Prevention of irritant contact dermatitis among health care workers by using evidence-based hand hygiene practices: a review

Assessing contact dermatitis risk among Manitoba workers in the Manitoba Occupational Disease Surveillance System

INTRODUCTION

This exploratory study aimed to assess contact dermatitis (CD) risk among workers using the Manitoba Occupational Disease Surveillance System (MODSS).

METHODS

The MODSS linked accepted time-loss claims from the Workers' Compensation Board of Manitoba (2006-2019), with administrative health data from medical and hospital records (1996-2020). CD risk by occupation and industry (hazard ratio, 95% confidence intervals) was estimated using Cox proportional hazard models, adjusted for age and stratified by sex.

RESULTS

Increased risk of new onset CD was observed among some occupations and industries with known skin irritants and allergens. Some occupations with known increased risks of CD remained elevated when removing the accepted WCB cases was performed, suggesting that all CD cases in these occupations may not show up in WCB statistics. Increased risk was also observed for occupations and industries with unknown exposures related to CD, whereas some groups known to be at risk of CD were not observed to have elevated risks in this cohort.

DISCUSSION

The MODSS successfully identified some occupations and industries known to be at high risk of occupational CD, but not others. Some occupations not typically associated with work-related CD were also identified, which warrants further investigation.

Itch and Pain Behaviors in Irritant Contact Dermatitis Produced by Sodium Lauryl Sulfate in Mice

Irritant contact dermatitis (ICD) is a nonspecific skin inflammation caused by irritants, leading to itch and pain. We tested whether differential responses to histamine-dependent and -independent pruritogens can be evoked in ICD induced by sodium lauryl sulfate (SLS). An ICD mouse model was established with 5% SLS in acetone versus a vehicle topically applied for 24 h to the cheek. Site-directed itch- and pain-like behaviors, occurring spontaneously and in response to mechanical, thermal, and chemical stimuli (histamine, ß-alanine, BAM8-22, and bradykinin) applied to the cheek, were recorded before (day 0) and after irritant removal (days 1, 2, 3, and 4). Skin inflammation was assessed through visual scoring, ultrasound, and measurements of skin thickness. SLS-treated mice exhibited hyperalgesia-like behavior in response to mechanical and heat stimuli on day 1 compared to the controls. SLS mice exhibited more spontaneous wipes (pain) but not scratching bouts (itch) on day 1. Pruritogen injections caused more scratching but not wiping in SLS-treated mice compared to the controls. Only bradykinin increased wiping behavior compared to saline. SLS-treated mice developed noticeable erythema, scaling, and increased skin thickness on days 1 and 2. SLS induced cutaneous inflammation and behavioral signs of spontaneous pain and itching, hyperalgesia to mechanical and heat stimuli and a chemical algogen, and enhanced itch response to pruritogens. These sensory reactions preceded the inflammation peak and lasted up to two days.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

Characterization of Cleaning and Disinfection Product Use, Glove Use, and Skin Disorders by Healthcare Occupations in a Midwestern Healthcare Facility

Healthcare facility staff use a wide variety of cleaning and disinfecting products during their daily operations, many of which are associated with respiratory or skin irritation or sensitization with repeated exposure. The objective of this study was to characterize the prevalence of cleaning and disinfection product use, glove use during cleaning and disinfection, and skin/allergy symptoms by occupation and identify the factors influencing glove use among the healthcare facility staff. A questionnaire was administered to the current employees at a midwestern Veterans Affairs healthcare facility that elicited information on cleaning and disinfection product use, glove use during cleaning and disinfection, skin/allergy symptoms, and other demographic characteristics, which were summarized by occupation. The central supply/environmental service workers (2% of the total survey population), nurses (26%,), nurse assistants (3%), and laboratory technicians (5%) had the highest prevalence of using cleaning or disinfecting products, specifically quaternary ammonium compounds, bleach, and alcohol. Glove use while using products was common in both patient care and non-patient care occupations. The factors associated with glove use included using bleach or quaternary ammonium compounds and using cleaning products 2-3 or 4-5 days per week. A high frequency of glove use (≥75%) was reported by workers in most occupations when using quaternary ammonium compounds or bleach. The use of alcohol, bleach, and quaternary ammonium compounds was associated with skin disorders (p < 0.05). These research findings indicate that although the workers from most occupations report a high frequency of glove use when using cleaning and disinfection products, there is room for improvement, especially among administrative, maintenance, and nursing workers. These groups may represent populations which could benefit from the implementation of workplace interventions and further training regarding the use of personal protective equipment and the potential health hazards of exposure to cleaning and disinfecting chemicals.

