The impact of alcohol hand sanitizer use on infection rates in an extended care facility

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

The Effects of an Advanced Air Purification Technology on Environmental and Clinical Outcomes in a Long-Term Care Facility

BACKGROUND

Long-term care facilities (LTCFs) are constantly working to reduce sources of infectious pathogens to improve resident care. LTCF residents are particularly susceptible to health care-associated infections (HAIs), many of which originate from the air. An advanced air purification technology (AAPT) was designed to comprehensively remediate volatile organic compounds (VOCs) and all airborne pathogens including all airborne bacteria, fungi, and viruses. The AAPT contains a unique combination of proprietary filter media, high-dose ultraviolet germicidal irradiation, and high-efficiency particulate air (HEPA) filtration.

METHODS

The AAPT was installed in an LTCF's heating, ventilation, and air-conditioning ductwork and 2 floors were studied: the study floor with comprehensive AAPT remediation and HEPA filtration and the control floor with only HEPA filtration. VOC loading and airborne and surface pathogen loading were measured in 5 locations on both floors. Clinical metrics such as HAI rates were also studied.

RESULTS

There was a statistically significant 98.83% reduction in airborne pathogens, which are responsible for illness and infection, an 89.88% reduction in VOCs, and a 39.6% reduction in HAIs. Surface pathogen loading was reduced in all locations except 1 resident room where the detected pathogens were linked to direct touch.

CONCLUSIONS

The removal of airborne and surface pathogens by the AAPT led to a dramatic reduction in HAIs. The comprehensive removal of airborne contaminants has a direct positive impact on resident wellness and quality of life. It is critical that LTCFs incorporate aggressive airborne purification methods with their current infection control protocols.

Efficacy of a New Alcohol-Free Organic Acid-Based Hand Sanitizer against Foodborne Pathogens

In light of the global health crisis triggered by the COVID-19 pandemic, numerous experts have deemed the utilization of hand sanitizers imperative as a precautionary measure against the virus. Consequently, the demand for hand sanitizers has experienced a substantial surge. Since the beginning of 2020, the utilization of alcohol-free hand sanitizers has been increasingly favored due to the potential risks associated with alcohol poisoning, flammability, as well as the adverse effects on skin lipid dissolution, dehydration, and sebum reduction, which can lead to severe cases of eczema and norovirus infections. In this study, we developed an aqueous hand sanitizer that does not contain alcohol. The sanitizer consists of naturally occurring, food-grade organic acids, including lactic, citric, and azelaic acids. Additionally, food-grade ammonium sulfate and a small amount of povidone-iodine (PVPI) were included in the formulation to create a synergistic and potent antibacterial effect. The effectiveness of the hand sanitizer was evaluated against four common foodborne pathogens, namely Clostridium botulinum, Escherichia coli, Listeria monocytogenes, and Staphylococcus aureus, via in vitro testing. The organic acids exhibited a synergistic inhibitory function, resulting in a 3-log reduction in CFU/mL. Furthermore, the presence of povidone-iodine and ammonium sulfate enhanced their antibacterial effect, leading to a 4-log reduction in CFU/mL. The hand sanitizer solution remained stable even after 60 days of storage. During this period, the detection of additional triiodide (I3-) ions occurred, which have the ability to release broad-spectrum molecular iodine upon penetrating the cell walls. This alcohol-free hand sanitizer may offer extended protection and is anticipated to be gentle on the skin. This is attributed to the presence of citric and lactic acids, which possess cosmetic properties that soften and smoothen the skin, along with antioxidant properties.

Effective infection prevention and control measures in long-term care facilities in non-outbreak and outbreak settings: a systematic literature review

BACKGROUND

Healthcare-associated infections in long-term care are associated with substantial morbidity and mortality. While infection prevention and control (IPC) guidelines are well-defined in the acute care setting, evidence of effectiveness for long-term care facilities (LTCF) is missing. We therefore performed a systematic literature review to examine the effect of IPC measures in the long-term care setting.

METHODS

We systematically searched PubMed and Cochrane libraries for articles evaluating the effect of IPC measures in the LTCF setting since 2017, as earlier reviews on this topic covered the timeframe up to this date. Cross-referenced studies from identified articles and from mentioned earlier reviews were also evaluated. We included randomized-controlled trials, quasi-experimental, observational studies, and outbreak reports. The included studies were analyzed regarding study design, type of intervention, description of intervention, outcomes and quality. We distinguished between non-outbreak and outbreak settings.

RESULTS

We included 74 studies, 34 (46%) in the non-outbreak setting and 40 (54%) in the outbreak setting. The most commonly studied interventions in the non-outbreak setting included the effect of hand hygiene (N = 10), oral hygiene (N = 6), antimicrobial stewardship (N = 4), vaccination of residents (N = 3), education (N = 2) as well as IPC bundles (N = 7). All but one study assessing hand hygiene interventions reported a reduction of infection rates. Further successful interventions were oral hygiene (N = 6) and vaccination of residents (N = 3). In outbreak settings, studies mostly focused on the effects of IPC bundles (N = 24) or mass testing (N = 11). In most of the studies evaluating an IPC bundle, containment of the outbreak was reported. Overall, only four articles (5.4%) were rated as high quality.

CONCLUSION

In the non-outbreak setting in LTCF, especially hand hygiene and oral hygiene have a beneficial effect on infection rates. In contrast, IPC bundles, as well as mass testing seem to be promising in an outbreak setting.

Impact on S. aureus and E. coli Membranes of Treatment with Chlorhexidine and Alcohol Solutions: Insights from Molecular Simulations and Nuclear Magnetic Resonance

Membranes form the first line of defence of bacteria against potentially harmful molecules in the surrounding environment. Understanding the protective properties of these membranes represents an important step towards development of targeted anti-bacterial agents such as sanitizers. Use of propanol, isopropanol and chlorhexidine can significantly decrease the threat imposed by bacteria in the face of growing anti-bacterial resistance via mechanisms that include membrane disruption. Here we have employed molecular dynamics simulations and nuclear magnetic resonance to explore the impact of chlorhexidine and alcohol on the S. aureus cell membrane, as well as the E. coli inner and outer membranes. We identify how sanitizer components partition into these bacterial membranes, and show that chlorhexidine is instrumental in this process.

