin colonisation (p<0.0001) and catheter colonisation (hr 1.650, 95% cl 1.21-2.26, p=0.0016) without iná uencing cr-bsi rates. hicpac identià ed three studies that investigated the efà cacy of a 2% chg-impregnated washcloth in reducing the risk of cr-bsi. 334 these studies were included in a subsequent systematic review and meta-analysis on the efà cacy of either 2% chg-impregnated cloths or 4% chg solution for daily skin cleansing in adult acute care settings, mostly icus. 467 twelve studies were included: one rct, one cluster nrct and 10 controlled interrupted time series. five studies that reported the insertion technique included the use of chg. there was a high level of clinical heterogeneity and moderate statistical heterogeneity, which remained following a subgroup analysis by type of chg formulation. the authors concluded that among icu patients, daily chg bathing with chg liquid (or 0.47, 95% ci 0.31-0.71) or cloths (or 0.41, 95% ci 0.25-0.65) reduces the risk of cr-bsi. similar beneà t is obtained regardless of whether chg cloths or liquid preparation is used (or 0.44, 95% ci 0.44-0.59). this review was not generalisable to paediatric care. whenever chg is used for insertion site dressings or skin cleansing, systems should be in place to ensure that it is not used for patients with a history of chlorhexidine sensitivity. 408 a single rct compared the efà cacy of two commercially available alcohol-based antiseptic solutions for preparation and care of cvc insertion sites, with and without octenidine dihydrochloride. 468 data were collected from 2002 to 2005 and published in 2010. the authors concluded that octenidine in alcoholic solution is a better option than alcohol alone for the prevention of cvc-associated infections, and may be as effective as chg in practice but a comparative trial is needed. ivad17 use a sterile, transparent, semipermeable polyurethane dressing to cover the intravascular insertion site. ivad18 transparent, semi-permeable polyurethane dressings should be changed every 7 days, or sooner, if they are no longer intact or if moisture collects under the dressing. ivad19 use a sterile gauze dressing if a patient has profuse perspiration or if the insertion site is bleeding or leaking, and change when inspection of the insertion site is necessary or when the dressing becomes damp, loosened or soiled. replace with a transparent semi-permeable dressing as soon as possible. ivad20 consider the use of a chlorhexidineimpregnated sponge dressing in adult patients with a central venous catheter as a strategy to reduce catheterrelated bloodstream infection. ivad21 consider the use of daily cleansing with chlorhexidine daily in adult patients with a central venous catheter as a strategy to reduce catheter-related bloodstream infection. ivad22 dressings used on tunnelled or implanted catheter insertion sites should be replaced every 7 days until the insertion site has healed unless there is an indication to change them sooner. a dressing may no longer be required once the insertion site is healed. research previously described in these guidelines has described the superior effectiveness of chg to minimise the density of microorganisms around vascular catheter insertion sites. 447, 448, 450 consequently, alcoholic chg is now widely used in the uk for disinfecting the insertion site during dressing changes. studies focused on the use of antimicrobial ointment applied under the dressing to the catheter insertion site to prevent catheter-related infection do not clearly demonstrate efà cacy. 454, 459 most modern intravascular catheters and other catheter materials are not damaged by contact with alcohol. however, alcohol, and other organic solvents and oil-based ointments and creams, may damage some types of polyurethane and silicon catheter tubing (e.g. some catheters used in haemodialysis). the manufacturer's recommendations to only use disinfectants that are compatible with specià c catheter materials must therefore be followed. ivad23 use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the central catheter insertion site during dressing changes, and allow to air dry. ivad24 use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the peripheral venous catheter insertion site during dressing changes, and allow to air dry. ivad25 do not apply antimicrobial ointment to catheter insertion sites as part of routine catheter site care. evidence indicates that the routine replacement of cvcs at scheduled time intervals does not reduce rates of cr-bsi. three randomised trials investigated strategies for replacing cvcs routinely at either 7 days 469,470 or 3 days 471 compared with changing catheters when clinically indicated. two studies were conducted in adult icus 469,471 and a third study was undertaken in a renal dialysis unit. 470 no difference in cr-bsi was observed in patients in the scheduled replacement groups compared with those replaced when clinically indicated. another suggested strategy for the prevention of cr-bsi is the routine scheduling of guidewire exchange of cvcs. a systematic review and meta-analysis 472 of 12 rcts concluded that when compared with insertion at a new site, guidewire exchange was associated with a trend towards increased rates of catheter colonisation (rr 1.26, 95% ci 0.87-1.84), regardless of suspected cr-bsi at the time of replacement. guidewire exchange was also associated with a trend towards increased rates of catheter exitsite infection (rr 1.52, 95% ci 0.34-6.73) and cr-bsi (rr 1.72, 95% ci 0.89-3.33), but also associated with fewer mechanical complications relative to insertion at a new site. 472 neither we nor hicpac identià ed any additional evidence for these recommendations whilst updating our systematic review. 334 we identià ed one rct that compared a routine 3-day re-siting of pvcs compared with a clinically indicated resiting. ivd-related complication rates were 68 per 1000 ivddays (clinically indicated) and 66 per 1000 ivd-days (routine replacement) (p=0.86, hazard ratio 1.03, 95% ci 0.74-1.43). re-siting a device on clinical indication would allow one in two patients to have a single cannula per course of intravenous treatment, as opposed to one in à ve patients managed with routine re-siting; overall complication rates appear similar. clinically indicated re-siting would achieve savings in equipment, staff time and patient discomfort. 473 a recent update of a cochrane review found no evidence to support changing catheters every 72-96 h. 474 evidence demonstrating that contamination of the catheter hub contributes to intraluminal microbial colonisation of catheters, particularly long-term catheters, was considered by hicpac. 346, [475] [476] [477] [478] [479] [480] catheter hubs are accessed more frequently when catheterisation is prolonged, and this increases the risk of cr-bsi originating from a colonised catheter hub rather than the insertion site. 346 evidence from a prospective cohort study suggested that frequent catheter hub manipulation increases the risk for microbial contamination. 481 additional studies concurred and recommended that hubs and sampling ports should be disinfected using either povidone iodine or chlorhexidine before they are accessed. 406, 482, 483 a randomised prospective clinical trial investigated the use of needleless connectors or standard caps attached to cvc luer connections. results suggested that the use of needleless connectors may reduce the microbial contamination rate of cvc luers compared with standard caps. furthermore, disinfection of needleless connectors with either chlorhexidine/alcohol or pvi signià cantly reduced external microbial contamination. both these strategies may reduce the risk of catheter-related infections acquired via the intraluminal route. 484 we found no rct evidence comparing the efà cacy of different methods for the decontamination of ports and hubs prior to access. expert opinion, based on consensus and evidence extrapolated from experimental studies of hub decontamination, 56, 485, 486 and studies of skin decontamination prior to insertion and during dressing changes, suggests that injection ports or catheter hubs should be decontaminated for a minimum of 15 s using chg in 70% alcohol before and after accessing the system. although most intravascular catheters and catheter hub materials are now chemically compatible with alcohol or iodine, some may be incompatible and therefore the manufacturer's recommendations should be followed. ivad30 a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) should be used to decontaminate the access port or catheter hub. the hub should be cleaned for a minimum of 15 s and allowed to dry before accessing the system. the procedure of á ushing and then leaving the lumen of a cvc à lled with an antibiotic solution is termed 'antibiotic lock prophylaxis' and has been described as a measure to prevent cr-bsi in haemodialysis or a patient who has a history of multiple cr-bsi despite optimal maximal adherence to the aseptic technique. evidence reviewed by hicpac 334 demonstrated the effectiveness of this type of prophylaxis. however, the majority of the studies were conducted in haemodialysis patients and therefore may not be generalisable. we identià ed a systematic review of rcts which concluded that the scientià c evidence for the effectiveness of the routine use of antibiotic-based lock solutions is weak, 487 thus supporting the hicpac evidence. in addition, there is concern that the use of such solutions could lead to an increase in antimicrobialresistant microorganisms. 334 an additional placebo-rct of daily ethanol locks to prevent cr-bsi in patients with tunnelled catheters 488 found that the reduction in the incidence of endoluminal cr-bsi using preventive ethanol locks was non-signià cant, although the low incidence of endoluminal cr-bsi precludes deà nite conclusions, and the low incidence of cr-bsi in the placebo arm meant the study was underpowered in retrospect. signià cantly more patients treated with ethanol locks discontinued their prophylactic treatment due to non-severe, ethanol-related adverse effects. ivad31 antimicrobial lock solutions should not be used routinely to prevent catheterrelated bloodstream infections. hicpac identià ed no studies which demonstrated that oral or parenteral antibacterial or antifungal drugs reduced the incidence of cr-bsi among adults. however, among lowbirthweight infants, two studies on vancomycin prophylaxis demonstrated a reduction in cr-bsi but no reduction in mortality. as the prophylactic use of vancomycin is an independent risk factor for the acquisition of vre, it is likely that the risk of acquiring vre outweighs the beneà t of using prophylactic vancomycin. 334, 489 topical mupirocin is used to suppress s. aureus in nasal carriers. some studies have shown that mupirocin applied nasally (or locally to the insertion site) results in reduced risk of cr-bsi. 334 however, rates of mupriocin resistance of 12% have been reported in the uk, 490 and its incompatibility with polyurethane catheters means that it should not be used routinely. 334 long-term tunnelled cvcs are frequently used for patients with cancer who require intravenous treatments. a cochrane review published in 2003 concluded that prophylactic antibiotics or catheter á ushing with vancomycin and heparin may be of beneà t in reducing the risk of catheter-related infections in these high-risk cancer patients. 