Ethanol is indispensable for virucidal hand antisepsis: memorandum from the alcohol-based hand rub (ABHR) Task Force, WHO Collaborating Centre on Patient Safety, and the Commission for Hospital Hygiene and Infection Prevention (KRINKO), Robert Koch Institute, Berlin, Germany

BACKGROUND

The approval of ethanol by the Biocidal Products Regulation has been under evaluation since 2007. This follows concern over alcohol uptake from ethanol-based hand rubs (EBHR). If ethanol is classified as carcinogenic, mutagenic, or reprotoxic by the European Chemicals Agency (ECHA), then this would affect infection prevention and control practices.

AIM

A review was performed to prove that ethanol is toxicological uncritical and indispensable for hand antisepsis because of its unique activity against non-enveloped viruses and thus the resulting lack of alternatives. Therefore, the following main points are analyzed: The effectiveness of ethanol in hand hygiene, the evidence of ethanol at blood/tissue levels through hand hygiene in healthcare, and the evidence of toxicity of different blood/tissue ethanol levels and the non-comparability with alcoholic consumption and industrial exposure.

RESULTS

EBHR are essential for preventing infections caused by non-enveloped viruses, especially in healthcare, nursing homes, food industry and other areas. Propanols are effective against enveloped viruses as opposed to non-enveloped viruses but there are no other alternatives for virucidal hand antisepsis. Long-term ingestion of ethanol in the form of alcoholic beverages can cause tumours. However, lifetime exposure to ethanol from occupational exposure < 500 ppm does not significantly contribute to the cancer risk. Mutagenic effects were observed only at doses within the toxic range in animal studies. While reprotoxicity is linked with abuse of alcoholic beverages, there is no epidemiological evidence for this from EBHR use in healthcare facilities or from products containing ethanol in non-healthcare settings.

CONCLUSION

The body of evidence shows EBHRs have strong efficacy in killing non-enveloped viruses, whereas 1-propanol and 2-propanol do not kill non-enveloped viruses, that pose significant risk of infection. Ethanol absorbed through the skin during hand hygiene is similar to consumption of beverages with hidden ethanol content (< 0.5% v/v), such as apple juice or kefir. There is no risk of carcinogenicity, mutagenicity or reprotoxicity from repeated use of EBHR. Hence, the WHO Task Force strongly recommend retaining ethanol as an essential constituent in hand rubs for healthcare.

Paediatric nurses', children's and parents' adherence to infection prevention and control and knowledge of antimicrobial stewardship: A systematic review

INTRODUCTION

Infection prevention and control precautions help to decrease microbial transmission, and through the appropriate use of antibiotics, Antimicrobial Stewardship programs aim to decrease the prevalence and emergence of Antimicrobial Resistance.

METHODS

A systematic review was undertaken to critically appraise and synthesise evidence for nurses', children's and parents' knowledge and understanding of antimicrobial stewardship, and of infection prevention and control in acute paediatric care settings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guided the review. Studies were included if they examined the factors that contributed to nurses' adherence to, or consumers' practice in relation to, antimicrobial stewardship and infection prevention and control.

RESULTS

Of the 16,957 papers identified, 50 studies conducted in acute paediatric settings met the eligibility criteria, and were included. Most studies were of low methodological quality. Fourteen studies evaluated nurses' knowledge and self-reported adherence to Infection Prevention and Control principles and identified consistent practice gaps by nurses. Six studies evaluating the effectiveness of education programs reported modest improvements in nurses' knowledge and adherence to infection prevention and control. There were 15 studies, that investigated consumers' involvement in infection prevention and control that identified the following themes: Consumer knowledge and attitudes to infection prevention and control and transmission-based precautions, and parents' willingness to take an active role in infection prevention. Six studies focused on paediatric nurses' role in antimicrobial stewardship, exploring the following themes: (1) nurses' understanding and beliefs of antimicrobial stewardship roles, and (2) barriers to nurses taking a greater role in antimicrobial stewardship. Nine studies explored the role of consumers in antimicrobial stewardship and identified consumers' misconceptions about the benefits and downplayed concerns regarding antibiotic use.

