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

Grounded procedures: A proximate mechanism for the psychology of cleansing and other physical actions

Experimental work has revealed causal links between physical cleansing and various psychological variables. Empirically, how robust are they? Theoretically, how do they operate? Major prevailing accounts focus on morality or disgust, capturing a subset of cleansing effects, but cannot easily handle cleansing effects in non-moral, non-disgusting contexts. Building on grounded views on cognitive processes and known properties of mental procedures, we propose grounded procedures of separation as a proximate mechanism underlying cleansing effects. This account differs from prevailing accounts in terms of explanatory kind, interpretive parsimony, and predictive scope. Its unique and falsifiable predictions have received empirical support: Cleansing attenuates or eliminates otherwise observed influences of prior events (1) across domains and (2) across valences. (3) Cleansing manipulations produce stronger effects the more strongly they engage sensorimotor capacities. (4) Reversing the causal arrow, motivation for cleansing is triggered more readily by negative than positive entities. (5) Conceptually similar effects extend to other physical actions of separation. On the flipside, grounded procedures of connection are also observed. Together, separation and connection organize prior findings relevant to multiple perspectives (e.g., conceptual metaphor, sympathetic magic) and open up new questions. Their predictions are more generalizable than the specific mappings in conceptual metaphors, but more fine-grained than the broad assumptions of grounded cognition. This intermediate level of analysis sheds light on the interplay between mental and physical processes.

Hand hygiene compliance: bridging the awareness-practice gap in sub-Saharan Africa

This review provides an exploratory overview of hand hygiene compliance in sub-Saharan Africa and examines strategies to bridge the compliance gap.

While there is increasing awareness on hand hygiene, empirical evidence suggests that there is no concurrent increase in correct hand hygiene practice among key populations in sub-Saharan Africa. Children, adolescents and even healthcare providers (HCPs) in sub-Saharan Africa consistently assume poor hand hygiene compliance levels resulting in negative health consequences. Faecal-oral diseases remain common among schoolchildren, leading to school absenteeism and disease-specific morbidity. Additionally, the incidence of nosocomial infections in health facilities in sub-Saharan Africa remains high, as many HCPs do not adopt good hand hygiene practice. Increased disease burden, high healthcare costs and eroding public confidence in the healthcare system are a few implications of HCPs’ poor compliance with hand hygiene. These trends underscore the inadequacies of educational approaches (cognition model) to hand hygiene promotion commonly adopted in sub-Saharan Africa.

It was therefore recommended that the governments of sub-Saharan Africa should focus on promoting skill-based hygiene education which will help schoolchildren develop good hand hygiene practice as a lifelong skill. In addition, efforts should be made to implement a multimodal hand hygiene strategy in healthcare facilities in order to increase compliance by healthcare providers.

Effects of hand disinfection with alcohol hand rub, ozonized water, or soap and water: time for reconsideration?

The effect of alcohol hand rub was tested in eradicating Escherichia coli, and compared with hand wash using ozonized tap water or soap and water. Alcohol eradicated all bacteria in 10 out of 35 participants, but with an average (SD) of 2330 (4227) cfu/mL left after disinfection, whereas ozonized water removed all bacteria in 10 out of 55 participants, with an average of only 538 (801) cfu/mL left (P = 0.045). Soap washing was the most effective with total removal of bacteria in six out of 20 participants, with an average of 98 (139) cfu/mL (P = 0.048 and 0.018 versus ozonized water and alcohol, respectively).

Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries

Background: The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient. Methods: Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs. Results: Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs. Conclusion: The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.

Influence of human wound exudate on the bactericidal efficacy of antiseptic agents in quantitative suspension tests on the basis of European Standards (DIN EN 13727)

The antimicrobial efficacy of antiseptics used in wound management is tested in vitro under standardised conditions according to DIN EN 13727, with albumin and sheep erythrocytes used as organic challenge. However, these testing conditions do not adequately simulate the wound bed environment. Thus, the aim of this study was to compare the efficacy of different antiseptics such as octenidine dihydrochloride (OCT), chlorhexidine digluconate (CHX), polyhexamethylene biguanide (PHMB), and povidone-iodine under challenge with human wound exudate instead of standardised organic load in an in vitro setting according to DIN EN 13727. Moreover, protein contents, pH, and temperature were compared with standardised testing conditions. The tested antiseptic agents were reduced to different extents based on their bactericidal efficacy, when challenged with human wound exudate compared with standardised conditions. Overall, 0.10% OCT showed the highest effects reaching full efficacy after 30 seconds. CHX and PHMB were the least efficient. Next to the protein content, other components of wound exudate, such as the microflora, seem to influence the efficacy of antiseptics. In summary, the optimisation of in vitro testing conditions in future applications, to more adequately simulate the wound bed environment, will allow a more realistic picture on the potential performance of antiseptics in clinical practice.

Reconciling Hygiene and Cleanliness: A New Perspective from Human Microbiome

The term hygiene is deeply rooted with the concept of maintaining sound health and alertness towards cleanliness, while "hygiene hypothesis" depicts the protective role of microbial community exposure in development of early immunity and initial allergic and aesthetic reactions. The tug-of-war has now been pushed toward the literal term "hygiene" over the "hygiene hypothesis" and has continued with disinfection of all microbial loads from the related environments to avoid infections in humans. With the advancement in the microbiome studies, it became clear that humans possess warm, and significant relationships with diverse microbial community. With this opinion article, we have emphasized on the importance of hygiene hypothesis in immunological responses. We also propose the individual/targeted hygiene instead of application of unanimous hygiene hypothesis. This review also elaborates the common practices that should be employed to maintain hygiene along with the balanced microbiome.

Association between microbial water quality, sanitation and hygiene practices and childhood diarrhea in Kersa and Omo Nada districts of Jimma Zone, Ethiopia

INTRODUCTION

Diarrhea is one of the leading causes of child morbidity and mortality in low- and middle-income countries like Ethiopia. The use of safe drinking water and improved sanitation are important practices to prevent diarrhea. However, limited research has been done to link water supply, sanitation and hygiene practices and childhood diarrhea. Therefore, this study aimed at assessing the association between microbial quality of drinking water, sanitation and hygiene practices and childhood diarrhea.

METHODS

Community-based matched case-control study design was applied on 198 paired children from June to July 2019 in Kersa and Omo Nada districts of Jimma Zone, Ethiopia. Cases are children < 5 years of age with diarrhea during the two weeks before the survey. The controls are children without diarrhea during the two weeks before the survey. Twenty-five percent matched pair samples of water were taken from households of cases and controls. Data were collected using structured questionnaire by interviewing mothers/caregivers. A sample of water was collected in nonreactive borosilicate glass bottles and analyzed by the membrane filtration method to count fecal indicator bacteria. A conditional logistic regression model was used; variables with p-value less than 0.05 were considered as significantly associated with childhood diarrhea.

RESULTS

A total of 396 (each case matched with control) under-five children with their mothers/caregivers were included in this study. In the analysis, variables like presence of under-five child in their home (AOR = 2.76; 95% CI: 1.33-5.71), wealth status (AOR = 5.39; 95% CI: 1.99-14.55), main sources of drinking water (AOR = 4.01; 95% CI: 1.40-11.44), hand washing practice before water collection (AOR = 4.28; 95% CI: 1.46-12.56), treating water at household level (AOR = 1.22; 95% CI: 0.48-3.09), latrine use all the times of the day and night (AOR = 0.22; 95% CI: 0.06-0.78), using pit as method of waste disposal (AOR = 4.91; 95% CI: 1.39-13.29) and use of soap for hand washing (AOR = 2.89; 95% CI: 1.35-6.15) were significantly associated with childhood diarrhea. Moreover, 30% of sampled water from cases and 26% of sampled water from controls families were free from Escherichia coli whereas all sampled water analyzed for Total coliforms were positive.

CONCLUSIONS

We conclude that the main sources of drinking water, hand washing before water drawing from a storage container, domestic waste disposal place and use of soap for hand washing were the most important factors for the prevention of childhood diarrhea.

