Hand hygiene: back to the basics of infection control.

Health care associated infections are drawing increasing attention from patients, insurers, governments and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these are preventable. The medical community is witnessing in tandem unprecedented advancements in the understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant infections in health care set-ups. These factors, compounded by the paucity of availability of new antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections. With "Clean Care is Safer Care" as a prime agenda of the global initiative of WHO on patient safety programmes, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention: hand hygiene.

Introduction

Hand hygiene is now regarded as one of the most important element of infection control activities. In the wake of the growing burden of health care associated infections (HCAIs), the increasing severity of illness and complexity of treatment, superimposed by multi-drug resistant (MDR) pathogen infections, health care practitioners (HCPs) are reversing back to the basics of infection preventions by simple measures like hand hygiene. This is because enough scientific evidence supports the observation that if properly implemented, hand hygiene alone can significantly reduce the risk of cross-transmission of infection in healthcare facilities (HCFs)1–5.

Historical background

The significance of hand washing in patient care was conceptualized in the early 19th century6–8. Labarraque6 provided the first evidence that hand decontamination can markedly reduce the incidence of puerperal fever and maternal mortality. Semmelweis7 worked in the Great hospital in Vienna in the 1840s. There were two maternity clinics in the hospital, with alternate day admission policy. The first clinic was attended by medical students, who moved straight from autopsy rooms to the delivery suite and had an average maternal mortality rate due to puerperal fever of about 10 per cent. The second clinic, attended by midwives had a maternal mortality of only 2 per cent. The puzzled Semmelweis got a breakthrough in 1847, following the death of colleague Jokob Kolletschka, who had been accidentally got a cut by a student's scalpel while performing an autopsy. His autopsy showed a pathological condition similar to that of women drying from puerperal fever. Semmelweis concluded that some “unknown cadaverous material” caused puerperal fever. He instituted a policy of washing hands with chlorinted lime for those leaving the autopsy room, following which the rate of maternal mortality dropped ten-folds, comparable to the second clinic. Thus, he almost conducted a controlled trial, in an era when microbes were yet to be discovered and the germ theory of disease was not defined6–8. In another landmark study in the wake of Staphylococcal epidemics in 1950s, Mortimer et al9 showed that direct contact was the main mode of transmission of S. aureus in nurseries. They also demonstrated that hand washing by patients’ contacts reduced the level of S. aureus acquisition by babies.

In 1975 and 1985, the CDC published guidelines on hand washing practices in hospitals, primarily advocating hand washing with non antimicrobial soaps; washing with antimicrobial soap was advised before and after performing invasive procedures or during care for high risk patients. Alcohol-based solutions were recommended only in situations where sinks were not available1011. In 1995, the Hospital Infection Control Practices Advisory Committee (HICPAC) advocated the use of antimicrobial soap or a waterless antiseptic agent for cleaning hands upon leaving the rooms of patients infected with multidrug-resistant pathogens12. In 2002, the CDC published revised guidelines for hand hygiene3. A major change in these guidelines was the recommendation to use alcohol based hand rubs for decontamination of hands between each patient contact (of non-soiling type) and the use of liquid soap and water for cleaning visibly contaminated or soiled hands. A systematic review of handwashing by the Thames Valley University as part of the evaluation of processes and indicators in infection control (EPIC) study13, concluded that there was a good evidence that direct patient contact resulted in hand contamination by pathogens. The EPIC study also showed the superiority of 70 per cent alcohol/ alcohol based antiseptic hand rubs1314.

With the growing burden of HAIs, limited options of effective antimicrobials evidence supporting the role of hand hygiene in reduction of HAIs, the WHO has launched a global hand hygiene campaign. In 2005, it introduced the first Global Patient Safety Challenge “Clean Care is Safer Care (CCiSC)”, as part of its world alliance for patient safety1516. In 2006, advanced draft guidelines on "Hand Hygiene in Health Care" were published and a suite of implementation tools were developed and tested17. The first Global Handwashing Day was observed on October 15, 2008. A WHO Patient Safety 2009 initiative has been established to catalyse this progress. This is the next phase of the ‘First Challenge's work on CCiSC′15–18. This initiative has, as of April 2009, seen a total of 3,863 health care facilities registering their commitment, effectively equating to a staff of over 3.6 million people, globally. On May 5, 2009, the WHO highlighted the importance of hand hygiene and launched guidelines and tools on hand hygiene, based on the next phase of patient safety work programme “SAVE LIVES: Clean Your Hands”1215–18.