Fabrication, assessment, and potential anti-bacterial activity of sandalwood oil nanoemulsion and its hand rub sanitizer

In the last decade, extensive research has been performed on developing hand sanitizers that can be used to eradicate the diseases that are caused due to poor hand hygiene. Essential oils possess antibacterial and antifungal properties and thus have great potential to replace the available antibacterial agents. In the present study, sandalwood oil-based nanoemulsion (NE) and sanitizer have been formulated and well characterized for their properties. Antibacterial activity was assessed using growth inhibition studies, agar cup, viability assay, etc. The sandalwood oil NE synthesized had oil to surfactant ratio of 1:0.5 (2.5% sandalwood oil and 0.5% Tween 80) and was observed to have a droplet diameter of 118.3 ± 0.92 nm, the zeta potential of - 18.8 ± 2.01 mV, and stability of 2 months. The antibacterial activity of sandalwood NE and sanitizer was evaluated against microorganisms. The antibacterial activity was assessed using the zone of inhibition value of sanitizer, which was in the range of 19 to 25 mm against all microorganisms. Morphological analysis showed distant changes in membrane shape and size and microorganisms' morphology. The synthesized NE was thermodynamically stable and efficient enough to be used in sanitizer, and the formulated sanitizer showed great antibacterial efficacy.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey

Background

Hand hygiene is an important measure to prevent healthcare-associated infections in long-term care facilities.

Objectives

To evaluate compliance with hand hygiene recommendations by different nursing professionals in long-term care facilities and to investigate determinants potentially influencing hand hygiene and whether these differed between the different cadres of staff.

Methods

We conducted two sub-studies: we measured hand hygiene compliance of 496 professionals in 14 long-term care facilities (23 wards) through direct observation using World Health Organisation’s ‘five moments of hand hygiene’ observation tool. In addition, we performed a survey to examine determinants that may influence hand hygiene and to determine differences between different cadres of staff. We used a principal component analysis approach with varimax rotation to explore the underlying factor structure of the determinants.

Results

We found an overall mean hand hygiene compliance of 17%. There was considerable variation between wards (5–38%) and between specific World Health Organization hand hygiene moments. In addition, hand hygiene compliance varied widely within and between different cadres of staff. The determinant analysis was conducted on 177 questionnaires. For all nursing professionals, we found multiple determinants in four domains: ‘social context and leadership’, ‘resources’, ‘individual healthcare professional factors’ and ‘risk perception’. In two domains, several barriers were perceived differently by nursing assistants and nurses. In the domain ‘social context and leadership’, this included (1) how the manager addresses barriers to enable hand hygiene as recommended and (2) how the manager pays attention to correct adherence to the hand hygiene guidelines. In the ‘risk perception’ domain, this included a resident's risk of acquiring an infection as a result of the nursing professional’s failure to comply with the hand hygiene guidelines.

Conclusion

Hand hygiene compliance was low and influenced by multiple factors, several of which varied among different cadres of staff. When designing interventions to improve hand hygiene performance in long-term care facilities, strategies should take into account these determinants and how they vary between different cadres of staff. We recommend exploring hand hygiene determinants at ward level and among different cadres of staff, for example by using our exploratory questionnaire.

Trial registration

Registration number 50-53000-98-113, ‘Compliance with hand hygiene in nursing homes: go for a sustainable effect’ on ClinicalTrials.gov. Date of registration 28-6-2016.

Bringing Transmission of SARS-CoV-2 to the Surface: Is there a Role for Fomites?

Understanding the contribution of routes of transmission, particularly the role of fomites in Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) transmission is important in developing and implementing successful public health infection prevention and control measures.This article will look at case reports, laboratory findings, animal studies, environmental factors, the need for disinfection, and differences in settings, as they relate to SARS-CoV-2 transmission.

Build upon basics: An intervention utilizing safety huddles to achieve near-zero incidence of catheter associated urinary tract infection at a department of Veterans Affairs long-term care facility

BACKGROUND

When traditional interventions are used in long term care for catheter associated urinary tract infection (CAUTI) prevention, residual rates are still high despite a decrease. We conducted a quality improvement study focusing our interventions on patient and staff behavioral patterns identified through a structured huddle process to improve upon the basics for CAUTI prevention.

METHODS

Baseline was from January 2016 to March 2017; the intervention period was from April 2017 to June 2020. We implemented a systematic huddle to determine root cause of each CAUTI and applied lessons throughout the facility. We measured the monthly CAUTI incidence per 1000 urinary catheter days and analyzed the reduction in CAUTI during the intervention period.

RESULTS

CAUTI decreased by 73% during the intervention period compared to the baseline period, with an IRR of 0.27 (95% confidence interval [CI]: 0.11-0.66; P = .004). The number of catheter days per month increased by 4% in the intervention period (17,407 in 39 months) compared to the baseline period (6,440 in 15 months) with IRR of 1.04 (95% confidence interval [CI]: 1.01-1.07; P = .008). No patterns were noted in organisms responsible for CAUTI.

CONCLUSIONS

Our findings stress the importance of looking beyond the traditional interventions for CAUTI prevention in long term care population. By doing this, interventions can be customized for this special population to achieve optimal outcomes.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions.

MAIN RESULTS

We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.

Effectiveness of a hand hygiene program to reduce acute gastroenteritis at child care centers: A cluster randomized trial

We aimed to assess the effectiveness of an educational and hand hygiene program in daycare centers (DCCs) and homes on acute gastroenteritis (AGE) incidence in children attending DCCs.

METHODS

A randomized, controlled, and open study of 911 children aged 0-3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up was employed. Two intervention groups of DCCs families performed educational and hand hygiene measures, 1 with soap and water (soap and water group; n = 274), another with hand sanitizer (hand sanitizer group [HSG]; n = 339), and the control group (CG; n = 298) followed usual handwashing procedures. We compared AGE episode rates with Poisson regression model.