Efficacy of the SuperTowel®: An Alternative Hand-washing Product for Humanitarian Emergencies

Handwashing with soap reduces the transmission of diarrheal pathogens, but access to hand-washing facilities, water, and soap in humanitarian emergencies is limited. The SuperTowel^® (ST) is a fabric treated with permanent antimicrobial bonding and has been designed as a soap alternative in emergency situations. The aim of this study was to test the efficacy of the ST as a hand-cleaning product. Two sets of laboratory tests, with 16 volunteers in each, were conducted to test the efficacy of different prototypes of the ST. Volunteers pre-contaminated their hands with nonpathogenic Escherichia coli. Comparisons were made between hand cleaning with the ST and handwashing with the reference soap, using a crossover design. Participants also completed a questionnaire about product perceptions. Three of the prototypes of the ST were more efficacious at removing E. coli from pre-contaminated hands than handwashing with soap (mean log₁₀ reduction of 4.11 ± 0.47 for ST1, 3.84 ± 0.61 for ST2, and 3.71 ± 0.67 for ST3 versus 3.01 ± 0.63 for soap [P < 0.001, P = 0.002, and P = 0.005, respectively]). The ST prototypes used less water than handwashing with soap, were well accepted, and were considered preferable in communal settings. The ST has the potential to be a suitable complementary hand-cleaning product for humanitarian emergencies.

Comparative Efficacy of Hand Disinfection Potential of Hand Sanitizer and Liquid Soap among Dental Students: A Randomized Controlled Trial

Background

Hands are the most common medium for initiation and spread of infection in clinics. Hand hygiene is the simplest and most economic method for reducing the healthcare-associated infections (HCAIs).

Aim

The aim of the present study was to compare the efficacy of hand sanitizer, liquid soap, and their combination for reducing the microbial colonies on hands.

Materials and methods

The study was a single-blinded randomized controlled trial executed in a dental college on 90 participants, which were randomly assigned into three intervention groups of 30 each. The participants were instructed to contaminate their hands followed by a hand hygiene protocol for the liquid hand-wash group, the alcohol-based hand sanitizer (ABHS) group, and the combination group according to WHO guidelines. The swabs were collected pre- and post-intervention and mean colony-forming units were determined for each group.

Results

Median percentage reduction was highest for the combination group (100%), followed by the ABHS group (94.29%) and lowest for the liquid soap (92.31%). This difference in the amount of colony-forming units (CFU) among all the groups was nonsignificant (p = 0.114).

Conclusion

The results of the study show that there was no significant difference in hand disinfection potential among hand sanitizer, liquid soap, or their combination. All the three interventions were equally effective with the reduction of total bacterial contamination from participants' hands.

How to cite this article

Khairnar MR, Anitha G, Dalvi TM, Kalghatgi S, Datar UV, Wadgave U, et al. Comparative Efficacy of Hand Disinfection Potential of Hand Sanitizer and Liquid Soap among Dental Students: A Randomized Controlled Trial. Indian J Crit Care Med 2020;24(5):336-339.

Antimicrobial properties of benzalkonium chloride derived polymerizable deep eutectic solvent

Benzalkonium chloride (BC) is a quaternary ammonium antimicrobial agent used in a variety of applications. In this work, BC was prepared into deep eutectic solvent (DES) with acrylic acid (AA) or methacrylic acid (MA). Within the newly prepared DES, BC is responsible for antimicrobial properties, while AA and MA are responsible for polymerization. Three types of microorganisms, E. coli (gram-negative bacilli), S. aureus (gram-positive cocci) and C. albicans (fungi), were assessed for antimicrobial properties through agar diffusion test. DES viscosity measurements and polymerizations were also conducted to assist the antimicrobial performance analysis. From this study, stronger antimicrobial effectiveness of BC-AA DES towards S. aureus and C. albicans was observed, while smaller inhibition zone widths were obtained for BC-AA DES polymer compared to BC-AA DES monomer which may due to the limited active component transportation after polymerization. When changing AA to MA, increased structural complexity and decreased linearity may limit the molecule movement thus reduce the inhibition zone width, which could be proved by the calculated activation energy results. Accurately determined eutectic ratio of DES is recommended to get optimized drug release control. This work offers a new sight for preparation of antimicrobial materials with stronger effectiveness and limited release.

Water supply, sanitation and hygiene interventions and childhood diarrhea in Kersa and Omo Nada districts of Jimma Zone, Ethiopia: a comparative cross-sectional study

BACKGROUND

Diarrhea is a major public health problem that disproportionately affects children in developing countries, including Ethiopia. Most of the diseases can be prevented through safe drinking water supply and provision of basic sanitation and hygiene. However, there is a paucity of information on childhood diarrhea related to interventions in kebeles (smallest administrative structure) where community-led total sanitation (CLTS) implemented and not implemented (non-CLTS). Thus, the aim of this study was to assess and compare the association of water supply, sanitation and hygiene interventions, and childhood diarrhea in CLTS implemented and non-implemented kebeles.

METHOD

A comparative cross-sectional study was conducted in Kersa and Omo Nada districts of Jimma Zone, Ethiopia from July 22 to August 9, 2018. Systematically selected 756 households with under-5 children were included in the study. Data were collected through interview using structured questionnaires. Water samples were collected in nonreactive borosilicate glass bottles. The binary logistic regression model was used; variables with a p value < 0.05 were considered as significantly associated with childhood diarrhea.

RESULTS

The prevalence of childhood diarrhea in the past 2 weeks was 17.7% (95% CI: 13.9-21.5) in CLTS kebeles and 22.0% (95% CI: 17.8-26.2) in non-CLTS kebeles. The occurrence of childhood diarrhea, increased among children whose families did not treat drinking water at home compared to those who treated in both CLTS (AOR = 2.35; 95% CI: 1.02-05.98) and non-CLTS (AOR = 1.98; 95% CI: 0.82-4.78) kebeles. About 96% of households in CLTS and 91% of households in non-CLTS kebeles had pit latrine with and without superstructure. Children from families that used water and soap to wash their hands were 76% less likely to have diarrhea in CLTS kebeles (AOR = 0.76; 95% CI: 0.31-1.88) and 54% less likely to have diarrhea in non-CLTS kebeles (AOR = 0.54; 95% CI: 0.17-1.72) when compared to children from families who used only water. The odds of having diarrhea was 1.63 times higher among children whose families live in CLTS non-implemented kebeles compared to those children whose families live in CLTS implemented kebeles (AOR = 1.63; 95% CI: 0.98-2.68).

CONCLUSIONS

No significant difference was observed in the prevalence of childhood diarrhea between CLTS and non-CLTS kebeles.

Barrier damaging effects of n-propanol in occlusion-modified tandem repeated irritation test: Modulation by exposure factors and atopic skin disease

BACKGROUND

Recent studies provide evidence for significant and previously underestimated barrier damaging effects of repeated exposure to 60% n-propanol in healthy skin in vivo.

OBJECTIVES

To investigate further the cumulative effects of a range of n-propanol concentrations relevant at the workplace in healthy and atopic dermatitis (AD) individuals, and study the modulation of the outcomes by co-exposure and host-related factors.

METHODS

Healthy adult and AD volunteers were exposed to n-propanol concentrations from 30% to 75% in occlusion-modified tandem repeated irritation test with measurements of erythema, transepidermal water loss, capacitance, and the natural moisturizing factor (NMF) levels at baseline and after 96 hours.

RESULTS

n-Propanol exerted significant barrier damaging effects even at the lowest concentration in both groups. Exposure to all n-propanol concentrations significantly reduced the NMF levels. Preceding low-grade trauma by occlusion/water exposure reduced the skin irritation threshold in both groups. The differences in the severity of the barrier function impairment after exposure to the same concentrations under the same conditions between the AD and control groups were significant.

CONCLUSIONS

The negative effects of cumulative exposure to n-propanol in healthy and atopic skin shown in the study suggest the need for critical re-evaluation of its irritant properties in vivo.