DISCUSSION

Although consumers articulated a willingness to be actively involved in infection prevention, observed practice remained lower than that required to consistently prevent infection transmission.

CONCLUSION

These findings highlight a critically important gap in current practice. In relation to optimal use of antimicrobials, although paediatric nurses were involved in supporting antimicrobial stewardship processes and educating consumers, they identified limited antimicrobial stewardship knowledge. Consumers appeared to lack understanding about the benefits of antibiotics and negated concerns regarding antibiotic use.

Alcohol-Based Hand Sanitizers in COVID-19 Prevention: A Multidimensional Perspective

The global use of alcohol-based hand sanitizers (ABHS) as an important means of controlling the transmission of infectious disease has increased significantly as governments and public health agencies across the world advocated hand hygiene as a preventative measure during the COVID-19 pandemic. Although the performance of these products is most commonly defined as a function of their alcohol concentration, they are multifaceted products in which an interplay of several factors is important in determining efficacy. This paper discusses the interplay between ABHS input (formulation) factors and output (product performance) factors in the context of a multidimensional perspective using a novel representative paradigm. In the model, represented in the form of a three-dimensional tetrahedron, each of the faces represents inputs in the manufacturing of the ABHS product, which are the type and amount of alcohol, the inactive ingredients, the formulation and the manufacturing practices. The four corners of the tetrahedron represent the product performance factors which include product efficacy, sensory characteristics, usage and compliance and product safety. The multidimensional approach to the formulation and evaluation of ABHS shows that several factors contribute to the effectiveness and utility of these products. The paradigm provides a useful framework for manufacturers of ABHS and related healthcare products.

Effect of Sodium Lauryl Sulfate (SLS) Applied as a Patch on Human Skin Physiology and Its Microbiota

In this study, we assessed the change in skin microbiota composition, relative abundance, and diversity with skin physiology disruption induced by SLS patch. Healthy women declaring to have a reactive skin were submitted to a 0.5% aqueous sodium lauryl sulfate solution application under occlusive patch condition for 24 h. Skin properties were characterized by tewametry, corneometry, and colorimetry and bacterial diversity was assessed by 16S rRNA sequencing. Analysis before and one day after SLS patch removal revealed an increase of skin redness and a decrease of stratum corneum hydration and skin barrier function. The relative abundance of taxa containing potential pathogens increase (Firmicutes: Staphylococcaceae; Proteobacteria: Enterobacteriaceae, Pantoea) while some of the most occurring Actinobacteria with valuable skin protection and repair capacities decreased (Micrococcus, Kocuria, and Corynebacterium). We observed an impaired skin barrier function and dehydration induced by SLS patch disturb the subtle balance of skin microbiota towards skin bacterial community dysbiosis. This study provides new insights on the skin bacterial composition and skin physiology simultaneously impaired by a SLS patch.

Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed medical practice worldwide. It posed a significant impact on different health services, including dermatology. A cross-sectional observational study of 200 health care providers and 100 dermatologists (survey 1 and 2, respectively) were conducted to determine the prevalence of occupational skin diseases among health care providers working amid the pandemic, and to show the outbreak's impact on dermatology practice.

Differences in itch and pain behaviors accompanying the irritant and allergic contact dermatitis produced by a contact allergen in mice

Supplemental Digital Content is Available in the Text.

Introduction:

Irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) are inflammatory skin diseases accompanied by itch and pain. Irritant contact dermatitis is caused by chemical irritants eliciting an innate immune response, whereas ACD is induced by haptens additionally activating an adaptive immune response: After initial exposure (sensitization) to the hapten, a subsequent challenge can lead to a delayed-type hypersensitivity reaction. But, the sensory and inflammatory effects of sensitization (ICD) vs challenge of ACD are insufficiently studied. Therefore, we compared itch- and pain-like behaviors and inflammatory reactions evoked in mice during the sensitization (ICD) vs challenge phase (ACD) of application of the hapten, squaric acid dibutylester (SADBE).