RESULTS

seven hundred fourteen AGE episodes were registered, significant differences between HSG and CG children were found during December and January. A multivariate model was applied and the adjusted incidence rate ratios by rotavirus vaccination found significant differences when children were previously vaccinated, the children in the soap and water group had a higher risk of AGE episodes (incidence rate ratio: 1.28, 95% confidence interval:1.0-1.64), compared with those in the HSG.

CONCLUSIONS

This study demonstrated that hand hygiene programs that included hand sanitizer were most effective in the winter months. Further, the largest reduction of AGE episodes occurred in the children that followed hand hygiene programs including hand sanitizer and educational measures for DCC staff, parents, and children, and were vaccinated for rotavirus.

Impact of Visibility and Accessibility on Healthcare Workers' Hand-Hygiene Behavior: A Comparative Case Study of Two Nursing Units in an Academic Medical Center

OBJECTIVES

This study aims to explore the impacts of visibility and accessibility of alcohol gel-based hand sanitizer dispensers (HSDs) on healthcare workers' hand-hygiene (HH) behaviors.

BACKGROUND

Despite the importance of HH in reducing nosocomial infection, few empirical studies have quantitatively investigated the impacts of unit shape and size, and the resulted visibility and accessibility on HH, due to the lack of consistent methods to measure and evaluate visibility.

METHODS

The research was developed as a cross-sectional comparative study of two nursing units (Units A and B) with similar patient acuity and nursing care model but different shape and layout. The study applied quantitative research methods including visibility and accessibility analysis using space syntax, 1-week on-site observation, and secondary data analysis on HH compliance rates.

RESULTS

Results indicate that the unit with higher visibility and accessibility is associated with higher HH frequencies. Unit B has significantly higher visibility of HSDs, p < .001, t(60) = 4.615, and significantly higher frequency of HH activity occurrences, 5.17% versus 1.52%; p < .001, t(16.750) = 5.332, than Unit A, even though Unit B has lower HSD to bed ratio (0.708:1 vs. 1.375:1). The linear regression models also demonstrate that visibility and accessibility of HSDs are significant predictors of HH behavior.

CONCLUSIONS

Overall, this exploratory study identified the importance of visibility of HSDs to improve the chances of HH. It also points out the impacts of nursing unit typology on the visibility of HSDs and in turn affects HH behavior.

Hand sanitizers: A review of ingredients, mechanisms of action, modes of delivery, and efficacy against coronaviruses

Background

The emergence of the novel virus, SARS-CoV-2, has posed unprecedented challenges to public health around the world. Currently, strategies to deal with COVID-19 are purely supportive and preventative, aimed at reducing transmission. An effective and simple method for reducing transmission of infections in public or healthcare settings is hand hygiene. Unfortunately, little is known regarding the efficacy of hand sanitizers against SARS-CoV-2.

Methods

In this review, an extensive literature search was performed to succinctly summarize the primary active ingredients and mechanisms of action of hand sanitizers, compare the effectiveness and compliance of gel and foam sanitizers, and predict whether alcohol and non-alcohol hand sanitizers would be effective against SARS-CoV-2.

Results

Most alcohol-based hand sanitizers are effective at inactivating enveloped viruses, including coronaviruses. With what is currently known in the literature, one may not confidently suggest one mode of hand sanitizing delivery over the other. When hand washing with soap and water is unavailable, a sufficient volume of sanitizer is necessary to ensure complete hand coverage, and compliance is critical for appropriate hand hygiene.

Conclusions

By extrapolating effectiveness of hand sanitizers on viruses of similar structure to SARS-CoV-2, this virus should be effectively inactivated with current hand hygiene products, though future research should attempt to determine this directly.

Does Nursing Home Compare Reflect Patient Safety In Nursing Homes?

The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities.

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.

Associations Between Hand Hygiene Education and Self-Reported Hand-Washing Behaviors Among Korean Adults During MERS-CoV Outbreak

BACKGROUND

Hand washing is an effective way to prevent transmission of infectious diseases. Education and promotional materials about hand washing may change individuals' awareness toward hand washing. Infectious disease outbreak may also affect individuals' awareness.

AIMS

Our study aimed to examine associations between hand-washing education and self-reported hand-washing behaviors among Korean adults during the year of the Middle East respiratory syndrome (MERS) outbreak.

METHODS

Data from the 2015 Community Health Survey were used for this study. The total study population comprised 222,599 individuals who were older than 20 years of age. A multiple linear regression model was used to investigate associations between hand hygiene education and self-reported hand-washing behaviors. Subgroup analyses stratified by age, sex, income, and MERS outbreak regions were also performed.

RESULTS

Individuals who received hand-washing education or saw promotional materials related to hand washing had significantly higher scores for self-reported use of soap or sanitizer (β = 0.177, P < .0001) and self-reported frequency of hand washing (β = 0.481, P < .0001) than those who did not have such experiences. The effect of hand-washing education on self-reported behavior change was greater among older adults, women, and lower income earners. The effect of hand hygiene education on self-reported use of soap or sanitizer was similar regardless of whether the participants lived in MERS regions.

CONCLUSION

Our findings emphasize the importance of education or promotions encouraging hand washing, especially for older adults, women, and lower income earners. In addition, MERS outbreak itself affected individuals' awareness of hand-washing behaviors. Well-organized campaigns that consider these factors are needed to prevent infectious diseases.