491 however, this practice should not be used routinely in order to minimise the development of antimicrobial resistance. 491 ivad32 do not routinely administer intranasal or systemic antimicrobials before insertion or during the use of an intravascular device to prevent catheter colonisation or bloodstream infection. the placement of any cvc or pulmonary artery catheter leads to thrombus formation shortly after insertion, providing a focus for bacterial growth. 492 catheters manufactured from silicone or polyethylene and placed in the subclavian vein are less frequently associated with thrombus formation. 493 between 35% and 65% of patients with long-term cvcs and piccs develop a thrombosis of the large vessels, and patients are treated with prophylactic heparin to prevent the formation of both deep vein thrombosis and catheter thrombus. 334, [494] [495] [496] [497] [498] [499] the use of anticoagulants heparin may be administered through several different routes. an early meta-analysis of rcts compared the effectiveness of heparin administration via an infusion, subcutaneously or intermittent á ush for the prevention of thrombus formation and cr-bsi in patients with short-term cvcs. 500 prophylactic heparin infusion was associated with a decrease in catheter thrombus formation, deep vein thrombosis, catheter colonisation and a trend towards reductions in cr-bsi, but this was not statistically h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 s49 signià cant. hicpac identià ed an additional prospective randomised trial that demonstrated a signià cant decrease in the rate of cr-bsi in patients with non-tunnelled cvcs who received continuous heparin infusion. 501 heparin-bonded (hb) catheters have also been shown to reduce the risk of both thrombus formation and cr-bsi. [502] [503] [504] [505] we identià ed one systematic review of hb cvcs in children. 506 the reviewers identià ed two rcts of 287 children aged 1 day to 16 years who received either an hb catheter or a standard catheter. there was no signià cant difference in the median duration of catheter patency in the two groups: 7 days in the hb catheter group and 6 days in the standard catheter group. the authors also reported a trend towards a reduction in the risk of catheter-related thrombosis and catheter occlusion in the hb group. the risks of catheter colonisation and catheterrelated infection were signià cantly reduced in the treatment group, with a delay to infection in the hb catheter group. however, the reviewers considered the need for further studies to conà rm the efà cacy of hb catheters. the use of warfarin has also been shown to reduce the risk of catheter-related thrombosis in some patient groups but not in others, and is generally not associated with a reduction in infection-related complications. 501,507-509 systemic heparin, as either an infusion or á ush, has a number of side effects that contraindicate its routine use for maintaining the patency of cvcs and preventing thrombus formation; these include thrombocytopenia, allergic reactions and bleeding. 510 normal saline is an alternative to the use of heparin á ush. hicpac refer to three systematic reviews, and meta-analysis of rcts evaluating the effect of heparin on the duration of catheter patency and on the prevention of complications associated with the use of peripheral venous and arterial catheters concluded that heparin at doses of 10 u/ml for intermittent á ushing is no more beneà cial than á ushing with normal saline alone. [511] [512] [513] [514] however, manufacturers of implanted ports or opened-ended catheter lumens may recommend heparin á ushes for maintaining cvcs that are accessed infrequently. we identià ed one systematic review and two rcts that compared heparin with normal saline to maintain the patency of cvcs and pvcs, respectively. 515-517 a systematic review 515 of heparin á ushing and other interventions to maintain the patency of cvcs concluded that the evidence base for heparin á ushing and other interventions to prevent catheter occlusion is limited and published studies are of low quality. the reviewers concluded that there is no direct evidence of the effectiveness of heparin á ushes to prevent cr-bsi or other central line complications. in a single-centre rct 516 of newly placed multi-lumen cvcs in patients in medical icus and surgical/burn/trauma icus, normal saline and heparin á ush solutions were found to have similar rates of lumen non-patency. given potential safety concerns with the use of heparin, normal saline may be the preferred á ushing solution for short-term use for cvc maintenance. secondary outcomes for cr-bsi were non-signià cant between groups. a single-centre cluster rct 517 of 214 medical patients found that twice-daily heparin (100 u/ml) á ushes for maintenance of pvcs was more effective than normal saline solution. the number of catheter-related phlebitis/occlusions and the number of catheters per patient was reduced; however, infection outcomes were not measured. ivad33 do not use systemic anticoagulants routinely to prevent catheter-related bloodstream infection. ivad34 use sterile normal saline for injection to á ush and lock catheter lumens that are accessed frequently. needle-free infusion systems and connection devices have been widely introduced to reduce the incidence of sharps injuries and minimise the risk of transmission of bloodborne pathogens to healthcare workers. 334 there is limited evidence that needleless devices or valves reduce the risk of catheter colonisation compared with standard devices. 334 in addition, the design features of some of these devices pose a potential risk for contamination, and have been associated with reports of an increase in bloodstream infection rates. [518] [519] [520] [521] ivad35 the introduction of new intravascular devices or components should be monitored for an increase in the occurrence of device-associated infection. if an increase in infection rates is suspected, this should be reported to the medicines and healthcare products regulatory agency in the uk. ivad36 when safer sharps devices are used, healthcare workers should ensure that all components of the system are compatible and secured to minimise leaks and breaks in the system. hicpac reviewed three well-controlled studies on the optimal interval for the routine replacement of intravenous solution administration sets. 334 a cochrane review 522 of 13 rcts with 4783 patients concluded that there is no evidence that changing intravenous administration sets more often than every 96 h reduces the incidence of bloodstream infection. the reviewers were unable to conclude if changing administration sets less often than every 96 h affects the incidence of infection from the studies. there were no differences between participants with central vs peripheral catheters, nor between participants who did and did not receive parenteral nutrition, or between children and adults. administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 h without increasing the incidence of infection. there is no evidence to suggest that administration sets which contain lipids should not be changed every 24 h as currently recommended. ivad37 administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-specià c recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced. class a ivad38 administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 h (whichever is sooner). ivad39 administration sets used for lipidcontaining parenteral nutrition should be changed every 24 h. ensuring that patients receive care that is evidence based is an essential element of delivering high-quality health care. in 2005, the department of health issued a series of highimpact interventions that were derived from national and international evidence-based guidelines for the prevention of healthcare-associated infection and based on experience from the institute of healthcare improvement 100,000 lives campaign focused on reducing patient harm. 523 the high-impact interventions focused on increasing the reliability of care and ensuring that recommendations were implemented every time for every patient. the intervention for the prevention of infection associated with the use of ivds included six key interventions often referred to as a 'care bundle', together with audit tools to measure adherence. these six practices included: • aseptic insertion of an appropriate device; • correct siting of the device; • effective cutaneous antisepsis; and for continuing care of the device: • hand decontamination and asepsis for any contact with the device; • daily observation of the insertion site; and • clean, intact dressing. a small number of well-designed studies 353,524 have described the use of 'bundled' approaches to reducing cr-bsi, and have stimulated individual observational and quality improvement reports of the results of using key evidence-based practices for the prevention of cr-bsi. the most prominent of these was a study conducted in the icu setting of 108 hospitals in the usa, which was then adopted by other countries including the uk. 525, 526 the authors reported the success of à ve evidence-based practices combined with system and organisational support, which resulted in a 66% decrease in cr-bsi 18 months after the inception of the programme (incidence rate ratio 0.62, 95% ci 0.47-0.81 to incidence rate ratio 0.34, 95% ci 0.23-0.50) and sustained reductions thereafter. 525 the intervention comprised: hand hygiene using abhr; msb precautions for insertion; cutaneous antisepsis of the insertion site with 2% chg; avoiding the femoral site; and removing cvcs as soon as they are no longer clinically indicated. in addition, system changes that prompted the clinician to 'do the right thing' included placing all the equipment needed in a cart for ease of access; the use of a checklist; authorising staff to halt procedures if best practice was not being followed; daily rounds to ensure the timely removal of cvcs; feedback of cr-bsi cases to clinical staff; and organisational support to purchase essential equipment and solutions prior to the start of the study. audit and feedback are an essential component of any quality improvement intervention as this promotes a continuous 'hawthorne effect' and enables staff to maintain vigilance and sustain improvement. the use of dashboards and statistical process control charts alerts clinicians to variability outside control limits, and prompts scrutiny of practice and organisational systems, and remedial action to be taken. 