Objectives:

Our aim was to compare itch- and pain-like behaviors and inflammatory reactions evoked in mice during the sensitization (ICD) vs challenge phase (ACD) of application of the hapten, squaric acid dibutylester (SADBE).

Methods:

Mice were sensitized on the abdomen with 1% SADBE (ACD) or vehicle treated (ICD, control). Spontaneous and stimulus-evoked itch- and pain-like behaviors were recorded in mice before and after 3 daily challenges of the cheek with 1% SADBE (ACD, ICD). Cutaneous inflammation was evaluated with clinical scoring, ultrasound imaging, skin thickness, histology, and analyses of selected biomarkers for contact dermatitis, IL-1β, TNF-α, CXCL10, and CXCR3.

Results:

Allergic contact dermatitis vs ICD mice exhibited more spontaneous site-directed scratching (itch) and wiping (pain). Allergic contact dermatitis—but not ICD—mice exhibited allodynia and hyperalgesia to mechanical and heat stimuli. Inflammatory mediators IL-1β and TNF-α were upregulated in both groups as well as the chemokine receptor, CXCR3. CXCL10, a CXCR3 ligand, was upregulated only for ACD. Inflammatory responses were more pronounced in ACD than ICD.

Conclusion:

These findings provide new information for differentiating the behavioral and inflammatory reactions to hapten-induced ICD and ACD.

Influences on use of hand moisturizers in nurses

Background

Nurses are at high risk of hand dermatitis. Regular hand moisturizing can prevent dermatitis, but nurses' use of hand moisturizers is suboptimal.

Aims

To establish (i) what beliefs about hand dermatitis and hand moisturizer use are associated with hand moisturizer use by nurses at home and at work and (ii) if hand moisturizer use behaviours in nurses are associated with the prevalence of hand dermatitis.

Methods

We used a questionnaire to investigate nurses' knowledge, beliefs and behaviours regarding hand dermatitis and use of hand moisturizers.

Results

The response rate was 55/65 (85%). Forty-two (76%) participants agreed that applying hand moisturizers reduced the risk of dermatitis, and 53 (96%) agreed that dermatitis increased the risk of skin carrying pathogenic organisms. Frequent moisturizer application was associated with beliefs that it was part of the nurse's role to apply hand creams, a belief that they had had training in the use of moisturizers and believing that patients approved of them moisturizing their hands.

Conclusions

Hand moisturizer use by nurses can be improved by enhancing their beliefs that it is part of their professional role to apply hand cream regularly.

Interventions for preventing occupational irritant hand dermatitis

BACKGROUND

Occupational irritant hand dermatitis (OIHD) causes significant functional impairment, disruption of work, and discomfort in the working population. Different preventive measures such as protective gloves, barrier creams and moisturisers can be used, but it is not clear how effective these are. This is an update of a Cochrane review which was previously published in 2010.

OBJECTIVES

To assess the effects of primary preventive interventions and strategies (physical and behavioural) for preventing OIHD in healthy people (who have no hand dermatitis) who work in occupations where the skin is at risk of damage due to contact with water, detergents, chemicals or other irritants, or from wearing gloves.

SEARCH METHODS

We updated our searches of the following databases to January 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLlNE, and Embase. We also searched five trials registers and checked the bibliographies of included studies for further references to relevant trials. We handsearched two sets of conference proceedings.

SELECTION CRITERIA

We included parallel and cross-over randomised controlled trials (RCTs) which examined the effectiveness of barrier creams, moisturisers, gloves, or educational interventions compared to no intervention for the primary prevention of OIHD under field conditions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were signs and symptoms of OIHD developed during the trials, and the frequency of treatment discontinuation due to adverse effects.