Situations Leading to Reduced Effectiveness of Current Hand Hygiene against Infectious Mucus from Influenza Virus-Infected Patients

Both antiseptic hand rubbing (AHR) using ethanol-based disinfectants (EBDs) and antiseptic hand washing (AHW) are important means of infection control to prevent seasonal influenza A virus (IAV) outbreaks. However, previous reports suggest a reduced efficacy of ethanol disinfection against pathogens in mucus. We aimed to elucidate the situations and mechanisms underlying the reduced efficacy of EBDs against IAV in infectious mucus. We evaluated IAV inactivation and ethanol concentration change using IAV-infected patients' mucus (sputum). Additionally, AHR and AHW effectiveness against infectious mucus adhering to the hands and fingers was evaluated in 10 volunteers. Our clinical study showed that EBD effectiveness against IAV in mucus was extremely reduced compared to IAV in saline. IAV in mucus remained active despite 120 s of AHR; however, IAV in saline was completely inactivated within 30 s. Due to the low rate of diffusion/convection because of the physical properties of mucus as a hydrogel, the time required for the ethanol concentration to reach an IAV inactivation level and thus for EBDs to completely inactivate IAV was approximately eight times longer in mucus than in saline. On the other hand, AHR inactivated IAV in mucus within 30 s when the mucus dried completely because the hydrogel characteristics were lost. Additionally, AHW rapidly inactivated IAV. Until infectious mucus has completely dried, infectious IAV can remain on the hands and fingers, even after appropriate AHR using EBD, thereby increasing the risk of IAV transmission. We clarified the ineffectiveness of EBD use against IAV in infectious mucus.IMPORTANCE Antiseptic hand rubbing (AHR) and antiseptic hand washing (AHW) are important to prevent the spread of influenza A virus (IAV). This study elucidated the situations/mechanisms underlying the reduced efficacy of AHR against infectious mucus derived from IAV-infected individuals and indicated the weaknesses of the current hand hygiene regimens. Due to the low rate of diffusion/convection because of the physical properties of mucus as a hydrogel, the efficacy of AHR using ethanol-based disinfectant against mucus is greatly reduced until infectious mucus adhering to the hands/fingers has completely dried. If there is insufficient time before treating the next patient (i.e., if the infectious mucus is not completely dry), medical staff should be aware that effectiveness of AHR is reduced. Since AHW is effective against both dry and nondry infectious mucus, AHW should be adopted to compensate for these weaknesses of AHR.

Bactericidal Activity of Ready-To-Use Alcohol-Based Commercial Wipes According to EN 16615 Carrier Standard

Background: The effectiveness of ready-to-use disinfectant wipes was previously assessed in standardized suspension tests, which were inadequate because they ignored that the wipes are rubbed against a surface. Thus, we assessed the effectiveness of commercially available disinfectant wipes impregnated with an alcoholic solution according to the 16615 standard, which includes a test with mechanical action. Methods: According to the EN 16615 standard, under clean conditions, four squares (5 cm × 5 cm), placed next to one another, were marked on a test surface. Enterococcus hirae, Pseudomonas aeruginosa, and Staphylococcus aureus were inoculated on the leftmost square, and a wipe impregnated with an alcoholic solution was placed to the left of that square. Then, the wipe was pressed with a 2.5 kg weight and moved to the right and back to the left. After contact times of 1, 5, 10, or 15 min, we measured the reduction in bacterial load. Results: Alcohol-based ready-to-use commercial wipes did not show sufficient bactericidal activity at the contact times of 1, 5, 10 and 15 min. Wipes containing propan-1-ol and a mixture of propan-1-ol and propan-2-ol were active against Pseudomonas aeruginosa at the contact times of 1 min and 15 min. None of the examined wipes were active against Enterococcus hirae or Staphylococcus aureus. Conclusion: Bactericidal parameters of ready-to-use disinfectant wipes should be determined in surface tests, in addition to suspension tests, because suspension tests do not simulate the conditions under which disinfectant wipes are used in practice.

Susceptibility of livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) to chlorhexidine digluconate, octenidine dihydrochloride, polyhexanide, PVP-iodine and triclosan in comparison to hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA): a standardized comparison

Background

Recent publications have raised concerns of reduced susceptibilities of clinical bacterial isolates towards biocides. This study presents a comparative investigation of the susceptibility of livestock-associated Methicillin-resistant Staphylococcus aureus (LA-MRSA), hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA) to the commonly used antiseptics chlorhexidine (CHX), octenidine (OCT), polyhexanide (PHMB), PVP-iodine (PVP-I) and triclosan (TCX) based on internationally accepted standards.

Methods

In total, 28 (18 LA-, 5 HA- and 5 CA) genetically characterized MRSA strains representing a broad spectrum of hosts, clonal complexes and spa-types, as well as the reference methicillin-sensitive Staphylococcus aureus (MSSA) strain ATCC 6538, were selected. Minimal inhibitory concentration (MIC) and minimal microbicidal concentration (MBC) were determined in accordance with DIN 58940-7, 58940-8 and DIN EN ISO 20776-1. The microbicidal efficacy was determined in accordance with DIN EN 1040.

Results

Results from the MIC/MBC and quantitative suspension tests revealed differences between antiseptic substances but not between epidemiological groups of MRSA strains. OCT and PHMB were the most active substances with a minimal MIC of 1 mg/L, followed by CHX (2 mg/L), TCX (32 mg/L) and finally PVP-I (1024 mg/L). The MSSA reference strain showed a tendency to a higher susceptibility compared to the MRSA strains.

Conclusions

This investigation of the susceptibility of a range of LA-, HA- and CA-MRSA strains using standardized conditions gave no indication that LA-MRSA strains are less susceptible to commonly used antiseptics compared to HA- and CA-MRSA strains.

Hand Hygiene Habits of Ghanaian Youths in Accra

The human palm has been identified as one of the richest habitats for human microbial accommodation making hand hygiene essential to primary prevention of infection. Since the hand is in constant contact with fomites which have been proven to be mostly contaminated, building hand hygiene habits is essential for the prevention of infection. This research was conducted to assess the hand hygiene habits of Ghanaian youths in Accra. This study used a survey as a quantitative method of research. The findings of the study revealed that out of the 254 participants who fully answered the questionnaire, 22% had the habit of washing their hands after outings while only 51.6% had the habit of washing their hands after using the bathroom. However, about 60% of the participants said they sometimes ate with their hands while 28.9% had the habit of eating with the hand very often, a situation that put them at risk of infection from their hands since some participants had poor handwashing habits; prompting the need for continuous education on hand hygiene.

Hand hygiene knowledge and attitude of medical students in western Saudi Arabia

Background

The practice of hand hygiene (HH) has prime importance among Health Care Professionals (HCPs) and non-compliance could cause adverse consequences. By keeping the importance of HH in mind, this study aims at investigating the knowledge and attitudes towards HH among medical students and interns at King Abdulaziz University (KAU), Jeddah, Saudi Arabia (SA).

Methods

The study includes 453 medical students and interns (189 males & 264 females). This study was completed in three months; from September to November 2017. The World Health Organization (WHO) HH questionnaire was used and data were analyzed on SPSS-21.

Results

Two-third of the participants 292 (64.2%) had formal training in HH in the last three years. Almost half of the participants 254 (56.1%) had correct knowledge regarding the major course of transmission of potentially detrimental microbes among patients in the healthcare premises. Just 124 (27.4%) of the respondents had the correct knowledge about the most common basis of germs accountable for healthcare-related infections. Females had significantly better knowledge than males regarding the type of HH technique needed before palpation of the abdomen (177(54%) Vs. 151(46%); P < 0.002), before an injection (175(54.5%) Vs. 146(45.5%); P < 0.007), after emptying a bedpan (207(64.7%) Vs. 113(35.3%); P < 0.001), following discarding examination gloves (256(60.4% Vs. 168(39.6%); P < 0.001] and after exposure to blood (200(64.1%) Vs. 112(35.%); P < 0.001). Female participants had better knowledge than males regarding the type of HH actions. Females also had a significantly better attitude towards the importance of HH than males (240(62.5%) Vs. 144(37.5%); P < 0.001).