527 we identià ed three additional studies that reported 'bundled interventions' to reduce cr-bsi. [528] [529] [530] none were included in the systematic review as they failed to meet study quality criteria. the features of any quality improvement initiative need to be tailored to the local conditions and may include some or all of the following: • hand hygiene, aseptic insertion using msb precautions (cvc), aseptic technique (pvc), cutaneous antisepsis using 2% chg in alcohol unless contraindicated, appropriate siting of the cvc or pvc, and prompt removal when no longer indicated; • audit and feedback; • education and training; and • accessibility of equipment and appropriate system changes developed with clinical staff to make best practice the norm. in one cost-effectiveness study, a markov decision model was used to evaluate the cost-effectiveness of a care bundle to prevent cr-bsi. 531 the care bundle included in the model was based on the bundle advocated by the institute for health improvement 100,000 lives campaign, 532 comprising optimal hand hygiene, chlorhexidine skin antisepsis, msb precautions for catheter insertion and insertion equipment kit, optimal insertion site and prompt catheter removal. costs included monitoring, education and clinical leadership activities. the authors estimated that the bundle would be cost-effective if the costs of implementation were less than aus$94,559 (£55,817) per icu. to support the appropriate use and management of intravascular access devices (central and peripheral venous catheters) and ensure their timely removal. these may include: • protocols for device insertion and maintenance; • reminders to review the continuing use or prompt the removal of intravascular devices; • audit and feedback of compliance with practice guidelines; and • continuing professional education. systematic review questions 1. what types of cvcs (material, coating, antibiotic impregnation, cuffed, tunnelled, midline, picc) and pvcs (material, coating, antibiotic impregnation) are most effective in reducing the risk of cr-bsi and related complications/adverse events including phlebitis, related mortality, catheter tip colonisation and premature line removal? 2. which cvc/pvc insertion site is associated with the lowest risk of cr-bsi and related complications including phlebitis, related mortality, catheter tip colonisation and premature line removal? 3. what is the evidence that additional ports or lumens increase the risk of cr-bsi and related complications/adverse events including phlebitis, mortality, catheter tip colonisation and premature line removal? 4. which infection prevention precautions used for inserting intravascular catheters are most effective in reducing the risk of cr-bsi and related complications/adverse events including phlebitis, catheter tip colonisation, premature line removal and mortality? 5. what levels of barrier precautions are most effective in reducing the risk of cr-bsi and related complications/adverse events including phlebitis, catheter tip colonisation, premature line removal and mortality? 6. what is the most effective skin antisepsis solution/antiseptic-impregnated product for decontamination of the skin prior to insertion of cvcs and pvcs to reduce the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 7. what is the effectiveness of antiseptics vs antiseptic-impregnated products (sponges or cloths) for decontaminating skin at the insertion site or surrounding area whilst a cvc or pvc is in situ in reducing the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 8. what is the evidence for the effectiveness of using antibiotics or antiseptics to lock, á ush or clean the catheter hub or entry ports of cvcs and pvcs in reducing the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 9. what is the effectiveness of low-dose systemic anticoagulation to reduce the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 10. which dressing type is the most clinically effective in reducing the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality, and how frequently should dressings be changed? 11. what is the optimal frequency to change or re-site pvcs or midline catheters to reduce the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 12. what is the evidence for the effectiveness of replacing administration sets to reduce the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 13. what is the effectiveness of the prophylactic administration of systemic antimicrobials in reducing the incidence of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 14. what is the evidence that the needle-safe devices are associated with increased risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 15. what is the effectiveness of system interventions in reducing the risk of cr-bsi and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality, and improving healthcare workers' knowledge and behaviour relating to the use of central venous access device (cvad) and peripheral vascular device (pvd)? total number of articles located = 8053 abstract indicates that the article: relates to infections associated with intravascular access devices; is written in english; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions. total number of articles retrieved from sift 1 = 96 full text conà rms that the article: relates to infections associated with intravascular access devices; is written in english; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a metaanalysis including the above designs; and informs one or more of the review questions. total number of studies selected for appraisal during sift 2 = 30 all articles that described primary research, a systematic review or a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers using sign and epoc criteria. consensus and grading was achieved through discussion. total number of studies accepted after critical appraisal = 22 total number of studies rejected after critical appraisal = 8 the epic project: developing national evidence-based guidelines for preventing healthcare associated infections. phase i: guidelines for preventing hospital-acquired infections national evidencebased guidelines for preventing healthcare-associated infections in nhs hospitals in england appraisal of guidelines for research and evaluation il sign 50: a guideline developer's handbook. edinburgh: heathcare improvement scotland cochrane effective practice and organisation of care review group. epoc resources. the cochrane collaboration department of health. the health and social care act 2008: code of practice for the nhs on the prevention and control of healthcare associated infections and related guidance. london: department of health decontamination of re-usable medical devices in the primary, secondary and tertiary care sectors (nhs and independent providers). london: department of health essential standards of quality and safety. london: care quality commission national patient safety agency. the revised healthcare cleaning manual guidance 36. prevention and control of healthcare-associated infections. quality improvement guide. london: national institute for health and care excellence widespread environmental contamination associated with patients with diarrhea and methicillin-resistant staphylococcus aureus colonization of the gastrointestinal tract importance of the environment in meticillin-resistant staphylococcus aureus acquisition: the case for hospital cleaning reservoirs of mrsa in the acute hospital setting: a systematic review bloomà eld sf. effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces role of environmental cleaning in controlling an outbreak of acinetobacter baumannii on a neurosurgical intensive care unit comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of clostridium difà cile infection environmental contamination due to methicillin-resistant staphylococcus aureus: possible infection control implications contamination of room door handles by methicillin-sensitive/methicillin-resistant staphylococcus aureus bacterial contamination of computer keyboards in a teaching hospital chlorhexidine resistance in antibiotic-resistant bacteria isolated from the surfaces of dispensers of soap containing chlorhexidine risk of acquiring multidrug-resistant gram-negative bacilli from prior room occupants in the intensive care unit risk of acquiring antibioticresistant bacteria from prior room occupants evaluation of hospital room assignment and acquisition of clostridium difà cile infection evidence that hospital hygiene is important in the control of methicillin-resistant staphylococcus aureus the impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover study in critical care units in two hospitals does disinfection of environmental surfaces iná uence nosocomial infection rates? a systematic review feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy united states hospital daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers' hands measuring the effect of enhanced cleaning in a uk hospital: a prospective cross-over study tackling contamination of the hospital environment by methicillin-resistant staphylococcus aureus (mrsa): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination the role of 'no-touch' automated room disinfection systems in infection prevention and control efà cacy, efà ciency and safety aspects of hydrogen peroxide vapour and aerosolized hydrogen peroxide room disinfection systems comparison of the efà cacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of clostridium difà cile spores an evaluation of environmental decontamination with hydrogen peroxide vapor for reducing the risk of patient acquisition of multidrug-resistant organisms sustained reduction of microbial burden on common hospital surfaces through introduction of copper copper continuously limits the concentration of bacteria resident on bed rails within the intensive care unit role of copper in reducing hospital environment contamination the antimicrobial efà cacy of copper alloy furnishing in the clinical environment: a crossover study copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit finding a benchmark for monitoring hospital cleanliness monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay a modià ed atp benchmark for evaluating the cleaning of some hospital environmental surfaces the effectiveness of existing and modià ed cleaning regimens in a welsh hospital use of audit tools to evaluate the efà cacy of cleaning systems in hospitals world health organization. who patient safety. who guidelines on hand hygiene in health care. geneva: world health organization outbreak of extendedspectrum beta-lactamase-producing klebsiella pneumoniae in a neonatal intensive care unit linked to artià cial nails bacterial contamination of the hands of hospital staff during routine patient care dynamics of bacterial hand contamination during routine neonatal care the impact of alcohol hand sanitizer use on infection rates in an extended care facility handwashing and respiratory illness among young adults in military training effectiveness of a hospital-wide programme to improve compliance with hand hygiene reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub healthcare infection control practices advisory committee; society for healthcare epidemiology of america/association for professionals in infection control/ infectious diseases society of america hand hygiene task force. guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/ idsa hand hygiene task force best practices for hand hygiene in all health care settings. toronto: ontario ministry of health and long-term care/public health division my à ve moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene infection: prevention and control of healthcare-associated infections in primary and community care: partial update of nice clinical guideline 2. nice clinical guidelines infection control: prevention of healthcare-associated infection in primary and community care chemical disinfectants and antiseptics. hygienic handrub. test method and requirements (phase 2/step 2) hand contamination before and after