A test for the assessment of 'hygienic' hand disinfection using rotavirus

Detection and quantification of infectious severe acute respiratory coronavirus-2 in diverse clinical and environmental samples

To explore the potential modes of Severe Acute Respiratory Coronavirus-2 (SARS-CoV-2) transmission, we collected 535 diverse clinical and environmental samples from 75 infected hospitalized and community patients. Infectious SARS-CoV-2 with quantitative burdens varying from 5 plaque-forming units/mL (PFU/mL) up to 1.0 × 10⁶ PFU/mL was detected in 151/459 (33%) of the specimens assayed and up to 1.3 × 10⁶ PFU/mL on fomites with confirmation by plaque morphology, PCR, immunohistochemistry, and/or sequencing. Infectious virus in clinical and associated environmental samples correlated with time since symptom onset with no detection after 7–8 days in immunocompetent hosts and with N-gene based C_t values ≤ 25 significantly predictive of yielding plaques in culture. SARS-CoV-2 isolated from patient respiratory tract samples caused illness in a hamster model with a minimum infectious dose of ≤ 14 PFU. Together, our findings offer compelling evidence that large respiratory droplet and contact (direct and indirect i.e., fomites) are important modes of SARS-CoV-2 transmission.

Detection and quantification of infectious severe acute respiratory coronavirus-2 in diverse clinical and environmental samples

To explore the potential modes of Severe Acute Respiratory Coronavirus-2 (SARS-CoV-2) transmission, we collected 535 diverse clinical and environmental samples from 75 infected hospitalized and community patients. Infectious SARS-CoV-2 with quantitative burdens varying from 5 plaque-forming units/mL (PFU/mL) up to 1.0 × 10⁶ PFU/mL was detected in 151/459 (33%) of the specimens assayed and up to 1.3 × 10⁶ PFU/mL on fomites with confirmation by plaque morphology, PCR, immunohistochemistry, and/or sequencing. Infectious virus in clinical and associated environmental samples correlated with time since symptom onset with no detection after 7-8 days in immunocompetent hosts and with N-gene based C_t values ≤ 25 significantly predictive of yielding plaques in culture. SARS-CoV-2 isolated from patient respiratory tract samples caused illness in a hamster model with a minimum infectious dose of ≤ 14 PFU. Together, our findings offer compelling evidence that large respiratory droplet and contact (direct and indirect i.e., fomites) are important modes of SARS-CoV-2 transmission.

Triclosan: An Update on Biochemical and Molecular Mechanisms

Triclosan (TCS) is a synthetic, chlorinated phenolic antimicrobial agent commonly used in commercial and healthcare products. Items made with TCS include soaps, deodorants, shampoos, cosmetics, textiles, plastics, surgical sutures, and prosthetics. A wealth of information obtained from in vitro and in vivo studies has demonstrated the therapeutic effects of TCS, particularly against inflammatory skin conditions. Nevertheless, extensive investigations on the molecular aspects of TCS action have identified numerous adversaries associated with the disinfectant including oxidative injury and influence of physiological lifespan and longevity. This review presents a summary of the biochemical alterations pertaining to TCS exposure, with special emphasis on the diverse molecular pathways responsive to TCS that have been elucidated during the present decade.