MAIN RESULTS

We included nine RCTs involving 2888 participants without occupational irritant hand dermatitis (OIHD) at baseline. Six studies, including 1533 participants, investigated the effects of barrier creams, moisturisers, or both. Three studies, including 1355 participants, assessed the effectiveness of skin protection education on the prevention of OIHD. No studies were eligible that investigated the effects of protective gloves. Among each type of intervention, there was heterogeneity concerning the criteria for assessing signs and symptoms of OIHD, the products, and the occupations. Selection bias, performance bias, and reporting bias were generally unclear across all studies. The risk of detection bias was low in five studies and high in one study. The risk of other biases was low in four studies and high in two studies.The eligible trials involved a variety of participants, including: metal workers exposed to cutting fluids, dye and print factory workers, gut cleaners in swine slaughterhouses, cleaners and kitchen workers, nurse apprentices, hospital employees handling irritants, and hairdressing apprentices. All studies were undertaken at the respective work places. Study duration ranged from four weeks to three years. The participants' ages ranged from 16 to 67 years.Meta-analyses for barrier creams, moisturisers, a combination of both barrier creams and moisturisers, or skin protection education showed imprecise effects favouring the intervention. Twenty-nine per cent of participants who applied barrier creams developed signs of OIHD, compared to 33% of the controls, so the risk may be slightly reduced with this measure (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.72 to 1.06; 999 participants; 4 studies; low-quality evidence). However, this risk reduction may not be clinically important. There may be a clinically important protective effect with the use of moisturisers: in the intervention groups, 13% of participants developed symptoms of OIHD compared to 19% of the controls (RR 0.71, 95% CI 0.46 to 1.09; 507 participants; 3 studies; low-quality evidence). Likewise, there may be a clinically important protective effect from using a combination of barrier creams and moisturisers: 8% of participants in the intervention group developed signs of OIHD, compared to 13% of the controls (RR 0.68, 95% CI 0.33 to 1.42; 474 participants; 2 studies; low-quality evidence). We are uncertain whether skin protection education reduces the risk of developing signs of OIHD (RR 0.76, 95% CI 0.54 to 1.08; 1355 participants; 3 studies; very low-quality evidence). Twenty-one per cent of participants who received skin protection education developed signs of OIHD, compared to 28% of the controls.None of the studies addressed the frequency of treatment discontinuation due to adverse effects of the products directly. However, in three studies of barrier creams, the reasons for withdrawal from the studies were unrelated to adverse effects. Likewise, in one study of moisturisers plus barrier creams, and in one study of skin protection education, reasons for dropout were unrelated to adverse effects. The remaining studies (one to two in each comparison) reported dropouts without stating how many of them may have been due to adverse reactions to the interventions. We judged the quality of this evidence as moderate, due to the indirectness of the results. The investigated interventions to prevent OIHD probably cause few or no serious adverse effects.

AUTHORS' CONCLUSIONS

Moisturisers used alone or in combination with barrier creams may result in a clinically important protective effect, either in the long- or short-term, for the primary prevention of OIHD. Barrier creams alone may have slight protective effect, but this does not appear to be clinically important. The results for all of these comparisons were imprecise, and the low quality of the evidence means that our confidence in the effect estimates is limited. For skin protection education, the results varied substantially across the trials, the effect was imprecise, and the pooled risk reduction was not large enough to be clinically important. The very low quality of the evidence means that we are unsure as to whether skin protection education reduces the risk of developing OIHD. The interventions probably cause few or no serious adverse effects.We conclude that at present there is insufficient evidence to confidently assess the effectiveness of interventions used in the primary prevention of OIHD. This does not necessarily mean that current measures are ineffective. Even though the update of this review included larger studies of reasonable quality, there is still a need for trials which apply standardised measures for the detection of OIHD in order to determine the effectiveness of the different prevention strategies.

Implementation of WHO multimodal strategy for improvement of hand hygiene: a quasi-experimental study in a Traditional Chinese Medicine hospital in Xi'an, China

Background

Hand hygiene (HH) is an essential component for preventing and controlling of healthcare-associated infection (HAI), whereas compliance with HH among health care workers (HCWs) is frequently poor. This study aimed to assess compliance and correctness with HH before and after the implementation of a multimodal HH improvement strategy launched by the World Health Organization (WHO).

Methods

A quasi-experimental study design including questionnaire survey generalizing possible factors affecting HH behaviors of HCWs and direct observation method was used to evaluate the effectiveness of WHO multimodal HH strategy in a hospital of Traditional Chinese Medicine. Multimodal HH improvement strategy was drawn up according to the results of questionnaire survey. Compliance and correctness with HH among HCWs were compared before and after intervention. Also HH practices for different indications based on WHO “My Five Moments for Hand Hygiene” were recorded.