different hand hygiene techniques: a randomized clinical trial skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use assessment of two hand hygiene regimens for intensive care unit personnel efà cacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial handwashing with soap or alcoholic solutions? a randomized clinical trial of its effectiveness effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units clinical assay of n-duopropenide alcohol solution on hand application in newborn and pediatric intensive care units: control of an outbreak of multiresistant klebsiella pneumoniae in a newborn intensive care unit with this measure a new alcohol solution (n-duopropenide) for hygienic (or routine) hand disinfection is more useful than classic handwashing: in vitro and in vivo studies in burn and other intensive care units assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses limited efà cacy of alcohol-based hand gels effectiveness of a nonrinse, alcohol-free antiseptic hand wash effectiveness of hand-cleansing agents for removing methicillin-resistant staphylococcus aureus from contaminated hands a close look at alcohol gel as an antimicrobial sanitizing agent effectiveness of hand-cleansing agents for removing acinetobacter baumannii strain from contaminated hands limited effectiveness of chlorhexidine based hand disinfectants against methicillinresistant staphylococcus aureus (mrsa) testing a new alcohol-free hand sanitizer to combat infection comparison of waterless hand antisepsis agents at short application times: raising the á ag of concern comparative efà cacy of hand hygiene agents in the reduction of bacteria and viruses interventions to improve hand hygiene compliance in patient care increased use of alcohol-based hand sanitizers and successful eradication of methicillin-resistant staphylococcus aureus from a neonatal intensive care unit: a multivariate time series analysis comparison of the antibacterial efà cacy of 4% chlorhexidine gluconate and 1% triclosan handwash products in an acute clinical ward hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of clostridium difà cile effectiveness of alcoholbased hand rubs for removal of clostridium difà cile spores from s54 efà cacy of soap and water and alcohol-based hand-rub preparations against live h1n1 iná uenza virus on the hands of human volunteers effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections uniforms and workwear: guidance on uniform and workwear policies for nhs employers. london: department of health alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized clinical trial of protocol efà cacy and time effectiveness iná uence of rub-in technique on required application time and hand coverage in hygienic hand disinfection effects of 4 handdrying methods for removing bacteria from washed hands: a randomized trial efà ciency of hand drying for removing bacteria from washed hands: comparison of paper towel drying with warm air drying infection control in the built environment. health building note 00-09. london: department of health the hygienic efà cacy of different hand-drying methods: a review of the evidence hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel hand dermatitis in intensive care units dermal tolerance of sterillium, a propanol-based hand rub double-blind, randomized, crossover trial of 3 hand rub formulations: fast-track evaluation of tolerability and acceptability pseudomonas aeruginosa outbreak in a neonatal intensive care unit: a possible link to contaminated hand lotion use of alcohol hand sanitizer as an infection control strategy in an acute care facility reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in argentina effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in argentina handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by mrsa and antibiotic costs differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers factors associated with hand hygiene practices in two neonatal intensive care units use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a russian neonatal intensive care unit compliance with hand hygiene and glove use in a university-afà liated hospital rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit evaluation of a patientempowering hand hygiene programme in the uk the effectiveness of interventions aimed at increasing handwashing in healthcare workers -a systematic review euro surveillance: bulletin européen sur les maladies transmissibles outcomes from the à rst 2 years of the australian national hand hygiene initiative interventions to improve hand hygiene compliance in patient care an integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. a beme systematic review: beme guide no. 22 impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial the feedback intervention trial (fit) -improving hand-hygiene compliance in uk healthcare workers: a stepped wedge cluster randomised controlled trial evaluation of the national cleanyourhands campaign to reduce staphylococcus aureus bacteraemia and clostridium difà cile infection in hospitals in england and wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study multiple component patient safety intervention in english hospitals: controlled evaluation of second phase patients' beliefs and perceptions of their participation to increase healthcare worker compliance with hand hygiene evaluation of patient participation in a patient empowerment initiative to improve hand hygiene practices in a veterans affairs medical center recovery of coliforms from the hands of nurses and patients: activities leading to contamination differences in skin á ora between inpatients and chronically ill outpatients could hospital patients' hands constitute a missing link? use of alcohol hand rub (ahr) at ward entrances and use of soap and ahr by patients and visitors: a study in 27 wards in nine acute nhs trusts patient hand hygiene: a clinical inquiry an exploratory study of patient's feelings about asking healthcare professionals to wash their hands hand hygiene: what about our patients? perceptions, attitudes, and behavior towards patient hand hygiene outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial outbreaks effectiveness of hand-washing teaching programs for families of children in paediatric intensive care units systematic patients' hand disinfection: impact on meticillin-resistant staphylococcus aureus infection rates in a community hospital guidance for clinical healthcare workers: protection against infection with bloodborne viruses. london: department of health uniform: an evidence review of the microbiological signià cance of uniforms and uniform policy in the prevention and control of healthcareassociated infections. report to the department of health (england) management of health and safety at work regulations. london: hse books personal protective equipment at work. personal protective equipment at work regulations 1992 (as amended): guidance on regulations control of substances hazardous to health regulations 2002 (as amended). approved code of practice and guidance personal protective equipment (ppe) at work: a brief guide. indg174 (rev2) knowledge of standard and isolation precautions in a large teaching hospital healthcare workers' knowledge of inoculation injuries and glove use critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers contact precautions for clostridium diffcile and methicillin-resistant staphylococcus aureus (mrsa): assessing the impact of a supportive intervention to improve practice tools of the trade; rcn guidance for healthcare staff on glove use and prevention of contact dermatitis. london: royal college of nursing choosing the right gloves to protect skin: a guide for employers. london: hse books the dirty hand in the latex glove'': a study of hand hygiene compliance when gloves are worn impact of improving glove usage on the hand hygiene compliance measurement of hand hygiene compliance and gloving practices in different settings for the elderly considering the location of hand hygiene opportunities during patient care hand decontamination practices and the appropriate use of gloves in two adult intensive care units in malaysia intervention to reduce transmission of resistant bacteria in intensive care medical gloves for single use. part 1: specià cation for freedom from holes. bs-en 455-1. london: british standards institution medical gloves for single use. part 2: specià cation for physical properties. bs-en 455-2. london: british standards institution medical gloves for single use. part 3: requirements and testing for biological evaluation. bs-en 455-3. london: british standards institution effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care department of health. health technical memorandum 07-01: safe management of healthcare waste. london: department of health to determine the effects of gloves stress, type of material (vinyl, nitrile, copolymer, latex) and manufacturer on the barrier effectiveness of medical examination gloves guideline for isolation precautions: preventing transmission of infectious agents in health care settings provision and decontamination of uniforms in the nhs contamination of nurses' uniforms with staphylococcus aureus contamination of protective clothing and nurses' uniforms in an isolation ward bacterial contamination of nurses' uniforms: a study bacterial contamination of uniforms microbial á ora on doctors' white coats bacterial á ora on the white coats of medical students transfer of staphylococcus aureus via nurses' uniforms bacillus cereus meningitis in two neurosurgical patients: an investigation into the source of the organism contamination of hospital linen by bacillus cereus contamination of gowns, gloves, and stethoscopes with s56 gowning by attendants and visitors in newborn nurseries for prevention of neonatal morbidity and mortality to gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci a prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycinresistant enterococci in an intensive care unit tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control pandemic (h1n1) 2009 iná uenza. a summary of guidance for infection control in healthcare settings. london: department of health the interdepartmental working group on tuberculosis: the prevention and control of tuberculosis in the united kingdom. london: department of health respiratory protective equipment at work: a practical guide physical interventions to interrupt or reduce the spread of respiratory viruses face masks to prevent transmission of iná uenza virus: a systematic review protecting healthcare workers from pandemic iná uenza: n95 or surgical masks? the use of masks and respirators to prevent transmission of iná uenza: a systematic review of the scientià c evidence control of substances hazardous to health regulations. approved codes of practice. london: hse books health and safety at work act 1974.london: hmso health and safety (sharp instruments in healthcare) regulations 2013. guidance for employers and employees the provision and use of work equipment regulations the reporting of injuries, diseases and dangerous occurrences regulations 1995. london: hse books personal protective equipment at work: personal protective equipment at work regulations. london: hmso the health and safety (first-aid) regulations 1981. approved code of practice