Strategies to Prevent Acute Diarrhea and Upper Respiratory Tract Infection among Disaster Relief Workers

Background

Sickness among field relief workers prompted us to develop strategies for preventing manpower loss. Most studies have focused on the preparedness and safety of medical responders in the prepared phase, but those parameters are lacking in the response phase. This study attempted to identify effective ways to prevent medical team members from acquiring acute diarrhea and upper respiratory tract infection (URI) based on our field reports. This was a retrospective cohort study. The 56 team members were from eight missions in total, including medial disaster relief and international humanitarian assistance, deployed between June 2007 and February 2010. The demographics of the participating members and their actions were examined for association with acute diarrhea and upper respiratory tract infection episodes using a mixed-effect logistic regression model. One member (7.0%) with acute diarrhea and 11 (26.1%) members without acute diarrhea took doxycycline. The relationship between doxycycline and acute diarrhea episodes was not statistically signifi cant. However, while 6 of 14 team members (42.9%) with acute diarrhea used hand sanitizer, 35 of 42 team members (83.3%) without diarrhea used hand sanitizer. Only hand sanitizer use was statistically related to the prevention of acute diarrhea and URI (p value = 0.021, 0.032). Hand sanitizer is suggested to protect medical teams from acute diarrhea and URI in such challenging environments. Chemoprophylaxis for malaria remains dependent on the area of deployment.

Methods

Sickness among field relief workers prompted us to develop strategies for preventing manpower loss. Most studies have focused on the preparedness and safety of medical responders in the prepared phase, but those parameters are lacking in the response phase. This study attempted to identify effective ways to prevent medical team members from acquiring acute diarrhea and upper respiratory tract infection (URI) based on our field reports. This was a retrospective cohort study. The 56 team members were from eight missions in total, including medial disaster relief and international humanitarian assistance, deployed between June 2007 and February 2010. The demographics of the participating members and their actions were examined for association with acute diarrhea and upper respiratory tract infection episodes using a mixed-effect logistic regression model. One member (7.0%) with acute diarrhea and 11 (26.1%) members without acute diarrhea took doxycycline. The relationship between doxycycline and acute diarrhea episodes was not statistically signifi cant. However, while 6 of 14 team members (42.9%) with acute diarrhea used hand sanitizer, 35 of 42 team members (83.3%) without diarrhea used hand sanitizer. Only hand sanitizer use was statistically related to the prevention of acute diarrhea and URI (p value = 0.021, 0.032). Hand sanitizer is suggested to protect medical teams from acute diarrhea and URI in such challenging environments. Chemoprophylaxis for malaria remains dependent on the area of deployment.

Results

Sickness among field relief workers prompted us to develop strategies for preventing manpower loss. Most studies have focused on the preparedness and safety of medical responders in the prepared phase, but those parameters are lacking in the response phase. This study attempted to identify effective ways to prevent medical team members from acquiring acute diarrhea and upper respiratory tract infection (URI) based on our field reports. This was a retrospective cohort study. The 56 team members were from eight missions in total, including medial disaster relief and international humanitarian assistance, deployed between June 2007 and February 2010. The demographics of the participating members and their actions were examined for association with acute diarrhea and upper respiratory tract infection episodes using a mixed-effect logistic regression model. One member (7.0%) with acute diarrhea and 11 (26.1%) members without acute diarrhea took doxycycline. The relationship between doxycycline and acute diarrhea episodes was not statistically signifi cant. However, while 6 of 14 team members (42.9%) with acute diarrhea used hand sanitizer, 35 of 42 team members (83.3%) without diarrhea used hand sanitizer. Only hand sanitizer use was statistically related to the prevention of acute diarrhea and URI (p value = 0.021, 0.032). Hand sanitizer is suggested to protect medical teams from acute diarrhea and URI in such challenging environments. Chemoprophylaxis for malaria remains dependent on the area of deployment.

Conclusion

Sickness among field relief workers prompted us to develop strategies for preventing manpower loss. Most studies have focused on the preparedness and safety of medical responders in the prepared phase, but those parameters are lacking in the response phase. This study attempted to identify effective ways to prevent medical team members from acquiring acute diarrhea and upper respiratory tract infection (URI) based on our field reports. This was a retrospective cohort study. The 56 team members were from eight missions in total, including medial disaster relief and international humanitarian assistance, deployed between June 2007 and February 2010. The demographics of the participating members and their actions were examined for association with acute diarrhea and upper respiratory tract infection episodes using a mixed-effect logistic regression model. One member (7.0%) with acute diarrhea and 11 (26.1%) members without acute diarrhea took doxycycline. The relationship between doxycycline and acute diarrhea episodes was not statistically signifi cant. However, while 6 of 14 team members (42.9%) with acute diarrhea used hand sanitizer, 35 of 42 team members (83.3%) without diarrhea used hand sanitizer. Only hand sanitizer use was statistically related to the prevention of acute diarrhea and URI (p value = 0.021, 0.032). Hand sanitizer is suggested to protect medical teams from acute diarrhea and URI in such challenging environments. Chemoprophylaxis for malaria remains dependent on the area of deployment.

A unified framework for developing effective hygiene procedures for hands, environmental surfaces and laundry in healthcare, domestic, food handling and other settings

Hygiene procedures for hands, surfaces and fabrics are central to preventing spread of infection in settings including healthcare, food production, catering, agriculture, public settings, and home and everyday life. They are used in situations including hand hygiene, clinical procedures, decontamination of environmental surfaces, respiratory hygiene, food handling, laundry hygiene, toilet hygiene and so on. Although the principles are common to all, approaches currently used in different settings are inconsistent. A concern is the use of inconsistent terminology which is misleading, especially to people we need to communicate with such as the public or cleaning professionals. This paper reviews the data on current approaches, alongside new insights to developing hygiene procedures. Using this data, we propose a more scientifically-grounded framework for developing procedures that maximize protection against infection, based on consistent principles and terminology, and applicable across all settings. A key feature is use of test models which assess the state of surfaces after treatment rather than product performance alone. This allows procedures that rely on removal of microbes to be compared with those employing chemical or thermal inactivation. This makes it possible to ensure that a consistent "safety target level" is achieved regardless of the type of procedure used, and allows us deliver maximum health benefit whilst ensuring prudent usage of antimicrobial agents, detergents, water and energy.

Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents

BACKGROUND

Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid.

PURPOSE

Systematic literature review of strategies to reduce UTIs in nursing home residents.

DATA SOURCES

Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015.

STUDY SELECTION

Interventional studies with a comparison group reporting at least 1 outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use.