Results

In total, 553 HCWs participated in the questionnaire survey and multimodal HH improvement strategy was developed based on individual, environment and management levels. A total of 5044 observations in 23 wards were recorded in this investigation. The rate of compliance and correctness with HH improved from 66.27% and 47.75% at baseline to 80.53% and 88.35% after intervention. Doctors seemed to have better compliance with HH after intervention (84.04%) than nurses and other HCWs (81.07% and 69.42%, respectively). When stratified by indication, compliance with HH improved for all indications after intervention (P < 0.05) except for “after body fluid exposure risk” and “after touching patient surroundings”.

Conclusion

Implementing the WHO multimodal HH strategy can significantly improve HH compliance and correctness among HCWs.

Electronic supplementary material

The online version of this article (10.1186/s13756-017-0254-4) contains supplementary material, which is available to authorized users.

Self-reported hand eczema among dental workers in Japan - a cross-sectional study

BACKGROUND

Dental workers are considered to have a high risk of developing occupational hand eczema.

OBJECTIVES

To estimate the prevalence of work-related hand eczema and associated risk factors in dental workers in Japan.

METHODS

A self-administered questionnaire was sent by mail to all dental clinics of Kumamoto City, Japan. In addition, patch testing with 24 dentistry-related allergens was offered.

RESULTS

In total, 46.4% of dental workers (n = 528: response 31.4%, based on 97 clinics) reported a lifetime history of chronic hand eczema. The 1-year prevalence was 36.2%. According to logistic regression analysis, the most important risk factors for the 1-year prevalence were a personal history of atopic dermatitis [odds ratio (OR) 4.7, 95% confidence interval (CI): 2.2-8.8], asthma and/or allergic rhinitis (OR 2.0, 95%CI: 1.3-3.0), dry skin (OR 1.7, 95%CI: 1.1-2.7), shorter duration of work (OR 2.0, 95%CI: 1.2-3.5 for up to 10 years versus >20 years), and washing hands >10 times per day (OR 1.6, 95%CI: 1.0-2.5). Fifty-four workers were patch tested. Rubber chemicals and acrylates were the most frequent occupationally relevant contact allergens.

CONCLUSIONS

Dental workers in Japan have a high prevalence of hand eczema. Health education to prevent hand eczema and more frequent patch testing are needed.

Self-perceived hand hygiene practices among undergraduate nursing students

Abstract Limited research has investigated the hand hygiene practices of undergraduate nursing students. A descriptive self-report survey explored the predictors of self-perceived hand hygiene compliance using a convenience sample of 306 undergraduate nursing students enrolled at a southwestern Ontario university. Compliance was defined as the performance of hand hygiene at least 90% of the time in the moments both before and after direct patient contact. The self-reported compliance rate among study participants was 74.8%. Logistic regression analysis revealed that the independent predictors of hand hygiene compliance included concern about reprimand or discipline (odds ratio (OR) 4.324; 95% confidence interval (CI) 1.465–12.758); motivation to protect patients from infection (OR 2.418; 95% CI 1.001–5.838); number of clinical placements (OR 0.815; 95% CI 0.702–0.947) and role modelling by the clinical instructor (OR 2.227; 95% CI 1.009–4.915). Other independent predictors were the perceived barriers of busyness (OR 0.231; 95% CI 0.126–0.423), forgetfulness (OR 0.356; 95% CI 0.186–0.678) and perceptions of alcohol rub-related skin damage (OR 0.163; 95% CI 0.070–0.380). The findings of this study provide research-based evidence that could be used by educators to understand better hand hygiene practices among undergraduate nursing students.

A person-oriented approach to hand hygiene behaviour: Emotional empathy fosters hand hygiene practice

OBJECTIVES

Adopting a social-psychological approach, this research examines whether emotional empathy, an affective reaction regarding another's well-being, fosters hand hygiene as this affects other's health-related well-being extensively.

DESIGN

Three studies tested this notion: (a) a cross-sectional study involving a sample of health care workers at a German hospital, (b) an experiment testing the causal effect of empathy on hand hygiene behaviour and (c) an 11-week prospective study testing whether an empathy induction affected disinfectant usage frequency in two different wards of a hospital.