and guidance national audit ofà ce. a safer place to work: improving the management of health and safety risks to staff in nhs trusts. london: the stationery ofà ce royal college of nursing. needlestick injury in 2008: results from a survey of rcn members. london: royal college of nursing eye of the needle: united kingdom surveillance of signià cant occupational exposures to bloodborne viruses in healthcare workers. london: health protection agency risk factors for hepatitis c virus transmission to health care workers after occupational exposure: a european case-control study department of health. hiv post-exposure prophylaxis: guidance from the uk chief medical ofà cers' expert advisory group on aids. london: department of health universal precautions for prevention of transmission of human immunodeà ciency virus, hepatitis b virus and other bloodborne pathogens in health care settings enforcement procedures for the occupational exposure to bloodborne pathogens. directive number cpl2-2.44d. washington dc: osha implementing the framework agreement on prevention from sharps injuries in the hospital and health care sector. concluded by hospeem and epsu an evaluation of the efà cacy of safer sharps devices. systematic review educational programmes and sharps injuries in health care workers use of safety devices and the prevention of percutaneous injuries among healthcare workers impact of safety needle devices on occupationally acquired needlestick injuries: a four-year prospective study introducing safety syringes into a uk dental school -a controlled study the effectiveness of a training program on reducing needlestick injuries/sharp object injuries among soon graduate vocational nursing school students in southern taiwan department of health. an organisation with a memory. london: stationery ofà ce the management of health safety and welfare: issues for nhs staff. london: stationery ofà ce sharps safety and needlestick prevention efà cacy of catheter needles with safeguard mechanisms effect of implementing safety-engineered devices on percutaneous injury epidemiology a comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers evaluation of a safety resheathable winged steel needle for prevention of percutaneous injuries associated with intravascular-access procedures among healthcare workers a comparative user evaluation of three needle-protective devices potential for reported needlestick injury prevention among healthcare workers through safety device usage and improvement of guideline adherence: expert panel assessment evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures blunt s57 needles for the reduction of needlestick injuries during cesarean delivery: a randomized controlled trial a retractable winged steel (butterá y) needle performance improvement project role of safetyengineered devices in preventing needlestick injuries in 32 french hospitals effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers safety-engineered device implementation: does it introduce bias in percutaneous injury reporting? guarded à stula needle reduces needlestick injuries in hemodialysis evaluation of interventions to prevent needlestick injuries in health care occupations assessing the effect of long-term availability of engineering controls on needlestick injuries among health care workers: a 3-year preimplementation and postimplementation comparison a prospective randomized trial of two safety peripheral intravenous catheters use of needle safety devices by clinical laboratories in north carolina hospitals the usability and acceptability of a needleless connector system organizational climate, stafà ng, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses national institute for occupational safety and health. preventing needlestick injuries in health care settings. cincinnati: department of health and human services infection control in clinical practices what features of educational interventions lead to competence in aseptic insertion and maintenance of cv catheters in acute care? beme guide no. 15 antt v2: an updated practice framework for aseptic technique guideline for prevention of catheter-associated urinary tract infections english national point prevalence survey on healthcare associated infections and antimicrobial use, 2011: preliminary data four country healthcare associated infection prevalence survey 2006: overview of the results urinary catheter care. essential steps to safe, clean care: reducing healthcare associated infections. london: department of health preventing catheter-associated urinary tract infections in the intensive care unit systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients a prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters catheter-associated urinary tract infections are physicians aware of which of their patients have indwelling urinary catheters? appropriateness of use of indwelling urinary catheters in patients admitted to the medical service overuse of the indwelling urinary tract catheter in hospitalized medical patients trends in catheter-associated urinary tract infections in adult intensive care units -united states clinical and economic consequences of nosocomial catheter-related bacteriuria recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit epidemiology of hospital-acquired urinary tract-related bloodstream infection at a university hospital silver alloy vs. uncoated urinary catheters: a systematic review of the literature catheter-associated urinary tract infections: new aspects of novel urinary catheters a review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections enhancing the safety of critically ill patients by reducing urinary and central venous catheterrelated infections comparison of urethral reaction to full silicone, hydrogen-coated and siliconised latex catheters effect of catheter material on the incidence of urethral strictures randomised study of the effect of midnight versus 0600 removal of urinary catheters the association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care aiming to reduce catheter associated urinary tract infections (cauti) by adopting a checklist and bundle to achieve sustained system improvements evidence for the use of silver-alloycoated urethral catheters the high impact actions for nursing and midwifery 5: protection from infection preventing catheter-related bacteriuria: should we? can we? how? epidemiology of urinary tract infections: incidence, morbidity, and economic costs guideline for prevention of catheter-associated urinary tract infections computerbased order entry decreases duration of indwelling urinary catheterization in hospitalized patients effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients systematic review and s58 meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study interventions to minimise the initial use of indwelling urinary catheters in acute care: a systematic review non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopaedic surgery and its effect on urinary tract infections a collaborative, nurse-driven initiative to reduce hospital-acquired urinary tract infections prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol continence clinic. catheters: design, selection and management urinary tract infections: detection, prevention and management. 5th ed. baltimore: williams and wilkins prevention of catheter-associated urinary tract infections study of patients with indwelling catheters rapid response report: female urinary catheters causing trauma to adult males. nspca effect of a siliconized latex urinary catheter on bacterial adherence and human neutrophil activity incidence and importance of bacteriuria in postoperative, short-term urinary catheterization types of urethral catheters for management of short-term voiding problems in hospitalized adults: a short version cochrane review a controlled trial of a new material for coating urinary catheters comparison of hydrophilic polymer-coated latex, uncoated latex and pvc indwelling balloon catheters in the prevention of urinary infection the epic project: updating the evidence base for national evidence-based guidelines for preventing healthcareassociated infections in nhs hospitals in england. a report with recommendations types of urethral catheters for management of short-term voiding problems in hospitalised adults the efà cacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis management of short term indwelling urethral catheters to prevent urinary tract infections. a systematic review is there evidence for recommending silver-coated urinary catheters in guidelines? clinical application of the bardex ic foley catheter a randomized crossover study of silver-coated urinary catheters in hospitalized patients the potential clinical and economic beneà ts of silver alloy urinary catheters in preventing urinary tract infection a comparison of the effect of early insertion of standard latex and silver-impregnated latex foley catheters on urinary tract infections in burn patients using silver to reduce catheter-associated urinary tract infections the impact of using silver alloy urinary catheters in reducing the incidence of urinary tract infections in the critical care setting effect of silver-coated urinary catheters: efà cacy, cost-effectiveness, and antimicrobial resistance a rapid method of impregnating endotracheal tubes and urinary catheters with gendine: a novel antiseptic agent gentamicin-releasing urethral catheter for short-term catheterization randomized multicentre trial of the effects of a catheter coated with hydrogel and silver salts on the incidence of hospital-acquired urinary tract infections use of silver-hydrogel urinary catheters on the incidence of catheter-associated urinary tract infections in hospitalized patients evaluation of the antimicrobial efà cacy of urinary catheters impregnated with antiseptics in an in vitro urinary tract model efà cacy of antimicrobialimpregnated bladder catheters in reducing catheter-associated bacteriuria: a prospective, randomized, multicenter clinical trial assessment of nosocomial urinary tract infections in orthopaedic patients: a prospective and comparative study using two different catheters a large randomized clinical trial of a silver-impregnated urinary catheter: lack of efà cacy and staphylococcal superinfection prevention of catheter-associated urinary tract infection with a silver oxide-coated urinary catheter: clinical and microbiologic correlates reà nements in the coating of urethral catheters reduces the incidence of catheter-associated bacteriuria. an experimental and clinical study silver alloy coated catheters reduce catheter-associated bacteriuria antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial preventing hospital-acquired infection: clinical guidelines. london: public health laboratory service philadelphia: lippincott-raven entry of bacteria into the urinary tracts of patients with inlying catheters technical advances in the prevention of urinary tract infection prevention of catheter-induced urinary-tract infections by sterile closed drainage factors predisposing to bacteriuria during indwelling urethral catheterization bacteriuria during indwelling catheter drainage: ii. effect of a closed sterile draining system does the addition of disinfectant to urine drainage bags prevent infection in catheterised