Efficacy of ethanol against viruses in hand disinfection

Ethanol is used worldwide in healthcare facilities for hand rubbing. It has been reported to have a stronger and broader virucidal activity compared with propanols. The aim of this review was to describe the spectrum of virucidal activity of ethanol in solution or as commercially available products. A systematic search was conducted. Studies were selected when they contained original data on reduction of viral infectivity from suspension tests (49 studies) and contaminated hands (17 studies). Ethanol at 80% was highly effective against all 21 tested, enveloped viruses within 30 s. Murine norovirus and adenovirus type 5 are usually inactivated by ethanol between 70% and 90% in 30 s whereas poliovirus type 1 was often found to be too resistant except for ethanol at 95% (all test viruses of EN 14476). Ethanol at 80% is unlikely to be sufficiently effective against poliovirus, calicivirus (FCV), polyomavirus, hepatitis A virus (HAV) and foot-and-mouth disease virus (FMDV). The spectrum of virucidal activity of ethanol at 95%, however, covers the majority of clinically relevant viruses. Additional acids can substantially improve the virucidal activity of ethanol at lower concentrations against, e.g. poliovirus, FCV, polyomavirus and FMDV although selected viruses such as HAV may still be too resistant. The selection of a suitable virucidal hand rub should be based on the viruses most prevalent in a unit and on the user acceptability of the product under frequent-use conditions.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Influence of Rings on the Efficacy of Hand Sanitization and Residual Bacterial Contamination

Background.

Previous studies, conducted before widespread use of scrubless, alcohol-based hand sanitizers, demonstrated increased residual bacterial counts after hand hygiene on hands with jewelry.

Objective.

To compare the impact of finger rings on the effectiveness of scrubless and water-aided alcohol-based hand sanitization methods with that of povidone-iodine scrub.

Design.

Randomized, controlled study.

Setting.

University hospital.

Participants.

Sixty volunteer subjects from a pool of perioperative staff and medical students.

Intervention.

After recruitment, participants wore a ring on one hand and no ring on the other hand. They were randomly assigned to perform hand hygiene with a povidone-iodine scrub, an alcohol wash, or a waterless alcohol-chlorhexidine lotion (n = 20 subjects per method). After subjects completed hand hygiene, gloves were placed on their hands by means of sterile methods, and a “glove juice” technique was used to obtain samples for culture. The number of colony-forming units in each culture was counted, and the data were compared.

Results.

There was no significant difference in the number of bacteria between hands with and hands without rings for the groups that used alcohol wash or alcohol-chlorhexidine lotion. However, for the povidone-iodine group, the number of bacteria on hands with rings was greater than the number on hands without rings (P < .05). The hands of participants who used waterless alcohol-chlorhexidine had the lowest bacterial count, regardless of the presence of rings (P < .01).

Conclusions.

The presence of rings does not negatively impact the effectiveness of alcohol-based hand sanitizers. Use of waterless alcohol-chlorhexidine lotion resulted in the lowest bacterial count.

Cytomegalovirus survival and transferability and the effectiveness of common hand-washing agents against cytomegalovirus on live human hands

Congenital cytomegalovirus (CMV) transmission can occur when women acquire CMV while pregnant. Infection control guidelines may reduce risk for transmission. We studied the duration of CMV survival after application of bacteria to the hands and after transfer from the hands to surfaces and the effectiveness of cleansing with water, regular and antibacterial soaps, sanitizer, and diaper wipes. Experiments used CMV AD169 in saliva at initial titers of 1 × 10(5) infectious particles/ml. Samples from hands or surfaces (points between 0 and 15 min) were placed in culture and observed for at least 2 weeks. Samples were also tested using CMV real-time PCR. After application of bacteria to the hands, viable CMV was recovered from 17/20 swabs at 0 min, 18/20 swabs at 1 min, 5/20 swabs at 5 min, and 4/20 swabs at 15 min. After transfer, duration of survival was at least 15 min on plastic (1/2 swabs), 5 min on crackers and glass (3/4 swabs), and 1 min or less on metal and cloth (3/4 swabs); no viable virus was collected from wood, rubber, or hands. After cleansing, no viable virus was recovered using water (0/22), plain soap (0/20), antibacterial soap (0/20), or sanitizer (0/22). Viable CMV was recovered from 4/20 hands 10 min after diaper wipe cleansing. CMV remains viable on hands for sufficient times to allow transmission. CMV may be transferred to surfaces with reduced viability. Hand-cleansing methods were effective at eliminating viable CMV from hands.