Normal flora of hands

There are two types of microbes colonizing hands: the resident flora, which consists of microorganisms residing under the superficial cells of the stratum corneum and the transient flora, which colonizes the superficial layers of the skin, and is more amenable to removal by routine hand hygiene. Transient microorganisms survive, but do not usually multiply on the skin. They are often acquired by health care workers (HCWs) during direct contact with patients or their nearby contaminated environmental surfaces and are the organisms most frequently associated with HCAIs1–3.

Colonization of hands with pathogens and their role in transmission

The hands of HCWs are commonly colonized with pathogens like methicillin resistant S. aureus (MRSA), vancomycin resistant Enterococcus (VRE), MDR-Gram Negative bacteria (GNBs), Candida spp. and Clostridium difficle, which can survive for as long as 150 h. Approximately 106 skin epithelial cells containing viable microorganisms are shed daily from the normal skin219, which can contaminate the gowns, bed linen, bedside furniture, and other objects in the patient's immediate environment. Hand carriage of resistant pathogens has repeatedly been shown to be associated with nosocomial infections1–3. The highest rates of hand contamination are reported from critical care areas, which also report most cases of cross-transmission. The hands may become contaminated by merely touching the patent's intact skin or inanimate objects in patients’ rooms or during the “clean” procedures like recording blood pressure1–3.

Importance of hand hygiene

Proper hand hygiene is the single most important, simplest, and least expensive means of reducing the prevalence of HAIs and the spread of antimicrobial resistance1–320–23. Several studies have demonstrated that handwashing virtally eradicates the carriage of MRSA which invariably occurs on the hands of HCPs working in ICUs2425. An increase in handwashing compliance has been found to be accompanied by a fall in MRSA rates26. The hand hygiene liason group identified nine controlled studies, all of which showed significant reductions in infection related outcomes, even in settings with a high infection rates in critically ill patients142728. Transmission of Health-care-associated Klebsiella sp. has also been documented to reduce with improvement in hand hygiene2323. The evidence suggests that adherence to hand hygiene practices has significantly reduced the rates of acquisition of pathogens on hands and has ultimately reduced the rates of HAIs in a hospital22232629–31.

Indications for hand hygiene during patient care

Wash hands with soap and water when (i) visibly dirty or contaminated with proteinaceous material, blood, or other body fluids and if exposure to Bacillus anthracis is suspected or proven (since the physical action of washing and rinsing hands in such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores); (ii) After using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water; and (iii) before and after having food1–321–2332.

In all other clinical situations described below, when hands are not visibly soiled, an alcohol-based hand rub should be used routinely for decontaminating hands1–321–2332. (i) Before having direct contact with patients. (ii) Before donning sterile gloves when inserting a central intravascular catheter. (iii) Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. (iv) After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). (v) After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. (vi) After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. (vii) After removing gloves. (viii) If moving from a contaminated body site to a clean body site during patient care.

The WHO “SAVE LIVES: Clean Your Hands” programme12 reinforces the “My 5 Moments for Hand Hygiene” approach as key to protect the patients, HCWs and the health-care environment against the spread of pathogens and thus reduce HAIs. This approach encourages HCWs to clean their hands: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient and after touching patient surroundings12.

Other precautions in relation to hand sanitation

Avoid unnecessary touching of surfaces in close proximity to the patient. In 2002, the CDC/HICPAC recommended that artificial fingernails and extenders not to be worn by HCPs who have contact with high-risk patients, due to their association with outbreaks of Gram-negative bacillary and candidal infections12. Although rings harbour a high count of pathogens, they have not been found to be associated with transmission of infections12.

Method of hand washing1221

For handwashing, remove the jewelry and rinse hands under running water (preferably warm). Lather with soap and using friction, cover all surfaces of hands and fingers. Wash thoroughly under running water. Turn off faucet with wrist/elbow. Dry hands with a single use towel or by using forced air drying. Pat skin rather than rubbing to avoid cracking. If disposable towels are used, throw in trash immediately. Skin excoriation may lead to bacteria colonizing the skin and the possible spread of blood borne viruses as well as other microorganisms. Sore hands may also lead to decreased compliance with hand washing protocols1221. If using antiseptic rub, take an adequate amount and rub on all surfaces for the recommended time. Let the antiseptic dry on its own.