patients? prevention of urinary tract infection in gynaecology reduction of mortality associated with nosocomial urinary tract infection incidence of urinary tract infections in patients with short-term indwelling urethral catheters: a comparison between a 3-day urinary drainage bag change and no change regimens decreased incidence of bacteriuria associated with periodic instillations of hydrogen peroxide into the urethral catheter drainage bag evaluation of h2o2 prophylaxis of bacteriuria in patients with long-term indwelling foley catheters: a randomized controlled study catheter-associated bacteriuria. failure to reduce attack rates using periodic instillations of a disinfectant into urinary drainage systems prevention of bacteriuria in female patients with indwelling catheters prevention of catheter-associated urinary tract infections. efà cacy of daily meatal care regimens evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheter-associated bacteriuria prevention of catheter-associated bacteriuria: clinical trial of methods to block three known pathways of infection daily meatal care for prevention of catheter-associated bacteriuria: results using frequent applications of polyantibiotic cream randomized trial of meatal care with silver sulfadiazine cream for the prevention of catheter-associated bacteriuria water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial does instillation of chlorhexidine into the bladder of catheterized geriatric patients help reduce bacteriuria? bladder irrigation with chlorhexidine for the prevention of urinary infection after transurethral operations: a prospective controlled study controlled trial of intravesical noxythiolin in the prevention of infection following outá ow tract surgery a randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter antibiotic irrigation and catheter-associated urinary-tract infections once-daily irrigation of long-term urethral catheters with normal saline. lack of beneà t assessment of the use of bladder washouts/instillations in patients with long-term indwelling catheters neomycin-polymyxin prophylaxis of urinary-tract infection associated with indwelling catheters the use of bladder wash-outs to reduce urinary catheter encrustation closing the quality gap: a critical analysis of quality improvement strategies evaluating the efà cacy of the infection control liaison nurse in the hospital guidelines for the prevention of intravascular catheter-related infections nosocomial bloodstream infection in critically ill patients. excess length of stay, extra costs, and attributable mortality is routine replacement of peripheral intravenous catheters necessary? peripheral teá on catheters: factors determining incidence of phlebitis and duration of cannulation phlebitis rate and time kinetics of short peripheral iv catheters routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial the risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies nosocomial bloodstream infections in us hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study national nosocomial infections surveillance system. overview of nosocomial infections caused by gram-negative bacilli the pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters saraà n hw. a semiquantitative culture method for identifying intravenous-catheter-related infection the pathogenesis and epidemiology of catheter-related infection with pulmonary artery swan-ganz catheters: a prospective study utilizing molecular subtyping ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement dna à ngerprinting analysis of coagulase negative staphylococci implicated in catheter related bloodstream infections colonization and infrequent hematogenous seeding in catheterrelated infections optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours? effectiveness of surveillance of central catheter-related bloodstream infection in an icu in korea effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit education of physiciansin-training can decrease the risk for vascular catheter infection impact of a prevention strategy targeted at vascularaccess care on incidence of infections acquired in intensive care septic complications of total parenteral nutrition. a à ve year experience catheter complications in total parenteral nutrition. a prospective study of 200 consecutive patients central venous catheter care in parenteral nutrition: a review prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation total parenteral nutrition-related infections: prospective epidemiologic study using semiquantitative methods colonization of bacteria on polyvinyl chloride and teá on intravascular catheters in hospitalized patients evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters. gauze, a transparent polyurethane dressing, and an iodophortransparent dressing sepsis from triplevs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients prospective evaluation of single and triple lumen catheters in total parenteral nutrition central catheter infections: single-versus triple-lumen catheters. iná uence of guide wires on infection rates when used for replacement of catheters infection rate for single lumen v triple lumen subclavian catheters use of triple-lumen subclavian catheters for administration of total parenteral nutrition increased infection rate in double-lumen versus single-lumen hickman catheters in cancer patients single-versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population triple-vs single-lumen central venous catheters. a prospective study in a critically ill population rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis colonization and bloodstream infection with single-versus multi-lumen central venous catheters: a quantitative systematic review guideline for prevention of intravascular devicerelated infections. hospital infection control practices advisory committee a prospective study of prolonged central venous access in leukemia broviac catheter-related bacteremia in oncology patients hickman catheter infections in patients with malignancies problems associated with indwelling central venous catheters complications of hickman-broviac catheters management of hickman catheter sepsis catheter-related septicemia in patients receiving home parenteral nutrition single-vs double-lumen central venous catheters in pediatric oncology patients bacteraemia related to indwelling central venous catheters: prevention, diagnosis and treatment low infection rate and long durability of nontunneled silastic catheters. a safe and costeffective alternative for long-term venous access lack of clinical beneà t from subcutaneous tunnel insertion of central venous catheters in immunocompromised patients a totally implanted injection port system for blood sampling and chemotherapy administration complications and management of implanted venous access catheters a totally implanted venous access system for the delivery of chemotherapy implantable subcutaneous venous catheters fifty-à ve patient years' experience with a totally implanted system for intravenous chemotherapy infection rates of broviac-hickman catheters and implantable venous devices complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: a randomized trial in 100 patients with solid tumors comparison of infections in hickman and implanted port catheters in adult solid tumor patients experience with a totally implantable venous access device (port-a-cath) in patients with aids infectious morbidity associated with long-term use of venous access devices in patients with cancer long-term central venous access effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study use of tunneled femoral catheters to prevent catheter-related infection. a randomized, controlled trial tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials peripheral access options long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters peripherally inserted central venous catheters. low-risk alternatives for ongoing venous access survey of the use of peripherally inserted central venous catheters in children peripherally inserted central catheters in patients with aids are associated with a low infection rate risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter. a randomized, controlled trial evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: a randomized controlled trial iná uence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia a meta-analysis dealing with the effectiveness of chlorhexidine and silver-sufhadiazine impregnated central venous catheters anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter cost-effectiveness of antiseptic-impregnated central venous catheters for the prevention of catheter-related bloodstream infection central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections. a randomized, double-blind trial. the texas medical center catheter study group decreasing catheter colonization through the use of an antiseptic-impregnated catheter: a continuous quality improvement project a comparison of two antimicrobial-impregnated central venous catheters efà cacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis prevention of intravascular catheter-related infections prevention of bloodstream infections with central venous catheters treated with antiinfective agents depends on catheter type and insertion time: evidence from a meta-analysis prolonged antimicrobial activity of a catheter containing chlorhexidine-silver sulfadiazine extends protection against catheter infections in vivo the clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults effectiveness of different central venous catheters for catheterrelated infections: a network meta-analysis anti-infective external coating of central venous catheters: a randomized, noninferiority trial comparing 5-á uorouracil with chlorhexidine/silver sulfadiazine in preventing catheter colonization immediate hypersensitivity to chlorhexidine is increasingly recognised in the united kingdom anaphylaxis to chlorhexidine-coated central venous catheters: a case series and review of the literature medical device alert: all medical devices and medicinal products containing chlorhexidine. mda/2012/075. london: medicines and healthcare products regulatory agency femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial impact of central venous catheter type and methods on catheter-related colonization and bacteraemia to reduce catheterrelated bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? complications of central venous catheters: internal jugular versus subclavian access -a systematic review comparison between the jugular and subclavian vein as insertion site for central venous catheters: microbiological aspects and risk factors for colonization and infection prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients a review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies the micro-organism responsible for central venous catheter s62 s1-s70 related bloodstream infection depends on catheter site prospective study of arterial and central venous catheter colonization and of arterial-and central venous catheter-related bacteremia in intensive care units complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial risk of infection due to central venous catheters: effect of site of placement and catheter type the incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population the risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis ultrasound guidance for placement of central venous catheters: a metaanalysis of the literature ultrasonic locating devices for central venous cannulation: meta-analysis guidance on the use of ultrasound locating devices for placing central venous catheters infection control in intravenous therapy prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review catheter-related sepsis: an overview -part 1 prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients alcoholic povidone-iodine to prevent central venous catheter colonization: a randomized unit-crossover study chlorhexidine compared with povidone-iodine solution for vascular cathetersite care: a meta-analysis vascular catheter site care: the clinical and economic beneà ts of chlorhexidine gluconate compared with povidone iodine guideline for use of topical antimicrobial agents catheter-related sepsis in long-term parenteral nutrition with broviac catheters. an evaluation of different disinfectants colonization of central venous catheters a clinical and bacteriologic study of infections associated with venous cutdowns application of antibiotic ointment to the site of venous catheterization -a controlled trial risk of infection with intravenous indwelling catheters: effect of application of antibiotic ointment the effects of antibiotic ointments and antiseptics on the skin á ora beneath subclavian catheter dressings during intravenous hyperalimentation a comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection the forgotten role of alcohol: a systematic review and meta-analysis of the clinical efà cacy and perceived role of chlorhexidine in skin antisepsis transparent polyurethane à lm as an intravenous catheter dressing. a metaanalysis of the infection risks gauze and tape and transparent polyurethane dressings for central venous catheters gauze and tape and transparent polyurethane dressings for central venous catheters using the collaborative evidence based practice model: a systematic review and uptake of chlorhexidine-impregnated sponge dressings on central venous access devices in a tertiary cancer centre economic evaluation of chlorhexidine-impregnated sponges for preventing catheterrelated infections in critically ill adults in the dressing study randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults the efà cacy of daily bathing with chlorhexidine for reducing healthcareassociated bloodstream infections: a meta-analysis skin disinfection with octenidine dihydrochloride for central venous catheter site care: a double-blind, randomized, controlled trial catheterrelated sepsis: prospective, randomized study of three methods of long-term catheter maintenance changing subclavian haemodialysis cannulas to reduce infection a controlled trial of scheduled replacement of central venous and pulmonary-artery catheters central venous catheter replacement strategies: a systematic review of the literature routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial clinically-indicated replacement versus routine replacement of peripheral venous catheters source and route of microbial colonisation of parenteral nutrition catheters catheter sepsis due to coagulase-negative staphylococci in patients on total parenteral nutrition a prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates adherence and growth of coagulase-negative staphylococci on surfaces of intravenous catheters pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures of catheter hub and segments a randomized trial on the effect of tubing changes on hub contamination and catheter sepsis during parenteral nutrition contamination of stopcocks mounted in administration sets for central venous catheters with replacement at 24 hrs versus 72 hrs: a prospective cohort study use of disinfectants to reduce microbial contamination of hubs of vascular catheters effectiveness of disinfectant techniques on intravenous tubing latex injection ports a randomized, prospective clinical trial to assess the potential infection risk associated with the posiflow ® needleless connector scrub the hub': cleaning duration and reduction in bacterial load on central venous catheters successful disinfection of needleless access ports: a matter of time and friction antibiotic-based catheter lock solutions for prevention of catheter-related bloodstream infection: a systematic review of randomised controlled trials prevention of catheter-related bacteremia with a daily ethanol lock in patients with tunnelled catheters: a randomized, placebo-controlled trial guidelines for the prevention of intravascular-catheter-related infections can high-level mupirocin resistance reporting be relied upon to ensure patients are prescribed appropriate treatment? prophylactic antibiotics for preventing early central venous catheter gram positive infections in oncology patients heparin bonding reduces thrombogenicity of pulmonaryartery catheters central venous access sites for the prevention of venous thrombosis, stenosis and infection the relationship between the thrombotic and infectious complications of central venous catheters thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: prospective evaluation by phlebography central vein thrombosis associated with intravenous feeding -a prospective study a cross-sectional study of catheter-related thrombosis in children receiving total parenteral nutrition at home catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding a prospective study of femoral catheter-related thrombosis in children beneà t of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials very low doses of warfarin can prevent thrombosis in central venous catheters. a randomized prospective trial randomized trial of prevention of catheter-related bloodstream infection by continuous infusion of low-dose unfractionated heparin in patients with hematologic and oncologic disease heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children surface heparinization of central venous catheters reduces microbial colonization in vitro and in vivo: results from a prospective, randomized trial use of heparincoated central venous lines to prevent catheter-related bloodstream infection heparin-bonded catheters for prolonging the patency of central venous catheters in children prevention of central venous catheter associated thrombosis using minidose warfarin in patients with haematological malignancies anticoagulation for thrombosis prophylaxis in cancer patients with central venous catheters anticoagulation in patients with cancer: an overview of reviews thrombosis prophylaxis in patient populations with a central venous catheter: a systematic review the heparin á ush syndrome: a cause of iatrogenic hemorrhage beneà t of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials a meta-analysis of effects of heparin á ush and saline á ush: quality and cost implications analysis of the research about heparinized versus nonheparinized intravascular lines heparin á ushing and other interventions to maintain patency of central venous catheters: a systematic review heparin or 0.9% sodium chloride to maintain central venous catheter patency: a randomized trial intermittent á ushing with heparin versus saline for maintenance of peripheral intravenous catheters in a medical department: a pragmatic clusterrandomized controlled study outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital increased catheterrelated bloodstream infection rates after the introduction of a new mechanical valve intravenous access port incidence of catheterrelated bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an australian hematology-oncology unit optimal timing for intravenous administration set replacement saving lives: a delivery programme to reduce healthcare associated infection including mrsa. london: department of health eliminating catheter-related bloodstream infections in the intensive care unit an intervention to decrease catheter-related bloodstream infections in the icu sustaining reductions in catheter related bloodstream infections in michigan intensive care units: observational study results of a multicentre randomised controlled trial of statistical process control charts and structured diagnostic tools to reduce ward-acquired meticillin-resistant staphylococcus aureus: the chart project a multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial effectiveness of stepwise interventions targeted to decrease central catheterassociated bloodstream infections matching michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in england costeffectiveness of a central venous catheter care bundle the 100,000 lives campaign: setting a goal and deadline for improving healthcare quality an initial search was made for national and international guidelines and systematic reviews of randomised controlled trials. search questions were based on the scope of the original review and advice from the guideline development group. databases to be searched were identià ed together with search strategy [i.e. relevant medical subject headings (mesh), free-text and thesaurus terms]. abstracts of all articles retrieved from the search were reviewed against pre-determined inclusion criteria (e.g. relevant to a review question, primary research/systematic review/meta-analysis, written in english). full text of all articles that met the inclusion criteria was reviewed against pre-determined criteria to identify primary research which answers review questions. all articles that described primary research, a systematic review or a meta-analysis were critically appraised by two experienced appraisers. consensus and grading was achieved through discussion in the context of pre-determined grading criteria. the following organisations were approached for comment: a chemical compound that contains 'energy-rich bonds' and is used by cells to store and deliver energy an organism that requires free oxygen for life and growth a hand decontamination preparation based on alcohol that, for the purposes of these guidelines, encompasses solutions, gels or wipes antimicrobial a substance that kills or inhibits the growth of microorganisms the absence of pathogenic microorganisms antiseptic a substance that destroys or inhibits the growth of microorganisms and is sufà ciently non-toxic to be applied to skin or mucous membranes a framework for the aseptic technique based on the concept of deà ning key parts and key sites to be protected from contamination. a carefully controlled procedure that aims to prevent contamination by microorganisms the presence of microorganisms in the bloodstream the presence of microorganisms in the urine. if there are no symptoms of infection, this is called 'asymptomatic bacteriuria' a complex structure comprising microorganisms and extracellular polymers that forms over surfaces, such as those in contact with water or tissues continuous á ow of a solution through the bladder to remove clots or debris a viral infection transmitted by exposure to blood and sometimes other bodily á uids. bloodborne viruses include hepatitis b and c as well as human immunodeà ciency virus the presence of microbes in the blood with symptoms of infection an analytical observational study that compares people with the disease of interest with a group of similar 'control' people