Conclusion

The majority of the participants' knowledge regarding HH was not up to the mark; however, female students had better knowledge compared to male students. The medical students and interns' knowledge and positive attitude towards HH can play a pivotal role in preventing HCPs associated infections and it would overall decrease the infection-related burden on the hospital and governmental budgets. It is suggested that multi-dimensional plans are required to change this low compliance to a higher rate.

Remodeling of pSK1 Family Plasmids and Enhanced Chlorhexidine Tolerance in a Dominant Hospital Lineage of Methicillin-Resistant Staphylococcus aureus

Staphylococcus aureus is a significant human pathogen whose evolution and adaptation have been shaped in part by mobile genetic elements (MGEs), facilitating the global spread of extensive antimicrobial resistance. However, our understanding of the evolutionary dynamics surrounding MGEs, in particular, how changes in the structure of multidrug resistance (MDR) plasmids may influence important staphylococcal phenotypes, is incomplete. Here, we undertook a population and functional genomics study of 212 methicillin-resistant S. aureus (MRSA) sequence type 239 (ST239) isolates collected over 32 years to explore the evolution of the pSK1 family of MDR plasmids, illustrating how these plasmids have coevolved with and contributed to the successful adaptation of this persistent MRSA lineage. Using complete genomes and temporal phylogenomics, we reconstructed the evolution of the pSK1 family lineage from its emergence in the late 1970s and found that multiple structural variants have arisen. Plasmid maintenance and stability were linked to IS256- and IS257-mediated chromosomal integration and disruption of the plasmid replication machinery. Overlaying genomic comparisons with phenotypic susceptibility data for gentamicin, trimethoprim, and chlorhexidine, it appeared that pSK1 has contributed to enhanced resistance in ST239 MRSA isolates through two mechanisms: (i) acquisition of plasmid-borne resistance mechanisms increasing the rates of gentamicin resistance and reduced chlorhexidine susceptibility and (ii) changes in the plasmid configuration linked with further enhancement of chlorhexidine tolerance. While the exact mechanism of enhanced tolerance remains elusive, this research has uncovered a potential evolutionary response of ST239 MRSA to biocides, one of which may contribute to the ongoing persistence and adaptation of this lineage within health care institutions.

Microbial contamination of keyboards and electronic equipment of ICU (Intensive Care Units) in Kashan University of medical sciences and health service hospitals

Microbial contamination of computer keyboards and inanimate surfaces of electronic equipment in ICU (Intensive Care Units) can have a significant role for ICU-acquired colonization and a spectrum of nosocomial infections. The aim of this study was to survey the incidence of bacterial contamination and the distribution of species of computer keyboards and inanimate surfaces of bed side equipment in ICUs in Kashan University of medical sciences and health service hospitals. This descriptive, cross-sectional study was done on 75 computer keyboards and inanimate surfaces electronic equipment in 5 ICUs during 2016-2017. Samples were collected from computer keyboards and electronic equipment with normal saline rinsed swabs. Samples were Cultivated on Blood Agar (BA), and MacConkey Agar (MAC) and growing bacteria were identified based on their morphology and biochemical properties. Seventy six (76%) out of 75 computer Keyboards and electronic equipment were contaminated with bacteria and fungi. The most contamination pertained to gram positive bacteria (70.7%) and the most isolated bacteria were coagulase-negative staphylococci. The highest contamination rates were found on computer keyboards and electronic equipment of which were nurses. •This study demonstrates that monitoring inanimate surfaces and considering these surfaces as source of nosocomial infections is necessary.•In total, Seventy six (76%) out of 75 computer keyboards and electronic equipment in ICUs had positive culture.•It can be concluded that it is necessary for ICUs of Kashan university of medical sciences and Health service hospitals to have practical and regular program to reduce nosocomial infections.

Safely Managed Hygiene: A Risk-Based Assessment of Handwashing Water Quality

Sustainable Development Goal (SDG) Indicator 6.2.1 requires household handwashing facilities to have soap and water, but there are no guidelines for handwashing water quality. In contrast, drinking water quality guidelines are defined: water must be "free from contamination" to be defined as "safely managed" (SDG Indicator 6.1.1). We modeled the hypothesized mechanism of infection due to contaminated handwashing water to inform risk-based guidelines for microbial quality of handwashing water. We defined two scenarios that should not occur: (1) if handwashing caused fecal contamination, indicated using Escherichia coli, on a person's hands to increase rather than decrease and (2) if hand-to-mouth contacts following handwashing caused an infection risk greater than an acceptable threshold. We found water containing <1000 E. coli colony-forming units (CFU) per 100 mL removes E. coli from hands with>99.9% probability. However, for the annual probability of infection to be <1:1000, handwashing water must contain <2 × 10^-6 focus-forming units of rotavirus, <1 × 10^-4 CFU of Vibrio cholerae, and <9 × 10^-6 Cryptosporidium oocysts per 100 mL. Our model suggests that handwashing with nonpotable water will generally reduce fecal contamination on hands but may be unable to lower the annual probability of infection risks from hand-to-mouth contacts below 1:1000.

The neglected element of hand hygiene - significance of hand drying, efficiency of different methods and clinical implication: A review

Hand hygiene is a fundamental strategy for controlling the spread of infection. Careful hand drying is integral to the process of hand hygiene, which aims to optimise the removal of potentially pathogenic microorganisms. Ineffective hand drying results in wet hands that are an infection risk increasing the potential for cross-infection, occupational contact dermatitis for healthcare practitioners, harm to patients and environmental contamination. Evidence indicates that there has been limited research regarding the significance of hand drying and the efficacy and clinical impact of different drying methods. The purpose of this review paper was to scope and evaluate the existing literature pertaining to hand drying; to examine the clinical consequences associated with wet hands for patients, healthcare practitioners and the clinical environment; to assess the efficacy of different drying methods; to consider the impact on patient safety; and to progress the research, debate and practice relating to hand drying. The methodological framework applied in this review was that of Arksey and O'Malley (2007). Twenty-one papers identified from 112 abstracts screened were included in the review. Analysis identified three primary themes emerging from the literature: (1) efficacy of hand drying methods; (2) drying method and microbial translocation, dispersion and environmental contamination; and (3) drying methods and environmental sustainability. This review highlights the equal importance of hand drying in the process of hand hygiene and suggests that the efficacy of hand drying is a critical factor in the prevention of the transfer of microorganisms to the environment, and from person to person following hand washing. In conclusion, this paper argues that greater attention needs to be given to hand drying in terms of practice, policy and research and its importance in clinical settings given greater focus.

Antimicrobial Resistance in Listeria Species

For nearly a century the use of antibiotics to treat infectious diseases has benefited human and animal health. In recent years there has been an increase in the emergence of antibiotic-resistant bacteria, in part attributed to the overuse of compounds in clinical and farming settings. The genus Listeria currently comprises 17 recognized species found throughout the environment. Listeria monocytogenes is the etiological agent of listeriosis in humans and many vertebrate species, including birds, whereas Listeria ivanovii causes infections mainly in ruminants. L. monocytogenes is the third-most-common cause of death from food poisoning in humans, and infection occurs in at-risk groups, including pregnant women, newborns, the elderly, and immunocompromised individuals.

Hand hygiene: An educational intervention targeting grass root level

BACKGROUND

Hands are the most common vehicle for the transmission of pathogens within the healthcare environment. Hand hygiene is the leading measure for reducing healthcare-associated infections (HCAIs) and preventing the spread of antimicrobial resistance.

OBJECTIVE

An interventional study was carried out to evaluate the knowledge, attitude and practices of hand hygiene among third semester medical students.

MATERIALS AND METHODS

A total of 152 medical students were evaluated using a pretest self-structured questionnaire to assess the knowledge, attitude and practices regarding hand hygiene. The students were trained by faculty of microbiology vigorously with the help of a lecture and demonstration on hand hygiene followed by hands-on training. The same group of students were then distributed the post-training questionnaire. The pre-training and post training data was analyzed and compared.