Agents used for hand hygiene

Table I lists the properties, advantages and disadvantages of the commonly used agents for hand hygiene1–42133.

Table I

Properties of hand hygiene products

Selecting hand hygiene products for health set-ups

The major determinants for product selection are antimicrobial profile, user acceptance, and cost2421. Post-contamination hand hygiene products must have at least bactericidal, fungicidal (yeasts), and virucidal (coated viruses) activity. Since hands of HCWs are frequently contaminated with blood during routine patient care, activity against coated viruses should be included in the minimum spectrum of activity of an agent for hand hygiene4. Additional activity against fungi (including molds), mycobacteria, and bacterial spores may be relevant in high risk wards or during outbreaks. Pre-operative hand hygiene should be at least bactericidal and fungicidal (yeasts), since the hands of most HCWs carry yeasts and surgical- site infections have also been associated with hand carriage of yeasts during an outbreak4.

Hospital administrators should also take into account the acceptability of product (smell, feel, skin irritation) by the users and its allergenic potential1–421. When comparing the cost of hand hygiene products, it has been found that the excess hospital cost associated with only 4-5 HAIs of average severity may equal the entire annual budget for hand hygiene products used for in-patient care areas334.

One of the key elements in improving hand hygiene practice is the use of an alcohol based hand rub instead of washing with soap and water. An alcohol-based hand rub requires less time, is microbiologically more effective and is less irritating to skin than traditional hand washing with soap and water2335. In the ICUs, switching to alcohol hand disinfection would decrease the time necessary for hand hygiene from 1.3 h (or 17% of total nursing time) to 0.3 h (or 4% of total nursing time)3536.

Reasons for poor hand hygiene practices

In most health care institutions, adherence to recommended hand-washing practices remains unacceptably low, rarely exceeding 40 per cent of situations in which hand hygiene is indicated3537. Hand hygiene reflects attitudes, behaviours and beliefs. Some of the observed/self reported factors found to be affecting hand hygiene behaviours are enlisted in Table II2338–41.

Table II

Factors affecting compliance to hand hygiene

Methods used to improve hand hygiene compliance

Multimodal strategies have been shown to be more successful in improving rates of adherence with hand hygiene in HCWs than single interventions16. Targeted, multi-faceted approaches focusing on system change, administrative support, motivation, availability of alcohol-based hand rubs, training and intensive education of HCWs and reminders in the workplace have been recommended for improvement in hand hygiene16.

Recent studies support the fact that interactive educational programmes combined with free availability of hand disinfectants significantly increased the hand hygiene compliance4243. A single lecture on basic hand hygiene protocols had a significant and sustained effect in enhancing hand hygiene compliance in a Swedish hospital42. The four member States of the European Union, which implemented National Hand Hygiene Campaigns found the following strategies to be extremely useful in their countries: Governmental support, the use of indicators for hand hygiene benchmarking, developing national surveillance systems for auditing alcohol based hand rub consumption and auditing hand hygiene compliance44. Trampuz et al35 advocated simple training sessions for HCWs to be held in each ward to introduce the advantage of alcohol hand rubs over hand washing.

Other factors like positive role modeling (hand hygiene behaviour of senior practitioners) and the use of performance indicators also remarkably improve adherence to hand hygiene4041. There should be adequate supply of hand hygiene products, lotions and creams, disposable towels and facilities for hand washing, where necessary2–4354041. Alcohol hand rubs should be available at the point of care in sufficient quantities. It needs to be emphasized that wearing gloves does not replace the need for hand hygiene and that contamination may occur during glove removal. Studies by Pitet2645 showed a remarkable and long lasting improvement in hand hygiene compliance using a multimodal strategy, which has been adopted by the first Global Patient Safety Challenge of WHO to develop hand hygiene strategies. The availability of individual, pocket carried bottles also increased compliance38–4046–48.

Apart from this, all hospitals should have a dynamic infection control team, robust surveillance system, adequate staff to disseminate evidence-based knowledge in an easily comprehensible way to all cadres of staff. At a more local or regional level, there is a need for institutional frameworks or programmes to deal with HAIs49. The Institute for Healthcare Improvement (www.ihi.org) offers elaborate training modules on various aspects of patient care. The guide for implementation of WHO's CCiSC and a range of tools to facilitate hand hygiene is available50.