Prospective surveillance of nosocomial viral infections during and after hospitalization at a university children's hospital

BACKGROUND

In Switzerland 5% to 10% of hospitalized adults acquire nosocomial infections (NI) but few data are available in children. Most former studies on NI in hospitalized children analyzed specific units or pathogens and neglected the postdischarge period. We aimed to prospectively assess viral NI occurring during and shortly after hospitalization in children.

METHODS

Prospective surveillance was performed during a 24-month period. Electronic standardized questionnaires were completed for each patient by physicians during hospital stay. On a ward-based rotational schedule, follow-up information was obtained from a subset of patients 1 week after hospital discharge. NI were defined using CDC recommendations.

RESULTS

Overall, 6250 patients (34,608 patient hospitalization days, PHD) were enrolled and 1272 patients were recruited for postdischarge surveillance. Mean hospitalization duration was 5 days. Fifty-two (0.8%) patients acquired 54 viral NI during hospitalization and 12 patients (1.1%) acquired 12 viral NI after hospital discharge (NI incidence: 1.9 per 1000 PHD including follow-up period). NI rate in infants was higher compared with children >12 months old (2.0% vs. 0.8%; P 0.05) and the infant ward also had the highest incidence (4.0 NI per 1000 PHD). Most NI were gastrointestinal tract infections with 55% caused by rotavirus infection. NI rates were highest between November and March.

CONCLUSIONS

A significant part of NI will only be detected if surveillance includes the immediate postdischarge period. Given the strong seasonality of pediatric NI, intensifying hygiene measurements particularly on infant wards and prior to the cold season would be beneficial in reducing NI incidence.

Safety of alcohol hand gel use among children and personnel at a child day care center

BACKGROUND

Alcohol hand gels (AHG) have been used by children in child day care centers (CDCCs) to prevent the transmission of microbes. Because parents and personnel have been concerned about the safety of AHGs, we conducted a trial to assess this.

METHODS

A total of 82 children age 3.5 to 7.2 years (mean, 5.7 years) at 2 CDCCs rubbed their hands with AHG. Alcohol concentrations in expiratory air were measured using an official police alcometer after 15 and 60 minutes. We also conducted a questionnaire survey asking how commonly AHGs were used in CDCCs, obtaining 128 answers from 68 CDCCs (with more than 1 person responding in 6 CDCCs).

RESULTS

All of the alcometer readings were < 0.01 per thousand, although up to 30 contacts with the mucous membranes (mean, 2.4) occurred during the first 15 minutes. An AHG was used in all 68 CDCCs, but only by adults at 11 of them. The most common occasions for using an AHG were before serving food and after cleaning secretions. One case of fire occurred when a worker lit a fire while his hands were covered with AHG. Personnel were most concerned about situations in which children put their fingers into their mouth or eyes after using an AHG.

CONCLUSION

The use of an AHG in CDCCs is safe. Even though children tend to put their hands into their mouth after disinfection, no significant amount of alcohol is absorbed.

Identification of risk factors associated with nosocomial infection by rotavirus P4G2, in a neonatal unit of a tertiary-care hospital

A rotavirus outbreak in newborns admitted to the 'La Paz' University Hospital, Madrid was detected, followed up and controlled. Uninfected children were selected as control subjects. Samples of faeces were taken once or twice weekly from all the newborns, including those who were asymptomatic and who were admitted to the neonatal unit for early detection of rotavirus and the positive were separated from the rest of the neonates. Contact-related precautions were taken for all patients, and alcohol solutions were used for hand washing. During the months of the outbreak, 1773 children were admitted to the hospital, 131 of whom were affected by the rotavirus infection (7.4%). Of these, 72 (55%) had symptomatic infections. In the first month of the outbreak, nine cases of necrotizing enterocolitis were diagnosed (one patient developed massive intestinal necrosis). The infections (symptomatic and asymptomatic) presented a bimodal distribution caused by a new outbreak of rotavirus type P4G2 after two patients who had acquired the infection outside the hospital were admitted when the first outbreak was subsiding. The characteristics of cases and controls were analysed using bivariate and multivariate methods (non-conditional multivariate logistic regression) to identify four risk factors strongly associated with rotavirus infection: premature birth, infections other than rotavirus, malformation, and changes in glycaemia and/or presence of jaundice.