RESULT

There was a significant improvement in knowledge, attitude and practice towards hand hygiene among students after intervention, as seen on comparison of results of post-test questionnaire from its pre-test counter-part because the doubts in the mind of the students got cleared in the education sessions.

CONCLUSION

Targeting medical students and teaching them the good standard practices was fruitful as they were young, easy to mold and enthusiastic and above all they are the future doctors. Such educational intervention regarding hand hygiene will be carried out for each batch of medical students in future.

An assay for determining the susceptibility of Salmonella isolates to commercial and household biocides

Poultry and meat products contaminated with Salmonella enterica are a major cause of foodborne illness in the United States. The food industries use a wide variety of antimicrobial interventions to reduce bacterial contamination. However, little is known about Salmonella susceptibility to these compounds and some studies have shown a concerning link between biocide resistance and antibiotic resistance. To investigate this, a 96 well panel of 17 common household and commercially used biocides was designed to determine the minimum inhibitory concentrations (MIC) of these compounds for Salmonella. The panel contained two-fold serial dilutions of chemicals including Dodecyltrimethylammonium chloride (DC), Benzalkonium chloride (BKC), Cetylpyridinium chloride (CPC), Hexadecyltrimethylammonium bromide (HB), Hexadecyltrimethylammonium chloride (HC), Acetic acid (AA), Lactic acid (LA), Citric acid (CA), Peroxyacetic acid (PXA), Acidified sodium chlorite (ASC), Sodium hypochlorite (SHB), 1,3 dibromo, 5,5 dimethylhydantoin (DBH), Chlorhexidine (CHX), Sodium metasilicate (SM), Trisodium phosphate (TSP), Arsenite (ARI), and Arsenate (ARA). The assay was used to test the susceptibility of 88 multidrug resistant (MDR) Salmonella isolates from animal sources. Bacteria are defined as multidrug resistant (MDR) if it exhibited non-susceptibility to at least one agent in three or more antimicrobial categories. The concentration of biocide at which ≥50% of the isolates could not grow was designated as the minimum inhibitory concentration or MIC50 and was used as the breakpoint in this study. The MIC50 (μg ml-1) for the tested MDR Salmonella was 256 for DC, 40 for BKC, 80 for CPC. HB and HC, 1,640 for AA, 5664 for LA, 3,156 for CA, 880 for PXA, 320 for ASC, 3.0 for CHX, 1,248 for DBH, 3,152 (6%) for SHB, 60,320 for SM, 37,712 for TSP, 56 for ARI and 832 for ARA. A few isolates were not susceptible at the MIC50 breakpoint to some chemicals indicating possible resistance. Isolates with MICs of two 2-fold dilutions above the MIC50 were considered resistant. Biocides for which resistant isolates were detected included CPC (n = 1 isolate), HB (1), CA (18), ASC (7), CHX (22), ARA (16), and ARI (4). There was no correlation detected between the biocide susceptibility of Salmonella isolates and antibiotic resistance. This assay can determine the MICs of bacteria to 17 biocides in a single test and will be useful in evaluating the efficacy of biocides and to detect the development of resistance to them.

An assessment of hand hygiene perception and practices among undergraduate nursing students in Lagos State: A pilot study

BACKGROUND

The contaminated hands of health-care professionals (HCPs) is an implicated vector in the transmission of potentially pathogenic organisms to vulnerable patients. The aim of this study was to derive baseline data on hand hygiene (HH) practices among a cohort of students at the Lagos State School of Nursing and to determine their perception about the adequacy of instructions they receive.

MATERIALS AND METHODS

A descriptive, cross-sectional study was conducted on a probability random sample of 69 nursing students at the Lagos State School of Nursing at the Alimosho Igando General Hospital. The knowledge, attitude, and practice as well as the perception of the respondents on the adequacy of their infection control instructions were obtained using an interviewer-administered questionnaire. Data entry and analysis were done using SPSS software version 20 (IBM Corp., Armonk, NY, USA), P < 0.05 was considered statistically significant. Multivariate linear and logistic regressions were done to assess which factors were truly significant predictors, with odds ratios (ORs) and 95% confidence intervals (CIs) specified as the measures of association between predictors and outcome variables.

RESULTS

Majority of participants were ≤20 years old (50.7%, n = 35) and were in their second year of study (44.9%, n = 31). Participants were least knowledgeable about the importance of discarding gloves and not washing or reusing them (16 [23.1%]). The mean score on the Hand Hygiene Beliefs Scale was 86.2 ± 9.0, with scores ranging from 23 to 88 out of a possible high score of 115. The most positive health beliefs were associated with being a role model for HH (3.57 ± 0.52), while the worst was associated with imitating bad HH practices performed by senior colleagues (1.29 ± 1.20). Caring for a wound (60 [87.0%]) was most associated with the need for HH, while demonstration and clinical practice were rated as the most effective teaching methods. Results of the multivariate logistic regression analysis, with the outcome variable of good self-reported HH practices, revealed that the odds of appropriate behavior were higher if the student nurses were in their third year of study (OR = 1.59; 95% CI: 1.01-2.45). An appropriate behavior was also more likely in student nurses with a higher risk perception (OR = 1.54; 95% CI: 1.03-2.51).

CONCLUSION

Despite the overwhelming evidence that HH is effective in the prevention of hospital-acquired infections, its performance among HCPs remains far less than optimal. Since students will someday be influencing future HH compliance behaviors of other health-care workers, the importance of HH should be adequately incorporated into their school curriculum.

Are the Hands of Veterinary Staff a Reservoir for Antimicrobial-Resistant Bacteria? A Randomized Study to Evaluate Two Hand Hygiene Rubs in a Veterinary Hospital

Hand hygiene (HH) is the most successful intervention for hospital infection control. HH rubs with residual action are desired. This study aimed to compare the efficacy of alcohol (A-HH) and lactic acid (LA-HH) rubs, with the latter being marketed as having residual activity. We investigated reductions in bacterial colony-forming units (CFUs), prevalence of antimicrobial-resistant (AMR) organisms, and risk factors for increased counts on the hands of veterinary staff. A randomized, crossover study (53 individuals) was performed in a referral veterinary teaching hospital. Hand plates were taken before, immediately after, and 6 hours after HH. A blinded investigator counted CFUs per plate. Methicillin-resistant Staphylococcus aureus/pseudintermedius (MRSA/MRSP), Enterobacteriaceae, and Pseudomonas species (spp.) were characterized. Gender, profession, time point, and HH product were included as variables within multivariable analyses. A significant reduction in bacterial CFU was seen immediately after A-HH rub application (p < 0.001); however, neither product showed any significant residual action. Veterinarians had higher bacterial CFUs than nurses (p = 0.005); contact with patients, rather than the environment, was also associated with higher counts (p < 0.001). MRSA, MRSP, Enterobacteriaceae spp., and Pseudomonas spp. were detected on 7%, 2%, 14%, and 2% of study participant's hands (n = 208 samples), respectively. Frequent HH administration using an A-HH rub was effective at reducing bacterial CFU on hands in vivo in this veterinary hospital setting, but its use needs further encouragement in veterinary staff. The high prevalence of antimicrobial bacteria on hands is of concern; they might act as reservoirs for patients, the environment, and in-contact people.

Children Are Exposed to Fecal Contamination via Multiple Interconnected Pathways: A Network Model for Exposure Assessment

In recent decades, quantitative microbial risk assessment (QMRA) has been widely used to assess exposure to fecal microbes and associated health risks. In this study, a multipathway exposure assessment model was developed to evaluate exposure to fecal microbes for children under 5 in highly contaminated urban environments. Children had contact with various environmental compartments. The contamination levels of these compartments were estimated from fecal indicator counts in the environmental samples. Structured observations of child behavior (including activities, locations, and time) were used to model behavioral sequences as a dynamic network. The exposure model combines behavior sequences with environmental contamination, using additional exposure factors when needed, to estimate the number of fecal microbes transferred from environmental sources to human oral ingestion. As fecal exposure in a highly contaminated urban environment consists of contributions from multiple pathways, it is imperative to study their relative importance. The model helps us better understand the characteristics of the exposure pathways that may be driven by variation in contamination and by variable behavior, like hygiene and high-risk activities. Importantly, the model also allows prediction of the quantitative effects of an intervention-the expected reduction in exposure due to infrastructural or behavioral changes-by means of scenario studies. Based on experience with this exposure model, we make specific recommendations for additional studies of child behavior and exposure factors in order to fill critical information gaps and improve the model structure and assumptions.