Research and education

To develop successful interventions, more research into behavioural determinants is needed, in particular, how these determinants can be applied to improve hand hygiene5152. Process indicators are vital and an understanding of why some interventions succeed and others fail is needed. Since hand hygiene is more of a behavioural practice, the first step towards the development of interventions should be to identify the prevalence of risk behaviours (i.e. non compliance) and the difference in risk behaviours. Since the reasons for non-compliance vary among countries, large scale systematic studies are needed to identify the reasons thereof and plan remedial strategies.

An expert panel has recommended that measuring hand hygiene compliance is essential to understand the current situation, facilitate change and to measure the impact of interventions53. This can be done by direct observation, automated electronic monitoring, product consumption and self reporting by HCW54.

The important aspect of role models for students, whose adherence is strongly influenced by their mentor's attitude at bed side should be exploited in moulding the behaviour of young medical students. A few lectures in the undergraduate curriculum may prime the medical students to this basic necessity. The Hand Hygiene Liason Group strongly advocates teaching of elementary hygiene practices at medical schools55. In an elaborate study focusing on MBBS students, it was noted that assessing the knowledge, attitude and practices of final year MBBS students and providing a positive role modeling at undergraduate level is a good initiative56.

Indian scenario

In India, the quality of healthcare is governed by various factors, the principal amongst these being whether the health care organization is government or private-sector run. There is also an economic and regional disparity throughout the country. About 75 per cent of health infrastructure, medical manpower and other health resources are concentrated in urban areas, where 27 per cent of the population lives57. There is a lack of availability of clean water for drinking and washing. Like in other developing countries, the priority given to prevention and control of HCAI is minimal. This is primarily due to lack of infrastructure, trained manpower, surveillance systems, poor sanitation, overcrowding and understaffing of hospitals, unfavourable social background of population, lack of legislations mandating accreditation of hospitals and a general attitude of non-compliance amongst health care providers towards even basic procedures of infection control. In India, although hand hygiene is imbibed as a custom and promoted at school and community levels to reduce the burden of diarrhoea, there is a paucity of information on activities to promote hand hygiene in HCFs. Sporadic reports document the role of hands in spreading infection and isolated efforts at improving hand hygiene across the country5458–60.

The practice of compulsory training on standard precautions, safe hospital practices and infection control for all postgraduates upon course-induction, as is being done in a few Delhi medical colleges seems very promising for our country. Such an exercise may be made mandatory across all medical and nursing colleges of India, especially since the “patient safety” is increasingly being prioritized by the Government of India and the country being one of the 120 signatories pledging support to the WHO launched world alliance (available at http://www.who.int/patientsafery/events/06/statememts/India_pledge.pdf).

Challenges ahead

Although evidence based guidelines are increasingly being implemented in the developed countries, the developing countries still lack basic health care facilities, surveillance networks and resources to curtail HAIs61–63. Lack of hand washing facilities (e.g., sinks, running water and sewage systems) are major deterrents for implementation of hand hygiene61. The use of WHO advocated alcohol based hand rubs is a practical solution to overcome these constraints, because these can be distributed individually to staff for pocket carriage and placed at the point of care. The major advantage is that its use is well applicable to situations typical of developing countries, such as two patients sharing the same bed, or patient's relatives being requested to help in care provision. Several hospitals are now reporting increased compliance after implementation of CCiSC64. Several countries have also initiated nationally co-ordinated activities (http://www.who.int/gpsc/national-campaigns/en/) to promote hand hygiene54. However, global Healthcare Infection Prevention programmes can only be successful, if these populous developing nations are able to control the menace by formulation of national or local policies and strictly implementing the guidelines.

Conclusion

Hand washing should become an educational priority. Educational interventions for medical students should provide clear evidence that HCWs hands become grossly contaminated with pathogens upon patient contact and that alcohol hand rubs are the easiest and most effective means of decontaminating hands and thereby reducing the rates of HAIs. Increasing the emphasis on infection control, giving the charge of infection control to senior organizational members, changing the paradigm of surveillance to continuous monitoring and effective data feedback are some of the important measures which need to be initiated in Indian hospitals.

One of the reasons microbes have survived in nature is probably their simplicity: a simple genomic framework with genetic encryptation of basic survival strategies. To tackle these microbes, human beings will have to follow basic and simple protocols of infection prevention. The health care practitioners in our country need to brace themselves to inculcate the simple, basic and effective practice of hand hygiene in their daily patient care activities and serve as a role model for future generations of doctors, nurses and paramedical personnels.