Decreasing hospital-associated rotavirus infection: a multidisciplinary hand hygiene campaign in a children's hospital

OBJECTIVE

Hand hygiene is an effective means of preventing hospital-associated infection, but compliance among health care workers is poor. Few studies aimed at increasing hand hygiene in the hospital setting have shown sustained improvement and concurrent decreases in hospital-associated infections, and even fewer have been performed in the pediatric setting.

METHODS

We implemented a hand hygiene program with the hopes of improving hand hygiene and decreasing hospital-associated rotavirus infection rates. A multidisciplinary group developed a hospital supported, house-wide campaign. Opportunities for hand hygiene were observed during 5 periods. The frequency of hospital-associated rotavirus infection was tracked over time by review of laboratory records. Correlates of hand hygiene were investigated with the use of multivariate logistic regression.

RESULTS

Overall hand hygiene compliance improved from 62% in period 1 to 81% in period 5 (P < 0.001). Soap and water was the most common method for practicing hand hygiene, and alcohol hand gel use increased from 4% to 29% between the first and last observation periods (P < 0.001). The rate of hospital-associated rotavirus infection decreased from 5.9 episodes per 1000 discharged patients in 2001 to 2.2 episodes per 1000 discharged patients in 2004 (P = 0.01). Period of observation, hospital ward, type of care provider and type of care performed were all independently associated with hand hygiene (adjusted P < or = 0.02 for all).

CONCLUSION

Improving hand hygiene is an important goal for health care institutions. These data can be useful for development of interventions aimed at improving hand hygiene.

Infection control policies and hospital-associated infections among surgical patients: variability and associations in a multicenter pediatric setting

BACKGROUND

Hospital-associated infections are an important cause of patient morbidity and death. Little is known about the variability of infection rates and infection control practices among pediatric hospitals.

METHODS

This cross-sectional study was performed with the Pediatric Health Information System database, which includes demographic and diagnostic data for 35 freestanding, noncompeting, children's hospitals, and with data from a survey of the hospitals, which yielded additional information on infection control policies and practices. Patients undergoing elective surgical procedures were included in this study.

RESULTS

Of the 35 eligible hospitals, 31 (89%) chose to participate in the survey component of this study. A total of 48278 patients met the inclusion criteria for the study; 2.3% of these patients had respiratory infections and 0.8% had gastrointestinal infections. The frequency of patients diagnosed with respiratory or gastrointestinal infections varied considerably among the hospitals and ranged from <1% to 6%. Certain infection control processes also varied among the hospitals during the study period. For instance, of the 31 hospitals, 12 monitored hand hygiene, 19 had administrative support of hand hygiene, and 16 had alcohol hand gel present for the entire study period. The presence of alcohol hand gel for the entire study was strongly and independently associated with lower odds of gastrointestinal infections (adjusted odds ratio: 0.64; 95% confidence interval: 0.49-0.85).

CONCLUSIONS

Hospitals should support the use of alcohol hand gel, with the aim of decreasing hospital-associated infection rates.

Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit

This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

Infections nosocomiales virales dans un service de pédiatrie : l'exemple des gastroentérites à rotavirus et des bronchiolites à VRS

Nosocomial infections are a preoccupation in a pediatric hospital mainly during the winter with bronchiolitis and gastroenteritis epidemics. We have examined the risk factors of nosocomial infections.

MATERIAL AND METHODS

A prospective study was conducted between November, 1999 and March, 2000 in the infants units of the Le Havre hospital. We systematically listed the admissions and contacted the family after their discharge by phone. A geographic information system was implemented to display the epidemiological data; this software is able to illustrate the sectors at risk.