Effectiveness of a Hand Hygiene Program at Child Care Centers: A Cluster Randomized Trial

OBJECTIVES

Respiratory infections (RIs) are an important cause of morbidity and excessive antibiotic prescriptions in children attending day care centers (DCCs). We aimed to assess the effectiveness of an educational and hand hygiene program in DCCs and homes in reducing RI incidence and antibiotic prescriptions in children.

METHODS

A cluster, randomized, controlled, and open study of 911 children aged 0 to 3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up. Two intervention groups of DCC families performed educational and hand hygiene measures, 1 with soap and water (SWG; n = 274), another with hand sanitizer (HSG; n = 339), and the control group (CG; n = 298) followed usual hand-washing procedures. RI episode rates were compared through multilevel Poisson regression models. The percentage of days missed were compared with Poisson exact tests.

RESULTS

There were 5211 RI episodes registered. Children in the HSG had less risk of RI episodes (incidence rate ratio [IRR]: 0.77; 95% confidence interval [CI]: 0.68-0.88) and antibiotic prescriptions (IRR: 0.69; 95% CI: 0.57-0.84) compared with the those in the CG. Children in the SWG had a higher risk of RI episodes (IRR: 1.21; 95% CI: 1.06-1.39) and antibiotic prescriptions (IRR: 1.31; 95% CI: 1.08-1.56) than those in the HSG. Pupils missed 5186 DCC days because of RIs, and the percentage of days absent was significantly lower in the HSG compared with the CG (P < .001) and the SWG (P < .001).

CONCLUSIONS

Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents, reduce absent days, RIs, and antibiotic prescriptions for these infections in children at DCCs.

Bacterial and Parasitic Assessment from Fingernails in Debre Markos, Northwest Ethiopia

BACKGROUND

Food handlers with untrimmed finger nails could contribute or serve as a vehicle for the transmission of food poisoning pathogens.

OBJECTIVES

This study was conducted to determine the prevalence of bacteria and intestinal parasites among food handlers and antibiotic susceptibility profile of the isolated bacteria in Debre Markos University, Ethiopia.

MATERIALS AND METHODS

This laboratory-based cross-sectional study involved 220 food handlers working in food service establishments in Debre Markos University between 1st January 2015 to 31th June 2016. Subjects' finger nail specimens of both hands were examined microscopically for intestinal parasites. For bacterial isolation, samples were cultured and bacterial species were identified following standard laboratory procedures. Antimicrobial susceptibility test was performed for all bacterial isolates by using Kirby-Bauer disk diffusion method.

RESULTS

Of the total 220 subjects examined, 29.5% showed positive culture for different bacterial species from their fingernail contents. Coagulase-negative Staphylococcus was the predominant bacteria species (12.3%) followed by Staphylococcus aureus (5%), E. coli (2.7%), Klebsiella species (2.7%), Enterococcus species (1.8%), Pseudomonas aeruginosa (1.8%), Proteus species (1.4%), Citrobacter species (1.4%), and Serratia species (0.9%). None of the food handlers showed positive culture for Shigella and salmonella and parasites in respect of their finger nail specimens. Isolation of bacteria in finger nail has significant association with finger nail status (P=0.044) and inverse relation with service years (P=0.048). All Staphylococcus aureus and coagulase-negative Staphylococcus species isolates were uniformly susceptible to vancomycin. Only one (9.1%) of Staphylococcus aureus isolates was resistant for methicillin.

CONCLUSION

To prevent the food poisoning pathogens, implementation and adherence to infection are the key practices, specially food handlers with long finger nail harbor food debris, microbial contaminations, and allergens.

Wettability of hands during 15-second and 30-second handrub time intervals: A prospective, randomized crossover study

OBJECTIVE

At present, the shortest recommended application time of alcoholic handrubs is an application interval of 30 seconds. However, application times shorter than 30 seconds are regularly practiced. Therefore, the aim of this study was to investigate whether a 15-second application time achieves a comparable wettability of hands to a 30-second handrub application.

SETTING

The wettability of 20 healthy volunteers' hands was compared after 15 seconds or 30 seconds of application time of an ultraviolet-light-active handrub, both before and after training in the application technique. Images of the ventral side and dorsal side of the hands were evaluated by computer software. Both groups' outcomes were analyzed with regard to the spread of the handrub on hands.

RESULTS

There was no difference between the wetted areas of the hands after 15 seconds or 30 seconds of handrub application. A significant difference was observed between the wetted areas of hands in trained volunteers compared with untrained volunteers, irrespective of application time.

CONCLUSION

Based on our results, a 15-second application time is equal to 30-second application time in terms of wettability of hands. The improvement of wettability after training underlines the necessity to instruct new and untrained health care workers in hand antisepsis. Using fluorescent handrubs may be a feasible method to control and retrain hand hygiene techniques of long-time employees.

Bactericidal and Virucidal Activity of Povidone-Iodine and Chlorhexidine Gluconate Cleansers in an In Vivo Hand Hygiene Clinical Simulation Study

Introduction

Standard in vitro and in vivo tests help demonstrate efficacy of hand hygiene products; however, there is no standard in vivo test method for viruses. We investigated the bactericidal and virucidal efficacy of povidone-iodine (PVP-I) 7.5% scalp and skin cleanser, chlorhexidine gluconate (CHG) 4% hand cleanser and the reference hand wash (soft soap) in 15 healthy volunteers following European Standard EN1499 (hygienic hand wash test method for bacteria), which was adapted for virucidal testing.

Methods

Separate test series were performed for bactericidal (Escherichia coli) and virucidal [murine norovirus (MNV)] testing. After pre-washing and artificial contamination of hands with test organisms, volunteers underwent testing with 3 and 5 mL of each product for contact times of 15, 30 and 60 s according to a Latin-square randomization. The number of test organisms released from fingertips into sampling fluids was assessed before and after hand washing and mean log₁₀ reduction factor (RF) was calculated. RFs (test-reference) were compared using a Wilcoxon–Wilcox multiple comparisons test per EN1499; efficacy was concluded if p ≤ 0.01.

Results

PVP-I 7.5% and CHG 4% cleansers both passed EN1499 requirements against E. coli, with statistically significantly greater (p ≤ 0.01) mean log₁₀ RFs compared with reference soft soap across all tests (PVP-I: 4.09–5.27; CHG: 4.12–5.22; soap: 2.75–3.11). The experimental design using EN1499 was applicable to testing with MNV as discriminatory and reproducible results were generated. Mean log₁₀ RFs of MNV were statistically significantly greater for PVP-I (1.57–2.57) compared with soft soap (1.24–1.62), while mean log₁₀ RFs with CHG (0.90–1.34) were lower than for soft soap across all tests.

Conclusion

PVP-I 7.5% cleanser showed superior efficacy against MNV compared to soft soap and CHG 4% cleanser, while both PVP-I and CHG were superior to soft soap against E. coli. The experimental set-up may be applicable to future testing for antiviral hand washes.

Funding

Mundipharma Manufacturing Pte Ltd.

Plain Language Summary

Plain language summary available for this article.