DATA EXTRACTION

Two authors abstracted study design, participant and intervention details, outcomes, and quality measures.

DATA SYNTHESIS

Of 5794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Quality (range, 8-25; median, 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; 9 studies employed general infection prevention strategies (eg, improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The 19 studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); 9 studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly).

LIMITATIONS

Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes.

CONCLUSIONS

Several practices, often implemented in bundles, such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions, appear to reduce UTI or CAUTI in nursing home residents. Journal of Hospital Medicine 2017;12:356-368.

Hand Hygiene Program Decreases School Absenteeism Due to Upper Respiratory Infections

BACKGROUND

We assessed the effectiveness of a handwashing program using hand sanitizer to prevent school absenteeism due to upper respiratory infections (URIs).

METHODS

This was a randomized, controlled, and open study on a sample of 1341 children 4-12 years old, attending 5 state schools in Almería (Spain), with an 8-month follow-up. The experimental group (EG) washed their hands with soap and water, together with using hand sanitizer, and the control group followed their usual handwashing procedures. Absenteeism rates due to URIs were compared between the 2 groups through a multivariate Poisson regression analysis. The percent of days missed in both groups were compared with a z test.

RESULTS

Overall, 1271 cases of school absenteeism due to URIs were registered. Schoolchildren from the EG had a 38% lower risk of absenteeism due to URIs, incidence rate ratio: 0.62, 95% confidence interval: 0.55-0.70, and a decrease in absenteeism of 0.45 episodes/child/academic year, p < .001. Pupils missed 2734 school days due to URIs and the percentage of days absent was significantly lower in the EG, p < .001.

CONCLUSIONS

Use of hand sanitizer plus handwashing with soap accompanied by educational support is an effective measure to reduce absenteeism due to URIs.

Efficacy of Instant Hand Sanitizers against Foodborne Pathogens Compared with Hand Washing with Soap and Water in Food Preparation Settings: A Systematic Review

Hands can be a vector for transmitting pathogenic microorganisms to foodstuffs and drinks, and to the mouths of susceptible hosts. Hand washing is the primary barrier to prevent transmission of enteric pathogens via cross-contamination from infected persons. Conventional hand washing involves the use of water, soap, and friction to remove dirt and microorganisms. The availability of hand sanitizing products for use when water and soap are unavailable has increased in recent years. The aim of this systematic review was to collate scientific information on the efficacy of hand sanitizers compared with washing hands with soap and water for the removal of foodborne pathogens from the hands of food handlers. An extensive literature search was carried out using three electronic databases: Web of Science, Scopus, and PubMed. Twenty-eight scientific publications were ultimately included in the review. Analysis of this literature revealed various limitations in the scientific information owing to the absence of a standardized protocol for evaluating the efficacy of hand products and variation in experimental conditions. However, despite conflicting results, scientific evidence seems to support the historical skepticism about the use of waterless hand sanitizers in food preparation settings. Water and soap appear to be more effective than waterless products for removal of soil and microorganisms from hands. Alcohol-based products achieve rapid and effective inactivation of various bacteria, but their efficacy is generally lower against nonenveloped viruses. The presence of food debris significantly affects the microbial inactivation rate of hand sanitizers.

Impact of the use of an alcohol-based hand sanitizer in the home on reduction in probability of infection by respiratory and enteric viruses

The goal of this study was to determine the reduction in risk of infection by viruses with the use of an alcohol-based hand sanitizer, used in addition to routine hand washing, in family members in households. A quantitative microbial risk model was used to determine the probability of infection from the concentration of virus on the hands. The model incorporated variation in hand size, frequency of touching orifices (nose, mouth, eyes), and percent transfer to the site of infection, as well as, dose-response for each virus. Data on the occurrence of virus on household members' hands from an intervention study using MS-2 coliphage was used to determine the reduction of viruses on the hands pre- and post-intervention. It was found that the risk of rhinovirus, rotavirus or norovirus infection after the intervention was reduced by 47-98% depending upon the initial concentration of virus on the hands.

Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

BACKGROUND

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

RESULTS

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

CONCLUSION

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

The Healthy Workplace Project: Results of a Hygiene-Based Approach to Employee Wellness

Purpose.

An employee wellness program was evaluated to assess changes in germ transmission, absenteeism, and cost of infection-related illness among office-based employees.

Design.

One-group pretest-posttest design, with intervention delivered for 90 days and measurement conducted over 1 year.

Setting.

Employees of a large office space in Georgia.

Subjects.

One thousand six hundred forty-five employees.

Intervention.

The Healthy Workplace Project is a 90-day wellness program aimed to increase health and productivity of employees through educational and engagement activities focusing on improving awareness, recognizing infection-related illnesses, and reducing the spread of germs in the workplace.

Measures.

Three types of data were collected: (1) bacterial audits through use of adenosine triphosphate monitoring of various work spaces; (2) self-report absenteeism data using the World Health Organization's Health and Work Performance Questionnaire; and (3) participant employees' medical claims/costs of infection-related minor illnesses.

Analysis.

Frequencies and bacterial audit data; Wilcoxon signed ranks tests to determine changes in rates on absenteeism and health care costs.

Results.

Bacterial audits demonstrated a reduction in contamination levels of 33% across all measured spaces. Absenteeism rates were reduced by 13%. Medical service utilization costs were not significantly reduced for individual employees over the project year.

Conclusion.

Educational strategies and individual monitoring of germ transmission appears effective in improving employees' health and decreasing absenteeism.

The impact of common infections on school absenteeism during an academic year

BACKGROUND

School absenteeism because of infections is one of the most important problems facing both public and private primary schools. The aim of the study was to assess the impact of infections on school absenteeism and their reduction with a handwashing program using hand sanitizer.

METHODS

The study was an 8-month-long, randomized, controlled open study (N = 1,609 children, aged 4-12 years old) at 5 state schools in Almeria (Spain). The experimental group (EG) washed their hands with soap and water, complemented with the use of hand sanitizer, and the control group (CG) followed the usual handwashing procedure. The total number of episodes and days missed as well as those because of upper respiratory infections and gastrointestinal infections were compared in both groups with a Z-test.