RESULTS

During the study, 687 infants were hospitalized of whom 458 for bronchiolitis and community-acquired gastroenteritis. Mean age was 5.4 months old. No nosocomial bronchiolitis occurred. Prevalence of nosocomial gastroenteritis was 10% (68 cases including nine after discharge). Infants with nosocomial infection were younger than those with community-acquired infection (6.6 months vs. 11.2 months, P < 0.01). The mean length of stay was longer in nosocomial infection (7.7 vs. 4.1 days, P < 0.05). Among the infants with bronchiolitis, 16% have developed nosocomial intestinal infections (RR = 2.65, IC: 1.59-4.4; P < 0.01). The geographic analysis pointed the area with nosocomial risk (bedroom without water, nearness of nurse office and games room).

CONCLUSION

Geographic information system is a part of the quality control system and may have some interaction effect on final decision making. Incidence of nosocomial infections showed the need for a prevention strategy in a pediatric hospital.

A systematic review on the effectiveness of alcohol-based solutions for hand hygiene

The use of alcohol has been proposed as an option for hand hygiene. A systematic review was conducted to evaluate the clinical evidence supporting the use of alcohol-based solutions in hospitals as an option for hand hygiene. Studies published between January 1992 and April 2002 in English and Thai, related to the effectiveness of alcohol-based solutions, were reviewed. The databases searched included Medline, DARE, CINAHL and Dissertation Abstracts International. All studies were assessed as having adequate methodological quality. Results of this systematic review supported that alcohol-based hand rubbing removes microorganisms effectively, requires less time and irritates hands less often than does handwashing with soap or other antiseptic agents and water. Furthermore, the availability of bedside alcohol-based solutions increases compliance with hand hygiene among health care workers.

The effects of test variables on the efficacy of hand hygiene agents

BACKGROUND

Hand hygiene is essential to interrupting disease transmission in health care facilities. Multiple hand hygiene agents are currently available for use in the health care setting. To evaluate the utility of these agents, both the user acceptability and the efficacy need to be evaluated. Different hand hygiene test methodologies have been used to measure the efficacy of these agents, but efficacy results vary depending on variations to key parameters in these methodologies. The purpose of this study was to evaluate the effect of test variables on the efficacy of hand hygiene agents.

METHODS

Both a comprehensive literature review and original hand hygiene efficacy studies were undertaken. The literature review was conducted using a Medline search, and hand hygiene efficacy studies were conducted under the American Society for Testing and Materials (ASTM). E 1174 Standard Test Method for Evaluation of the Effectiveness of Health Care Personnel Handwash Formulation.

RESULTS

The literature review and our original data showed that the following variables affected the hand hygiene efficacy measurements: hand jewelry, experimental contamination versus normal flora, method of application of test organism, hand hygiene agent, concentration of active ingredient, volume of hand hygiene agent, duration of application of hand hygiene agent, method of application of hand hygiene agent, and study method (human challenge trial versus in vitro suspension test).

CONCLUSIONS

Although many methodological variables affect efficacy results, infection control professionals in their analysis of product information should always assess the results in light of the following key variables: concentration and type of active ingredient, duration of exposure to hand hygiene agent, volume of hand hygiene agent applied, test organism, and study method (ie, human challenge vs. in vitro suspension test).

Effectiveness of Alcohol-based solutions for Hand Hygiene: A Systematic Review

: Hand hygiene is an important measure in reducing the transmission of nosocomial infections in hospitals, but adherence is poor among health care workers (HCWs).More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol.Hand rubbing with alcohol-based products is commonly used in some countries instead of handwashing. This review evaluates the scientific and clinical evidence on the use of alcohol-based hand rubs in health care settings as a new option for hand hygiene.

OBJECTIVES

To conduct a systematic review to determine the best available evidence related to effectiveness of alcohol-based solutions for hand hygiene. The specific review questions addressed were: the effectiveness in reducing microorganisms, compliance with hand hygiene, and the incidence of skin problems. Application time (consumption) addressed efficiency.