Antiseptic Agents Elicit Short-Term, Personalized, and Body Site-Specific Shifts in Resident Skin Bacterial Communities

Despite critical functions in cutaneous health and disease, it is unclear how resident skin microbial communities are altered by topical antimicrobial interventions commonly used in personal and clinical settings. Here we show that acute exposure to antiseptic treatments elicits rapid but short-term depletion of microbial community diversity and membership. Thirteen subjects were enrolled in a longitudinal treatment study to analyze the effects of topical treatments (i.e., ethanol, povidone-iodine, chlorhexidine, and water) on the skin microbiome at two skin sites of disparate microenvironment: forearm and back. Treatment effects were highly dependent on personalized and body site-specific colonization signatures, which concealed community dynamics at the population level when not accounted for in this analysis. The magnitude of disruption was influenced by the identity and abundance of particular bacterial inhabitants. Lowly abundant members of the skin microbiota were more likely to be displaced, and subsequently replaced, by the most abundant taxa prior to treatment. Members of the skin commensal family Propionibactericeae were particularly resilient to treatment, suggesting a distinct competitive advantage in the face of disturbance. These results provide insight into the stability and resilience of the skin microbiome, while establishing the impact of topical antiseptic treatment on skin bacterial dynamics and community ecology.

Cholera outbreak in a naïve rural community in Northern Nigeria: the importance of hand washing with soap, September 2010

INTRODUCTION

Cholera outbreaks in rural communities are associated with high morbidity and mortality. Effective interventions to control these outbreaks require identification of source and risk factors for infection. In September, 2010 we investigated a cholera outbreak in Bashuri, a cholera naïve rural community in northern Nigeria to identify the risk factors and institute control measures.

METHODS

We conducted an unmatched case-control study. We defined a case as any resident of Bashuri community two years and above with acute watery diarrhea with or without vomiting and a control as any resident two years and above without acute watery diarrhea and vomiting. We recruited 80 hospital-based cases and 80 neighborhood controls. We collected and analyzed data on demographic characteristics, clinical information and risk factors. Laboratory analysis was performed on 10 stool samples and 14 open-well samples.

RESULTS

Mean age was 29 years (± 20 years) for cases and 32 years (± 16 years) for controls; 38 (47.5%) of cases and 60 (75%) of controls were males. Compared to controls, cases were less likely to have washed hands with soap before eating (age-adjusted odds ratio (AAOR) = 0.27, 95% confidence interval (CI): 0.10-0.72) and less likely to have washed hands with soap after using the toilet (AAOR = 0.34, 95% CI: 0.15-0.75). Vibrio cholerae O1 was isolated from six stool samples but not from any open-well samples.

CONCLUSION

Unhygienic hand washing practices was the key risk factor in this outbreak. We educated the community on personal hygiene focusing on the importance of hand washing with soap.

Surveillance of bacterial colonisation on contact surfaces in different medical wards

This study was conducted to determine the bacterial colonization of some bacterial groups, including extended-spectrum β-lactamase (ESBLs) producers and methicillin-resistant Staphylococcus aureus (MRSA), on surfaces of the equipment and instruments in patient rooms and other workspaces in three different medical wards. The number of microorganisms on swabs was determined with the colony count method on selective microbiological mediums. The aerobic mesophylic microorganisms were found in 73.5 % out of 102 samples, with the average and maximum values of 2.6 × 102 and 4.6 × 103 colony forming units (CFU) 100 cm-2, respectively. Members of the family Enterobacteriaceae, coagulase positive staphylococci, coagulase-negative staphylococci, and enterococci were detected in 23.4, 31.4, 53.2, and 2.9 % of samples, respectively. The differences in bacterial counts on the surfaces of the psychiatric, oncology, and paediatric wards were statistically significant (P<0.001). About 40 % out of 19 isolates from the family Enterobacteriaceae showed multiple resistance to three or more different groups of tested antibiotics, while ESBL was confirmed for only one strain. Staphylococci isolates were mostly resistant to penicillin. MRSA was confirmed in 5.2 % of the tested S. aureus isolates. Greater attention should be paid to cleaning and the appropriate choice of disinfectants, especially in the psychiatric ward. Employees should be informed about the prevention of the spreading of nosocomial infections. Routine application of rapid methods for hygiene control of surfaces is highly recommended.

Role of Hand Hygiene Ambassador and Implementation of Directly Observed Hand Hygiene Among Residents in Residential Care Homes for the Elderly in Hong Kong

OBJECTIVEMultidrug-resistant organisms (MDROs) are increasingly reported in residential care homes for the elderly (RCHEs). We assessed whether implementation of directly observed hand hygiene (DOHH) by hand hygiene ambassadors can reduce environmental contamination with MDROs.METHODSFrom July to August 2017, a cluster-randomized controlled study was conducted at 10 RCHEs (5 intervention versus 5 nonintervention controls), where DOHH was performed at two-hourly intervals during daytime, before meals and medication rounds by a one trained nurse in each intervention RCHE. Environmental contamination by MRDOs, such as methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum β-lactamse (ESBL)-producing Enterobacteriaceae, was evaluated using specimens collected from communal areas at baseline, then twice weekly. The volume of alcohol-based hand rub (ABHR) consumed per resident per week was measured.RESULTSThe overall environmental contamination of communal areas was culture-positive for MRSA in 33 of 100 specimens (33%), CRA in 26 of 100 specimens (26%), and ESBL-producing Enterobacteriaceae in 3 of 100 specimens (3%) in intervention and nonintervention RCHEs at baseline. Serial monitoring of environmental specimens revealed a significant reduction in MRSA (79 of 600 [13.2%] vs 197 of 600 [32.8%]; P<.001) and CRA (56 of 600 [9.3%] vs 94 of 600 [15.7%]; P=.001) contamination in the intervention arm compared with the nonintervention arm during the study period. The volume of ABHR consumed per resident per week was 3 times higher in the intervention arm compared with the baseline (59.3±12.9 mL vs 19.7±12.6 mL; P<.001) and was significantly higher than the nonintervention arm (59.3±12.9 mL vs 23.3±17.2 mL; P=.006).CONCLUSIONSThe direct observation of hand hygiene of residents could reduce environmental contamination by MDROs in RCHEs.Infect Control Hosp Epidemiol 2018;39:571-577.

Evaluating the Sporicidal Activity of Disinfectants against Clostridium difficile and Bacillus amyloliquefaciens Spores by Using the Improved Methods Based on ASTM E2197-11

Spore-forming pathogenic bacteria, such as Clostridium difficile, are associated with nosocomial infection, leading to the increased use of sporicidal disinfectants, which impacts socioeconomic costs. However, C. difficile can be prevented using microorganisms such as Bacillus amyloliquefaciens, a prophylactic agent that has been proven to be effective against it in recent tests or it can be controlled by sporicidal disinfectants. These disinfectants against spores should be evaluated according to a known and recommended standard. Unfortunately, some newly manufactured disinfectants like Bioxy products have not yet been tested. ASTM E2197-11 is a standard test that uses stainless steel disks (1 cm in diameter) as carriers, and the performance of the test formulation is calculated by comparing the number of viable test organisms to that on the control carriers. Surface tests are preferable for evaluating disinfectants with sporicidal effects on hard surfaces. This study applies improved methods, based on the ASTM E2197-11 standard, for evaluating and comparing the sporicidal efficacies of several disinfectants against spores of C. difficile and B. amyloliquefaciens, which are used as the test organisms. With the improved method, all spores were recovered through vortexing and membrane filtration. The results show that chlorine-based products are effective in 5 min and Bioxy products at 5% w/v are effective in 10 min. Although Bioxy products may take longer to prove their effectiveness, their non-harmful effects to hospital surfaces and people have been well established in the literature.

Prevalence and Source of Fecal and Oral Bacteria on Infant, Child, and Adult Hands

Bacteria live all around us, and we are constantly exposed to them during our everyday lives. Modern standards of hygiene aim to limit exposure to fecal bacteria, and yet bacteria rapidly colonize the gut in early life and following antibacterial treatment. Exposures to fecal and oral microbes provide risk of disease, but are also necessary since commensal microbes play important roles in health. This work establishes that bacteria of both fecal and oral origins are commonly found on hands. It also establishes that the uniqueness of fecal and oral bacterial communities across people can allow for determination of the likely individual from whom the fecal and oral bacteria came. These techniques allow for understanding the hands as a vector for microbial transmission within families and across populations, which has important implications for public health.