RESULTS

The students were absent 12,386 days in 7,945 episodes. The incidence of total absent episodes and percent of missed days, including those because of upper respiratory infections and gastrointestinal infections, were significantly lower in the EG than the CG (P < .001), and this was maintained through the flu pandemic period.

CONCLUSION

School absenteeism because of infections in schools is reduced when a hand hygiene program utilizing sanitizing gels is properly carried out, especially during the flu season.

Effectiveness of a multifactorial handwashing program to reduce school absenteeism due to acute gastroenteritis

BACKGROUND

Acute gastroenteritis (AGE) is one of the most common diseases among children and an important cause of school absenteeism. The aim of this study was to assess the effectiveness of a handwashing program using hand sanitizers for the prevention of school absenteeism due to AGE.

METHODS

A randomized, controlled and open study of a sample of 1341 children between 4 and 12 years of age, attending 5 state schools in Almería (Spain), with an 8-month follow up (academic year). The experimental group (EG) washed their hands with soap and water, complementing this with the use of a hand sanitizer, and the control group (CG) followed the usual handwashing procedure. Absenteeism rates due GI were compared between the 2 groups through the multivariate Poisson regression analysis. Percent days absent in both groups were compared with a Z-test.

RESULTS

446 cases of school absenteeism due to AGE were registered. The school children from the EG had a 36% lower risk of absenteeism due to AGE (IRR: 0.64, 95% confidence interval: 0.52-0.78) and a decrease in absenteeism of 0.13 episodes/child/academic year (0.27 of EG vs 0.40 CG/episodes/child/academic year, P < 0.001). Pupils missed 725 school days due to AGE and absent days was significantly lower in the EG (EG: 0.31%, 95% confidence interval: 0.28-0.35 vs. CG: 0.44%, 95% confidence interval: 0.40-0.48, P < 0.001).

CONCLUSIONS

The use of hand sanitizer as a complement to handwashing with soap is an efficient measure to reduce absent days and the number of school absenteeism cases due to AGE.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Surveillance study of bacterial contamination of the parent's cell phone in the NICU and the effectiveness of an anti-microbial gel in reducing transmission to the hands

OBJECTIVE

To determine the bacterial contamination rate of the parent's cell phone and the effectiveness of anti-microbial gel in reducing transmission of bacteria from cell phone to hands.

METHODS

Cross-sectional study of cultures from the cell phone and hands before and after applying anti-microbial gel (n=50).

RESULTS

All cell phones demonstrated bacterial contamination. Ninety percent had the same bacteria on the cell phone and their cleaned hands. Twenty two percent had no growth on their hands after applying anti-microbial gel after they had the same bacteria on the cell phone and hands. Ninety-two percent of parents were aware that cell phones carried bacteria, but only 38% cleaned their cell phones at least weekly.

CONCLUSIONS

Bacterial contamination of cell phones may serve as vectors for nosocomial infection in the neonatal intensive care unit. Bacteria transmitted from cell phone to hands may not be eliminated using anti-microbial gel. Development of hand hygiene and cell phone cleaning guidelines are needed regarding bedside cell phone use.

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

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

Current and emergent strategies for disinfection of hospital environments

A significant number of hospital-acquired infections occur due to inefficient disinfection of hospital surfaces, instruments and rooms. The emergence and wide spread of multiresistant forms of several microorganisms has led to a situation where few compounds are able to inhibit or kill the infectious agents. Several strategies to disinfect both clinical equipment and the environment are available, often involving the use of antimicrobial chemicals. More recently, investigations into gas plasma, antimicrobial surfaces and vapour systems have gained interest as promising alternatives to conventional disinfectants. This review provides updated information on the current and emergent disinfection strategies for clinical environments.

A risk assessment approach to use of antimicrobials in the home to prevent spread of infection

Home and everyday life hygiene is a key part of the public health strategy to reduce infectious disease, but an effective code of practice is required. This short review summarizes the basic scientific principles of a risk-based approach to home hygiene where hygiene procedures are applied at critical points at appropriate times. It suggests that, although detergent-based cleaning can be used to break the chain of infection, in some cases an antimicrobial agent is required.

Infection prevention in long-term care: a systematic review of randomized and nonrandomized trials

The purpose of this systematic review was to critically review and synthesize current evidence and the methodological quality of nonpharmacological infection-prevention interventions in long-term care (LTC) facilities for older adults. Two reviewers searched three electronic databases for studies published over the last decade assessing randomized and nonrandomized trials designed to reduce infections in older adults in which primary outcomes were infection rates and reductions of risk factors related to infections. To establish clarity and standardized reporting of findings, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used. Data extracted included study design, sample size, type and duration of interventions, outcome measures reported, and findings. Two reviewers independently assessed study quality using a validated quality assessment tool. Twenty-four articles met inclusion criteria; the majority were randomized control trials (67%) in which the primary purpose was to reduce pneumonia (66%). Thirteen (54%) studies reported statistically significant results in favor of interventions on at least one of their outcome measures. The methodological clarity of available evidence was limited, placing them at potential risk of bias. Gaps and inconsistencies surrounding interventions in LTC are evident. Future interventional studies need to enhance methodological rigor using clearly defined outcome measures and standardized reporting of findings.

Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility

BACKGROUND

Alcohol-based hand rubs play a key role in reducing the transmission of pathogens in acute care settings, especially as part of a comprehensive hand hygiene program. However, their use in long-term care facilities (LTCFs) has been virtually unstudied.

METHODS

Infection data, including those meeting McGeer et al and the Pennsylvania Patient Safety Authority's surveillance definitions, for lower respiratory tract infections (LRTIs) and skin and soft-tissue infections (SSTIs), as well as hospitalization data were collected in a 174-bed LTCF for 22 months (May 2009 to February 2011). In March 2010, a comprehensive hand hygiene program including increased product availability, education for health care personnel (HCP) and residents, and an observation tool to monitor compliance, was implemented.