who do not in order to determine potential causes or risk factors a scientià c article that describes an individual case in detail a report describing a series of several similar events the presence of symptoms or signs attributable to microorganisms that have infection (cauti)invaded the urinary tract, where the patient has, or has recently had, a urinary catheter microorganisms present on a surface of a catheter that could potentially lead to infection an infection of the bloodstream where microorganisms are found in the blood infection (cr-bsi) of a patient with a central venous access device, the patient has clinical signs of infection (e.g. fever, chills and hypotension) and there is no other apparent source for the infection. for surveillance purposes, this often refers to bloodstream infections that occur in patients with a central venous access device and where other possible sources of infection have been excluded. a more rigorous deà nition is where the same microorganism is cultured from the tip of the catheter as grown from the blood; simultaneous quantitative blood cultures with at least a 5:1 ratio of microorganisms cultured from the central venous access device vs peripheral; differential time to positivity of at least 2 h for blood cultures cultured peripherally vs from central venous access device waste material that consists wholly or partly of human or animal tissue, blood or body á uids, excretions, drugs or other pharmaceutical products, swabs/ dressings, syringes, needles or other sharp instruments closed urinary drainage system a system where a urinary catheter is connected via tubing to a collecting bag.the system relies on gravity to drain the urine a prospective or retrospective follow-up study where groups to be followed-up are deà ned on the basis of presence or absence of exposure to a risk factor or intervention microorganisms that establish themselves in a particular environment, such as a body surface, without producing disease an estimate of the number of viable bacterial cells made by counting visible colonies derived from the replication of a single microbial cell transmission of a pathogenic organism from one person to another a comparison of the outcome between two or more groups of patients that are exposed to different regimens of treatment/intervention where the groups exchange treatment/intervention after a pre-arranged period a process that removes hazardous substances, including chemicals or microorganisms a cleansing agent that removes dirt from a surface by bonding with lipids and other particles a process that reduces the number of pathogenic microorganisms to a level at which they are not able to cause harm, but which does not usually destroy spores particles 1-10 õm in diameter comprising the dried residue formed by evaporation of droplets coughed or sneezed from the respiratory tract difà cult or painful urination urinary proteins, salts and crystals that adhere to the internal and external surface of a urinary catheter the use of equipment designed to prevent injury to the operator administration of nutrients into stomach or other part of the gastrointestinal tract using tubes infections caused by microorganisms acquired from another person, animal or the environment opinion derived from seminal works and appraised national and international guidelines the type of bacteria as identià ed by gram's staining method. gram-positive bacteria appear dark blue or purple under a microscope. such bacteria have a thick layer of peptidoglycan on their cell walls. gram-negative bacteria appear red under a microscope and have an outer layer of lipoprotein and a thin layer of peptidoglycan a wire used to facilitate insertion of the intravascular catheter into the body blood in the pleural cavity, usually due to injury. if the blood is not drained, it may impair the movement of the lungs or become infected the use of soap and water or an antiseptic solution to reduce the number of microorganisms on the hands a phenomenon in which the participants change their behaviour or performance in response to being studied infection acquired as a result of the delivery of health care either in an acute (hospital) or non-acute setting any person employed by a health service, social service, local authority or agency to provide care for sick, disabled or elderly people a central venous access device that is tunnelled under the skin with a subcutaneous port or reservoir with a self-sealing septum that is accessible by needle puncture through intact skin the number of new events (e.g. cases of disease) occurring in a population over a deà ned period of time a catheter inserted into the bladder via the urethra and left in place for a period of time microorganisms that have entered the body and are multiplying in the tissues, typically causing specià c symptoms an analysis in which the results of the study are based on initial treatment assignment and not on a treatment actually received a study in which measurements from the group under investigation are taken repeatedly before and after the intervention a device inserted into a vascular system in order to administer á uids, medicines and nutrients or to obtain blood samples. these include devices inserted peripherally, as well as those inserted into larger veins any device that requires insertion through skin or other normal body defences a system of attaching catheters, syringes, tubes and any other components of ivad to each other external opening of the urethra the combination of data from several studies to produce a single estimate of an effect of a particular intervention strains of s. aureus that are resistant to many of the antibiotics commonly staphylococcus aureus (mrsa) used to treat infections. epidemic strains also have a capacity to spread easily from person to person a long peripheral venous catheter inserted in the antecubital vein and advanced to a vein in the upper arm. designed for short-term (up to 4 weeks) intravenous access a membrane lining many tubular structures and cavities such as respiratory tractneedle-free devices (also needleless intravascular connector systems developed to help reduce the incidence of intravascular catheter connectors) needlestick injury while facilitating medication delivery through intravascular catheters. there are three types of needle-free connectors: blunt cannula (two-piece) systems, one-piece needle-free systems, and one-piece needlefree systems with positive pressure needle safety device (also needle any device designed to reduce the risk of injury associated with a protection/prevention device) contaminated needle. this may include needle-free devices or mechanisms on a needle, such as an automated resheathing device, that cover the needle immediately after use the puncture of skin by a contaminated needle or other sharp medical device abnormal decrease in the number of neutrophils in peripheral blood, which results in increased susceptibility to infections nitrile a synthetic rubber made from organic compounds and cyanide a retrospective or prospective study in which the investigator observes participants, with or without control groups any derivative of a living or once-living organism two or more cases of the same disease where there is evidence of an epidemiological link between them administration of nutrients by an infusion into a vein h. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70 particulate à lter masks (or respirator masks) face masks designed to protect the wearer from inhaling airborne particles including microorganisms. they are made to deà ned performance standards that include à ltration efà ciency. to be effective, they must be à tted close to the face to minimise leakage pathogen a microorganism that causes disease an independent assessment or evaluation of the research by a professional with knowledge of the à eld an injury that results in a sharp instrument/object (e.g. needle, scalpel) puncturing the skin a vascular catheter inserted into the superior vena cava from the basilic or catheter (picc) cephalic vein specialised clothing or equipment worn to protect against substances or situations that present a hazard to health or safety post-exposure prophylaxis drug treatment regimen administered as soon as possible after an occupational exposure to reduce the risk of acquisition of a bloodborne virus a topical preparation used for antisepsis of the skin in a form of solution or ointment the number of events (e.g. cases of disease) present in a deà ned population at one point in time study in which people are entered into the research and then followed-up over a period of time with events recorded as they happen a small, á exible tube placed into a peripheral vein for the safe infusion of medications, hydration á uids, blood products and nutritional supplements quasi-experimental research designs specià cally lack the element of random assignment of participants (individuals or clinical settings/units) to the treatment or the control group. randomisation minimises the risk that patients entered into the control and treatment groups will be different an rct is a clinical trial where at least two treatment groups are compared, non-randomised controlled trial (nrct) one of them serving as the control group. allocation to the group uses a random, unbiased method. an nrct compares a control and treatment group but allocation to each group is not random. bias is more likely to occur in an nrct microorganisms that live in the deeper crevices of skin and hair follicles. these form part of the normal á ora of the body and are not readily transferred to other people or objects, or removed by the mechanical action of soap and water. they can be reduced in number with the use of antiseptic soap a mask that covers the mouth and nose to prevent droplets from the wearer being expelled into the environment. as they are also á uid repellent, they provide some protection for the wearer against exposure of mucous membranes to splashes of blood/body á uid research that summarises the evidence on a clear question according to a deà ned protocol using explicit and systematic methods to identify, select and appraise relevant studies and extract, collate and report their à ndings an infection where the pathogen is distributed throughout the body, rather than being concentrated in one area the decontamination of a room or patient area after a patient has been transferred or discharged in order to ensure that any dirt, dust or contamination by potentially pathogenic microorganisms is removed before use by another patient a reduction in the number of platelets (thrombocytes) in the blood. this may result in bleeding into the skin, spontaneous bruising or prolonged bleeding after injury a clot in a blood vessel caused by coagulation of blood phlebitis (vein iná ammation) related to a thrombus (blood clot) microorganisms acquired on the skin through contact with surfaces. the hostile environment of skin means that they can usually only survive for a short time, but they are readily transferred to other surfaces touched. can be removed by washing with soap and water, and most are destroyed by alcohol-based hand rubs the invasion of the tissues of the bladder by microorganisms causing symptoms or signs of infection such as dysuria, loin pain, suprapubic tenderness, fever, pyuria and confusion 