CRITERIA FOR CONSIDERING STUDIES IN THIS REVIEW

This review considered all studies that included alcohol-based solutions that related to the objectives of the review. Outcomes included measures for the reduction of organisms, compliance with hand hygiene, the types of skin problems, and application time. The review primarily considered any intra-individual trials (IITs), randomised controlled trials (RCTs) and controlled clinical trials (CCTs) relating to the effectiveness of alcohol-based solutions but also included quasi-experimental designs.

SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES

The search sought to find published and unpublished studies. The databases searched included: Medline, CINAHL, ProQuest and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.

ASSESSMENT AND DATA EXTRACTION

All studies were checked for methodological quality by two reviewers and data were extracted using a tool.

DATA ANALYSIS

The study results were pooled in statistical meta-analysis using Review Manager software and summarized in narrative form where statistical pooling was not appropriate or possible.

RESULTS

This systematic review included thirty seven studies that supports the use of alcohol-based solutions for routine hand hygiene and surgical hand scrub. Alcohol-based hand rub removes microorganisms from hands of personnel more effectively, requires less time, and irritates hands less often than traditional handwashing with nonmedicated soap or other antiseptic agents and water. The combination of 61% ethanol and 1% chlorhexidine gluconate (CHG) is even more effective in producing residual antibacterial properties on the skin. Furthermore, the availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs.

CONCLUSION

Rubbing hands with alcohol-based agents has been proved to be effective in the reduction of microorganisms from hands. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Addition of CHG to alcohol-based solution can produce residual antibacterial properties on the skin. The use of alcohol-based solutions containing emollients causes less skin irritation and dryness and requires less time than washing hands with soap or other disinfectants. The promotion of bedside, alcohol-based hand rubs contributes to the increase in compliance with hand hygiene by HCWs.

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

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

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

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

An outbreak of diarrhea in a neonatal medium care unit caused by a novel strain of rotavirus: investigation using both epidemiologic and microbiological methods

OBJECTIVE

In December 1999, an outbreak of diarrhea was reported in a general hospital neonatal medium care unit (NMCU) caused by a novel strain of rotavirus with genotype P[6], G9. An investigation was conducted to determine risk factors for illness among neonates.

DESIGN

Rotavirus diagnosis was by latex agglutination and typing by reverse transcriptase polymerase chain reaction. A case-control study was performed using data collected from medical records on exposures in a 3-day period before illness (cases) or a random 3-day period (controls). Environmental swabs were tested for rotavirus. Antenatal blood samples from mothers and blood samples provided by hospital staff were analyzed for rotavirus antibodies.

RESULTS

Fifty-six cases of rotaviral illness were confirmed by latex agglutination. Forty-seven of these were among 118 neonates exposed to the NMCU (attack rate, 40%). There was a 4-week period with no clinical cases in the course of the outbreak. Increased frequency (> or = 15 times in 3 days) of ungloved nasogastric feeding was a significant risk factor (adjusted odds ratio, 8.79), controlling for birth weight and gestational age. Environmental sampling showed persistence of the virus on ward surfaces despite cleaning. None of 24 NMCU staff members had high levels of antibodies against P[6], G9. Three (8%) of 38 mothers had high antibody levels; 2 had infants who became ill. The outbreak ended with a 7-day ward closure, disinfection, and introduction of gloved nasogastric feeding.

CONCLUSIONS

Case-control studies can be successful in identiffying risk factors for nosocomial outbreaks of diarrhea. High levels of rotavirus antibodies in mothers may not protect infants. The environment may be the most important reservoir of rotavirus during outbreaks.

Hygienic hand antiseptics: should they not have activity and label claims against viruses?