RESULTS

Infection rates for LRTIs were reduced from 0.97 to 0.53 infections per 1,000 resident-days (P = .01) following the intervention, a statistically significant decline. Infection rates for SSTIs were reduced from 0.30 to 0.25 infections per 1,000 resident-days (P = .65). A 54% compliance rate was observed among HCP.

CONCLUSION

This study demonstrates that the use of alcohol-based hand rubs, as part of a comprehensive hand hygiene program for HCP and residents, can decrease infection rates in LTCFs.

Hand hygiene deficiency citations in nursing homes

Hand hygiene (HH) is recognized as an effective way to decrease transmission of infections. Little research has been conducted surrounding HH in nursing homes (NHs). In this research, deficiency citations representing potential problems with HH practices by staff as identified in the certification process conducted at almost all US NHs were examined. The aims of the study were to identify potential relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment. We used a panel of 148,900 observations with information primarily coming from the 2000 through 2009 Online Survey, Certification, And Reporting data (OSCAR). An average of 9% of all NHs per year received a deficiency citation for HH. In the multivariate analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs receiving deficiency citations for potential problems with HH identified in this research, more attention should be placed on this issue.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.

OBJECTIVES

To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

SEARCH STRATEGY

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

SELECTION CRITERIA

In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.

DATA COLLECTION AND ANALYSIS

We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.

MAIN RESULTS

We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.

AUTHORS' CONCLUSIONS

Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

A prospective study of nosocomial urinary tract infection in hip fracture patients

AIM

To investigate risk factors and consequences of nosocomial urinary tract infection in hip fracture patients.

BACKGROUND

Nosocomial urinary tract infection is a well-known problem in hip fracture patients. There are several risk factors for nosocomial urinary tract infection described in the literature.

DESIGN

Prospective observational study with a descriptive and comparative design.

METHODS

Hip fracture patients were included consecutively between April 2006-March 2007. Excluded were those under 50, having an indwelling urinary catheter, signs of cognitive impairment or additional severe physical problems at the time of admission. To verify nosocomial urinary tract infection, a urine specimen was taken at admission and discharge. Patients with and without nosocomial urinary tract infection were compared.

RESULTS

The study included 86 hip fracture patients, of whom 45 (52·3%) contracted nosocomial urinary tract infection in hospital. Earlier reported risk factors for nosocomial urinary tract infection were not confirmed in this study, with one exception: diabetes. All diabetic patients in the study contracted urinary tract infections. Patients receiving cloxacillin as antibiotic prophylaxis for wound infection contracted UTI less often than other patients. There were no statistical differences between groups with regard to urinary tract infection frequency four months after fracture or with regard to mortality after one year.

CONCLUSION

Diabetes was the only previously known risk factor for nosocomial urinary tract infection confirmed among hip fracture patients in this study. Cloxacillin as antibiotic prophylaxis for surgery seemed to offer a certain protection against nosocomial urinary tract infection.

RELEVANCE TO CLINICAL PRACTICE

Nurses in clinical practice should be aware of the risk of urinary tract infections in hip fracture patients and especially in hip fracture patients with diabetes. Patients given cloxacillin as antibiotic prophylaxis seem less likely to contract nosocomial urinary tract infection.

Nursing home deficiency citations for infection control

BACKGROUND

This study examined the deficiency citation for infection control (ie, F-Tag 441). This information represents potential problems in infection control as identified in the yearly certification process of almost all US nursing homes.

METHODS

The data used came primarily from the Online Survey, Certification, and Reporting data base, which contains information on both deficiency citations and characteristics of nursing homes. The data for each nursing home from 2000 through 2007 were combined, providing a panel of 100,000 observations. Multivariate analyses and generalized estimating equations with a logit link were used.

RESULTS

An average of 15% of all nursing homes received a deficiency citation for infection control each year from 2000 to 2007. In the multivariate analyses, several staffing levels were robust in their significance. For all 3 types of caregiver examined (ie, nurse aides, Licensed Practical Nurses, and Registered Nurses), low staffing levels were associated with receipt of a deficiency citation for infection control.

CONCLUSION

The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders.

The role of education in the prevention and control of infection: a review of the literature

This paper discusses a literature review which was undertaken prior to a research study about student nurses' and midwives' experiences of learning infection control in clinical practice. Its aim is to identify the role of education in the prevention and control of infection, with a specific focus on compliance with infection control precautions and reduction in infection rates. It also identifies the methods used for teaching infection control. The review concludes that there is no rigorous and convincing evidence that education improves compliance with infection control precautions or reduces rates of infection, particularly in the long-term. Areas for future research are identified.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable

The risk of inadequate hand hygiene in food handling settings is exacerbated when water is limited or unavailable, thereby making washing with soap and water difficult. The SaniTwice method involves application of excess alcohol-based hand sanitizer (ABHS), hand "washing" for 15 s, and thorough cleaning with paper towels while hands are still wet, followed by a standard application of ABHS. This study investigated the effectiveness of the SaniTwice methodology as an alternative to hand washing for cleaning and removal of microorganisms. On hands moderately soiled with beef broth containing Escherichia coli (ATCC 11229), washing with a nonantimicrobial hand washing product achieved a 2.86 (±0.64)-log reduction in microbial contamination compared with the baseline, whereas the SaniTwice method with 62 % ethanol (EtOH) gel, 62 % EtOH foam, and 70 % EtOH advanced formula gel achieved reductions of 2.64 ± 0.89, 3.64 ± 0.57, and 4.61 ± 0.33 log units, respectively. When hands were heavily soiled from handling raw hamburger containing E. coli, washing with nonantimicrobial hand washing product and antimicrobial hand washing product achieved reductions of 2.65 ± 0.33 and 2.69 ± 0.32 log units, respectively, whereas SaniTwice with 62 % EtOH foam, 70 % EtOH gel, and 70 % EtOH advanced formula gel achieved reductions of 2.87 ± 0.42, 2.99 ± 0.51, and 3.92 ± 0.65 log units, respectively. These results clearly demonstrate that the in vivo antibacterial efficacy of the SaniTwice regimen with various ABHS is equivalent to or exceeds that of the standard hand washing approach as specified in the U.S. Food and Drug Administration Food Code. Implementation of the SaniTwice regimen in food handling settings with limited water availability should significantly reduce the risk of foodborne infections resulting from inadequate hand hygiene.