MAIN OUTCOME MEASURES

Self-reported hand hygiene behaviour based on day reconstruction method was measured in Study 1, actual hand sanitation behaviour was observed in Study 2 and disinfectant usage frequency in two different hospital wards was assessed in Study 3.

RESULTS

Study 1 reveals an association of empathy with hand hygiene cross-sectionally, Study 2 documents the causal effect of empathy on increased hand sanitation. Study 3 shows an empathy induction increases hand sanitiser usage in the hospital.

CONCLUSIONS

Increasing emotional empathy promotes hand hygiene behaviour, also in hospitals. Besides providing new impulses for the design of effective interventions, these findings bear theoretical significance as they document the explanatory power of empathy regarding a distal explanandum (hand hygiene).

Occupational dermatitis in health care workers evaluated for suspected allergic contact dermatitis

BACKGROUND

Contact dermatitides occur commonly among health care workers (HCWs).

OBJECTIVE

To contrast the atopic status and incidence, location, and final diagnosis of skin diseases afflicting HCWs versus non-HCWs (NHCWs) evaluated for suspicion of allergic contact dermatitis (ACD); and among the population diagnosed with ACD, to compare the incidence and occupational relatedness of allergens found in HCWs with the rates observed in NHCWs.

METHODS

Between July 1, 1994, and May 30, 2014, 2611 patients underwent patch testing by the senior author. Of these, 165 were classified as HCWs based on their primary occupation. Statistical analysis was done using a χ test.

RESULTS

Health care workers were more likely than NHCWs to be women and to have hand dermatitis. Women, but not men, HCWs suffered more irritant contact dermatitis. Health care workers had significantly more work-related ACD, especially to formaldehyde, quaternium-15, 2-bromo-2-nitropropane-1,3-diol, cocamide diethanolamine (DEA), thiuram mix, carba mix, thimerosal, benzalkonium chloride, glutaraldehyde, and bacitracin.

LIMITATIONS

Only patients suspected of having ACD were tested. Our population was geographically limited to metropolitan Kansas City, MO and metropolitan New York, NY.

CONCLUSIONS

Health care workers suffer more from occupational ACD, especially of the hands, than do NHCWs, including to allergens not present on available standard allergen series.

The impact of national-level interventions to improve hygiene on the incidence of irritant contact dermatitis in healthcare workers: changes in incidence from 1996 to 2012 and interrupted times series analysis

BACKGROUND

Reducing healthcare-associated infections (HCAI) has been a priority in the U.K. over recent decades and this has been reflected in interventions focusing on improving hygiene procedures.

OBJECTIVES

To evaluate whether these interventions coincided with an increased incidence of work-related irritant contact dermatitis (ICD) attributed to hand hygiene or/and other hygiene measures in healthcare workers (HCWs).

METHODS

A quasi-experimental (interrupted time series) design was used to compare trends in incidence of ICD in HCWs attributed to hygiene before and after interventions to reduce HCAI with trends in the same periods in control groups (ICD in other workers). Cases of ICD reported to a U.K. surveillance scheme from 1996 to 2012 were analysed. The time periods compared were defined objectively based on the dates of the publication of national evidence-based guidelines, the U.K. Health Act 2006 and the Cleanyourhands campaign.

RESULTS

The reported incidence of ICD in HCWs attributed to hygiene has increased steadily from 1996 to 2012 [annual incidence rate ratio (95% confidence interval): hand hygiene only 1.10 (1.07-1.12); all hygiene 1.05 (1.03-1.07)], whereas the incidence in other workers is declining. An increase in incidence of ICD in HCWs attributed to hand hygiene was observed at the beginning of the Cleanyourhands campaign.

CONCLUSIONS

The increasing incidence of ICD in HCWs combined with the popularity of interventions to reduce HCAI warrants increased efforts towards identifying products and implementing practices posing the least risk of ICD.

A survey of occupational skin disease in UK health care workers

BACKGROUND

Occupational skin disease is a common problem among health care workers (HCWs). The prevalence of occupational skin disease in HCWs has been reported in several international studies, but not in the UK.

AIMS

To estimate the prevalence of occupational skin disease in a population of UK HCWs and to explore possible causative factors.