Enteric and respiratory viruses are among the most frequent causes of human infections, and hands play an important role in the spread of these and many other viral diseases. Regular and proper hand hygiene by caregivers and food handlers in particular is essential to decontaminate hands and potentially interrupt such spread. What would be considered a proper decontamination of hands? Handwashing with regular soap and water is often considered sufficient, but what of hygienic handwash and handrub antiseptic products? Are they more effective? The evidence suggests that some clearly are. Activity against bacteria may not reflect the ability of hygienic hand antiseptics to deal with viruses, especially those that are nonenveloped. In spite of the acknowledged importance of hands as vehicles for viruses, there is a lack of suitable regulatory mechanism for handwash or handrub products to make claims of efficacy against viruses. This is in contrast with the ability of general-purpose disinfectants to make antiviral claims, although transmission of viruses from surfaces other than those of reusable medical devices may play only a minor role in virus transmission. This review discusses the (1). recent information on the relative importance of viruses as human pathogens, particularly those causing enteric and respiratory infections; (2). the survival of relevant viruses on human hands in comparison with common gram-negative and gram-positive bacteria; (3). the potential of hands to transfer or receive such contamination on casual contact; (4). role of hands in the spread of viruses; (5). the potential of hygienic measures to eliminate viruses from contaminated hands; (6). relative merits of available protocols to assess the activity of hygienic hand antiseptics against viruses; and (7). factors considered crucial in any tests to assess the activity of hygienic hand antiseptics against viruses. In addition, this review proposes surrogate viruses in such testing and discusses issues for additional consideration by researchers, manufacturers, end-users, and regulators.

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

INTRODUCTION

Standard handwashing is a key measure for the prevention of crossed nosocomial infection, but this measure is not always observed. We study whether fast disinfection with an alcohol solution is better than handwashing and whether it can enhance observance.

MATERIALS AND METHODS

The effects of several alcohol solutions on native and acquired microbiota are compared with classic handwashing in 'in vitro' and 'in vivo' (health volunteers) quantitative tests. A field assay was subsequently performed in severely ill patient intensive care units (ICUs) (Burn and other ICUs), using a semiquantitative method to compare the effects of disinfection with standard handwashing (n=102) with N-duopropenide alcohol application (n=264).

RESULTS AND DISCUSSION

In both designs--health volunteers and hospital ward teams--we found significant differences between handwashing and N-duopropenide application. Handwashing barely modified the native or acquired microbiota (only 0.1 to <2 log10 reduction) and did not eliminate Staphylococcus aureus and Gram-negative bacteria (from 34 to 23%: P>0.05). However, N-duopropenide reduced the acquired microbiota by 5 log (10) and the native hand microbiota by more than 2 log10, as well as significantly reducing S. aureus and Gram-negative bacteria (33-1.3%; P<0.01).

A comparison of soap, alcohol and glove use during the nappy-changing procedure in a special care baby unit

This study was conducted in a special care baby unit (SCBU) in a district general hospital and concentrated on hand decontamination and glove-wearing during the nappy-changing procedure. The aims were to determine whether or not nurses were adhering to existing infection control policies and guidelines, and to determine the most appropriate product to be used for hand decontamination.

Nurses were observed carrying out nappy changes to determine their existing hand-washing and glove-wearing practices. A microbiological analysis of nurses' hands during the nappy change was performed in order to compare the effectiveness of soap, alcohol, and glove use in eliminating bacteria from the hands.

The observation study demonstrated that not all nurses were adhering to existing infection control policies and guidelines. The microbiological analysis found that on the majority of occasions, alcohol was better than soap at removing bacteria from the hands but that gloves provided the best protection overall for both babies and nurses by preventing the acquisition of bacteria.

Together these findings suggest that nurses' hands may be providing a route for the transmission of hospital-acquired infection in the SCBU. Ideally, nurses should be wearing gloves during the nappy-changing process and using alcohol to decontaminate their hands.