Developing decontamination strategies and monitoring tools

Decontamination within the healthcare setting plays a significant role in reducing the risk of healthcare-associated infections. This article will examine decontamination from hand hygiene to sterilization of instruments and discuss how hazard analysis at critical control points (HACCP) can be used to monitor and record practice, ensuring that consistent standards are based on recommended guidelines, the law and policies.

Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents

BACKGROUND

many elderly suffer from urinary incontinence and use absorbent pads. Pad use per day (PPD) is a frequently used measure of urinary incontinence. Nursing home residents are often dependent on help from nursing staff to change pads. This study was performed in order to determine whether PPD is a reliable method to quantify urinary incontinence in nursing home residents. Furthermore, the association between urinary tract infections (UTIs), PPD and fluid intake was studied.

METHODS

data were retrieved from a multicentre, prospective surveillance among nursing home residents. Data on the use of absorbent pads, fluid intake and incontinence volumes were collected during 48 h. During a 1-year follow-up period, data on UTIs were collected.

RESULTS

in this study, 153 residents were included, of whom 118 (77%) used absorbent pads. Residents who used absorbent pads were at increased risk of developing UTIs compared to residents who did not use pads (41 vs 11%; P = 0.001). Daily fluid intake was not associated with UTIs (P = 0.46). The number of pad changes showed no correlation with the risk of developing UTIs (P = 0.62). Patients with a given PPD presented a wide range of incontinence volumes.

CONCLUSION

the use of absorbent pads is associated with an increased risk of developing UTIs. PPD and daily fluid intake are not correlated with the risk of developing UTIs. PPD is an unreliable measure of urinary incontinence in nursing home residents.

Survey of healthcare-associated infection rates in a nursing home resident population

In this study we assessed the incidence and types of healthcare-associated infection (HCAI) in a nursing home resident population. The influences of home size, resident category, gender and age were also examined. Fifteen homes were recruited and infection rates recorded from 1 October 2006 to 2 December 2006. A rate of 6.04 infections/1000 bed days was recorded for the complete study. Infection rates for the four main categories of infection (number of infections/ 1000 bed days) were respiratory (2.52), urinary (1.87), skin and soft tissue (1.57) and gastrointestinal (0.41). Infection rates for small, medium and large homes were 4.64 (range 1.95—6.51), 5.9 (range 0.49—10.76) and 7.79 (range 5.79—9.39), respectively; however, statistical significance was not achieved ( p = 0.335). Results indicate that respiratory infection rates are higher in larger homes (4.08) than in small (1.88) or medium size homes (2.22). Urinary infection rates were similar in small (1.89), medium (1.88) and large (1.82) homes and skin and soft tissue infections were lower in small homes (0.87) but similar in medium (1.69) and large (1.90) homes. We found a statistically significant relationship between the type of infection acquired and both resident category ( p = 0.017) and gender ( p = 0.005); the relationship between type of infection and age did not reach statistical significance ( p = 0.346).

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a world-wide threat. Antiviral drugs and vaccinations may be insufficient to prevent catastrophe.

OBJECTIVES

To systematically review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2); MEDLINE (1966 to May 2009); OLDMEDLINE (1950 to 1965); EMBASE (1990 to May 2009); and CINAHL (1982 to May 2009).

SELECTION CRITERIA

We scanned 2958 titles, excluded 2790 and retrieved the full papers of 168 trials, to include 59 papers of 60 studies. We included any physical interventions (isolation, quarantine, social distancing, barriers, personal protection and hygiene) to prevent transmission of respiratory viruses. We included the following study designs: randomised controlled trials (RCTs), cohorts, case controls, cross-over, before-after, and time series studies.

DATA COLLECTION AND ANALYSIS

We used a standardised form to assess trial eligibility. RCTs were assessed by: randomisation method; allocation generation; concealment; blinding; and follow up. Non-RCTs were assessed for the presence of potential confounders, and classified into low, medium, and high risks of bias.

MAIN RESULTS

The risk of bias for the four RCTs, and most cluster RCTs, was high. The observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis.The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. Six case-control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that N95 respirators were superior to simple surgical masks, but were more expensive, uncomfortable, and caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. There was limited evidence that social distancing was effective especially if related to the risk of exposure.

AUTHORS' CONCLUSIONS

Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long-term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic.

Investigation into the effect of an alcohol-based hand product on infection rate in a nursing home setting

The study assessed the impact on nursing home (NH) resident infection rates of providing staff with a personal alcohol-based hand product (ABHP) with and without training on its use.

Fifteen North Wales NHs were recruited and randomly allocated into one of three groups. All monitored infection rates throughout the study period of 18 weeks (Phase I [weeks 1—9], Phase II [weeks 11—19]). NHs used liquid soap and water for hand washing throughout the study. Groups B and C introduced interventions during week ten: Group B were provided with personal ABHPs without training on use; Group C personal ABHPs with standard training from the sponsoring hand hygiene company. Infection rates between groups and pre- and post-intervention were compared.

Infection rates (per 1,000 bed days) for Phase I vs. Phase II of the study were: Group A: 6.99 vs. 7.16; Group B: 6.08 vs. 3.46; and Group C: 5.04 vs. 6.78 respectively. Change in infection rates in Groups B and C pre- and post-intervention did not reach statistical significance, p = 0.097 and p = 0.072 respectively.

Comparison of rates in non-intervention Group A with the intervention groups indicated a significantly lower rate after the intervention in Group B ( p = 0.035) but not Group C ( p = 0.765).

Findings are limited due to sample size; introduction of personal ABHPs with training did not reduce infection rates. This conflicts with other studies examining education and improvement of hand hygiene compliance. However, infection rates fell in NHs not receiving training, possibly mediated through a sense of `ownership' of the intervention.