Modern hygienic practices are applied to avoid exposure to pathogens that spread via fecal-oral transmission. Despite this, the gastrointestinal tract is quickly colonized by fecal microbes. The hands are an important vector for the transmission of microbes, but the frequency at which fecal and oral microbes exist on hands and the source of those microbes have not been extensively described. Using data from a previous study that characterized the fecal, oral, and skin microbiota from 73 families, we found a significant incidence of fecal and oral microbes on hands. Of palms, 48.9% had fecal signal and 67.2% had oral signal. Fecal, oral, and forehead microbes were tracked to family members and an individual’s own palms far more often than to unrelated individuals and showed relationships with age, gender, and parental status. For instance, oral microbes that were specifically sourced to the same individual (oneself) were most common on infant palms; mothers had more infant-child-sourced and oral-sourced microbes on their palms than nonparents. Fecal microbes on palms more often sourced to members of the family than unrelated individuals, but more often to other members of the family than oneself. This study supports that the hands are an important vector for the transfer of fecal and oral microbes within families.

IMPORTANCE Bacteria live all around us, and we are constantly exposed to them during our everyday lives. Modern standards of hygiene aim to limit exposure to fecal bacteria, and yet bacteria rapidly colonize the gut in early life and following antibacterial treatment. Exposures to fecal and oral microbes provide risk of disease, but are also necessary since commensal microbes play important roles in health. This work establishes that bacteria of both fecal and oral origins are commonly found on hands. It also establishes that the uniqueness of fecal and oral bacterial communities across people can allow for determination of the likely individual from whom the fecal and oral bacteria came. These techniques allow for understanding the hands as a vector for microbial transmission within families and across populations, which has important implications for public health.

Hand Hygiene and Tuberculosis Risk in Korea: An Ecological Association

Hand hygiene is a basic but effective strategy against infectious disease. This study investigated an ecological association between hand hygiene and tuberculosis (TB) risk in Korea. Hand hygiene data were obtained from the 2015 Community Health Survey. Information on TB incidence and mortality in 2015 were obtained from the National Infectious Diseases Surveillance System and death monitoring database, respectively. In multiple linear regression analysis, frequent hand washing rates after using the restroom (B = -0.78, P = .037), after returning from the outdoors (B = -0.28, P = .049), and with soap or hand sanitizer (B = -0.54, P = .018) were negatively associated with TB incidence. TB mortality were associated with frequent hand washing rates after returning from the outdoors (B = -0.05, P = .035), and with soap or hand sanitizer (B = -0.10, P = .010), respectively. Hand washing was associated with lower TB incidence and mortality at the community level. These results could contribute to develop community-based health promotion strategies.

Evaluation of green tea extract as a safe personal hygiene against viral infections

Background

Viral infections often pose tremendous public health concerns as well as economic burdens. Despite the availability of vaccines or antiviral drugs, personal hygiene is considered as effective means as the first-hand measure against viral infections. The green tea catechins, in particular, epigallocatechin-3-gallate (EGCG), are known to exert potent antiviral activity. In this study, we evaluated the green tea extract as a safe personal hygiene against viral infections.

Results

Using the influenza virus A/Puerto Rico/8/34 (H1N1) as a model, we examined the duration of the viral inactivating activity of green tea extract (GTE) under prolonged storage at various temperature conditions. Even after the storage for 56 days at different temperatures, 0.1% GTE completely inactivated 10⁶ PFU of the virus (6 log₁₀ reduction), and 0.01% and 0.05% GTE resulted in 2 log₁₀ reduction of the viral titers. When supplemented with 2% citric acid, 0.1% sodium benzoate, and 0.2% ascorbic acid as anti-oxidant, the inactivating activity of GTE was temporarily compromised during earlier times of storage. However, the antiviral activity of the GTE was steadily recovered up to similar levels with those of the same concentrations of GTE without the supplements, effectively prolonging the duration of the virucidal function over extended period. Cryo-EM and DLS analyses showed a slight increase in the overall size of virus particles by GTE treatment. The results suggest that the virucidal activity of GTE is mediated by oxidative crosslinking of catechins to the viral proteins and the change of physical properties of viral membranes.

Conclusions

The durability of antiviral effects of GTE was examined as solution type and powder types over extended periods at various temperature conditions using human influenza A/H1N1 virus. GTE with supplements demonstrated potent viral inactivating activity, resulting in greater than 4 log₁₀ reduction of viral titers even after storage for up to two months at a wide range of temperatures. These data suggest that GTE-based antiviral agents could be formulated as a safe and environmentally friendly personal hygiene against viral infections.

Anti-staphylococcal biofilm activity of miconazoctylium bromide

Alkylmiconazolium salts possess a high potency to disrupt bacterial biofilms.

Impact of Educational Intervention for Hand Hygiene on Dental Students' Knowledge, Attitude, and Bacterial Contamination Level on Hands

AIM

The present study aimed to investigate the impact of the educational intervention for hand hygiene (HH) on knowledge, attitude, and mean colony-forming bacterial counts and type of bacteria on hands of undergraduate dental students.

MATERIALS AND METHODS

A total of 86 dental students from different clinical grades were included in the study. They were divided into two groups, group I (55 students) received onetime educational session for HH at the start of the academic year and group II (31 students) received an extra reenforce-ment session 6 months later. After 2 weeks of reenforcement session, a self-administrated questionnaire was directed to all participants assessing their knowledge and attitude about HH. Fingertip prints of the five fingers of the dominant hand from every participant were pressed onto blood agar plates in triplets at the same clinical session, before and after HH. Bacterial colony-forming units (CFUs) on each plate were recorded and identified microbiologically.

RESULTS

The overall scores of knowledge and attitude showed higher levels in group II than in group I with nonsignificant differences between both groups as regards knowledge and significant differences (p < 0.05) as regards attitude. Mean CFUs showed extremely significant differences (p < 0.000) between 2nd and 3rd counts and between 1st and 2nd counts except for students of group I where the difference was only significant (p < 0.05). Normal bacterial flora was identified in 94.9% of the plates (92.2% coagulase-negative Staphylococci and 2.7% Micrococcus). Potentially pathogenic bacteria isolated from the other plates were Klebsiella pneumonia, Pseudomonas spp., and spore-forming aerobic nonhemolytic Bacilli.

CONCLUSION

Reenforcement session had a positive impact on HH knowledge, attitude, and reduction of bacterial CFUs.

CLINICAL SIGNIFICANCE

Continuous education with frequent training sessions is recommended to reinforce HH compliance and reduce cross-contamination.

Sensitizing Clostridium difficile Spores with Germinants on Skin and Environmental Surfaces Represents a New Strategy for Reducing Spores via Ambient Mechanisms

Background

Clostridium difficile is a leading cause of healthcare-associated infections worldwide. Prevention of C. difficile transmission is challenging because spores are not killed by alcohol-based hand sanitizers or many commonly used disinfectants. One strategy to control spores is to induce germination, thereby rendering the spores more susceptible to benign disinfection measures and ambient stressors.

Methods/Results

C. difficile spores germinated on skin after a single application of cholic acid-class bile salts and co-germinants; for 4 C. difficile strains, recovery of viable spores from skin was reduced by ~0.3 log₁₀CFU to 2 log₁₀CFU after 2 hours and ~1 log₁₀CFU to > 2.5 log₁₀CFU after 24 hours. The addition of taurocholic acid to 70% and 30% ethanol significantly enhanced reduction of viable spores on skin and on surfaces. Desiccation, and to a lesser extent the presence of oxygen, were identified as the stressors responsible for reductions of germinated spores on skin and surfaces. Additionally, germinated spores became susceptible to killing by pH 1.5 hydrochloric acid, suggesting that germinated spores that remain viable on skin and surfaces might be killed by gastric acid after ingestion. Antibiotic-treated mice did not become colonized after exposure to germinated spores, whereas 100% of mice became colonized after exposure to the same quantity of dormant spores.

Conclusions

Germination could provide a new approach to reduce C. difficile spores on skin and in the environment and to render surviving spores less capable of causing infection. Our findings suggest that it may be feasible to develop alcohol-based hand sanitizers containing germinants that reduce spores on hands.