Transmission of viruses via contact in ahousehold setting: experiments using bacteriophage straight phiX174 as a model virus

Contamination of the environment with pathogens is the prerequisite for contact infections. The aim of this study was to elucidate how viruses can be transmitted from a primary contact person to further individuals. Bacteriophage straight phiX174 was chosen as a model virus. In its stability straight phiX174 is comparable with the most resistant human pathogenic viruses, e.g. polio- or parvoviruses. About 10(7)pfu were applied to exposed contact points such as door handles or the hands of volunteers. After touching of these handles and common social contacts like hand shaking, re-isolation rates were determined from the hands of our test persons. Contaminated door handles and skin surfaces were found to be efficient sources for potential infection. At least 14 persons could be contaminated by horizontal spread, one after the other by touching the same door handle. Successive transmission from one person to another could be followed up to the sixth contact person. These results were confirmed under everyday life conditions in a flat shared by four students. The transmission could not be prevented by the usual standards of hand hygiene, practised in this household. straight phiX174 could be reisolated after 24h from the hands of all persons tested even after normal use and cleaning of their hands. This might be improved by the use of liquid soap dispensers.

Replace hand washing with use of a waterless alcohol hand rub?

Hand hygiene is one of the basic components of any infection control program and is frequently considered synonymous with hand washing. However, health care workers frequently do not wash their hands, and compliance rarely exceeds 40%. Hand rubbing with a waterless, alcohol-based rub-in cleanser is commonly used in many European countries instead of hand washing. Scientific evidence and ease of use support employment of a hand rub for routine hand hygiene. It is microbiologically more effective in vitro and in vivo, it saves time, and preliminary data demonstrate better compliance than with hand washing. Therefore, a task force comprising experts from the Centers for Disease Control and Prevention and from professional societies is designing guidelines for the use of a hand rub in the United States. Today, most countries of Northern Europe recommend a hand rub for hand hygiene unless the hands are visibly soiled. Side effects are rare and are mainly related to dryness of the skin. This review evaluates the scientific and clinical evidence that support the use of alcohol-based hand rubs in health care facilities as a new option for hand hygiene.

A novel approach using an attenuated recombinant vaccinia virus to test the antipoxviral effects of handsoaps

Evidence indicates an increase in nosocomial and household infections due to viruses (Jeffries, D.J., 1995. Viral hazards to and from health care workers. J. Hosp. Infect. 30, 140-155). An antiviral assay was developed for evaluating efficiency of handsoaps at inactivating cell-free and cell-associated virus. A recombinant vaccinia virus, lacking a virulence factor (Isaacs, S.N., Kotwal, G.J., Moss, B., 1992. Vaccinia virus complement-control protein prevents antibody-dependent complement-enhanced neutralization of infectivity and contributes to virulence. Proc. Natl. Acad. Sci. USA 89, 628-632), whose construction was described earlier (Kotwal, G.J., Isaacs, S.N., McKenzie, R., Frank, M.M., Moss, B., 1990. Inhibition of the complement cascade by the major secretory protein of vaccinia virus. Science 250, 827-830), was used as the representative poxvirus. Two antibacterial handsoaps, one surgical handsoap, one moisturizing handsoap, and a sanitizing agent were tested. An aliquot of the virus was mixed and incubated with soap, then titrated onto BSC-1 cells for incubation at 37 degrees C for 48 h. The soaps' effect on cell-associated virus was tested similarly. The antibacterial soaps inactivated all cell-free virus in 1 min. The surgical soap was effective with a 5-min incubation. None of the soaps eliminated all of the cell-associated virus in 1 min. This safe and reproducible assay seems efficient to establish the comparative efficacy of household and surgical soaps.

A review of the test methods used to establish virucidal activity

Testing the efficacy of disinfectants has been the domain of bacteriologists for many years. Recently interest has grown in the virucidal effects of disinfectants, due to increased awareness of viral infections and concern for possible cross-infection. Findings have demonstrated significant differences in the susceptibility of certain viruses, particularly non-enveloped viruses, e.g. enteroviruses, to disinfectants compared to some bacteria. For example Escherichia coli and herpes simplex virus are inactivated by 20% isopropyl alcohol (IPA) whereas Staphylococcus aureus requires > or = 50% and poliovirus is not inactivated by IPA. Currently there is little or no standardization in the methods used for the determination of virucidal activity in suspension, or on hands and surfaces. Methods in use in Europe and the USA will be reviewed and their relevance to the clinical situation discussed.