METHODS

Clinical and non-clinical HCWs attending for an influenza vaccine during October and November 2013 were invited to complete a brief skin questionnaire. Data from staff who stated their skin had suffered as a result of work were compared with data from staff who did not, to explore differences in potential causative factors.

RESULTS

A total of 2762 questionnaires were analysed. The estimated prevalence of occupational skin disease was 20% for clinical and 7% for non-clinical staff. In total, 424 clinical staff stated their skin had been made worse by work. There were statistically significant differences between clinical staff with and without reported skin symptoms regarding a history of eczema, frequent hand washing and moisturizer use but no statistically significant difference in the relative proportions of soap and alcohol hand gel use. Non-clinical staff reported significantly more use of soap relative to alcohol gel than clinical staff.

CONCLUSIONS

This study demonstrated the prevalence of occupational skin disease in a population of UK HCWs. More work is indicated to explore if the ratio of soap and alcohol gel reported in this study are typical and whether this has any impact on the development of occupational skin disease.

Prevalence of antibiotic-resistant bacteria in residents of nursing homes in a Swedish municipality: healthcare staff knowledge of and adherence to principles of basic infection prevention

BACKGROUND

The aims of this study were to investigate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in residents living in Swedish nursing homes, and if carriage of resistant bacteria was related to antibiotic treatment, other risk factors, and/or staff's adherence to guidelines for infection control.

METHODS

Five hundred and sixty residents from 9 nursing homes on a total of 67 wards participated in the study and had microbiological cultures taken. Faecal samples were obtained from 495 residents (88.3%). ESBL-positive residents were followed for 2 y with repeated sampling. Two hundred and ninety-six [corrected] staff members were interviewed and observed regarding familiarity with and adherence to infection control guidelines.

RESULTS

No resident was positive for MRSA or VRE. Fifteen of the residents were found to be ESBL-positive. Residents living on wards where ESBL-positive residents were identified had been treated more frequently with antibiotics (42%), compared to those on wards where no residents with ESBL were found (28%; p = 0.02). ESBL-positive Escherichia coli isolates from residents living in adjacent rooms were found to be closely genetically related when analysed by pulsed-field gel electrophoresis, indicating transmission between residents. Staff adherence to infection control guidelines sometimes revealed shortcomings, but no significant differences regarding compliance to the guidelines could be found.

CONCLUSION

Carriage of resistant bacteria was uncommon and only ESBL-producing Enterobacteriaceae were identified in Swedish nursing homes. Usage of antibiotics was higher on wards where ESBL-positive residents were detected and there was an indication of transmission of ESBL between residents.

Skin reactions in a phase 3 study of a testosterone topical solution applied to the axilla in hypogonadal men

OBJECTIVE

Axiron (testosterone topical solution 2%) is an approved topical testosterone replacement therapy applied to the axilla. The axilla is a novel application site for testosterone replacement therapy, with differences in skin structure and exposure that could impact the type and/or severity of skin reactions observed with testosterone topical solution 2%. We therefore present a detailed description of data from a pivotal clinical trial regarding the incidence, time of onset, duration, and severity of patient-reported skin reactions as well as visual assessments made by investigators and rated using Draize scoring. *Axiron is a trademark of Eli Lilly and Company, Indianapolis, IN, USA.

METHODS

Data were analyzed from a multinational, open-label, clinical study in which a 2% testosterone topical solution was applied to the axilla in hypogonadal men. The primary study was for 120 days (N = 155) with a 60-day extension that evaluated skin safety (N = 71). At each visit investigators asked patients about adverse skin reactions (including those occurring between study visits); visually assessed the application site; and graded observed instances of erythema or edema using Draize scoring (rated from 0 to 4).

RESULTS

Application-site irritation following study drug application was the most commonly reported event (n = 12 patients) and was generally mild (n = 11; moderate, n = 1) in severity. Application-site irritation did not increase in severity over time and led to only one discontinuation. Erythema was the second most common patient-reported skin reaction (n = 10 patients) and was also generally mild (n = 9; moderate, n = 1). Draize scoring rated all directly observed cases of erythema as grade 1 (very slight, 6 patients) or grade 2 (well-defined, two patients), and identified two instances of erythema not reported by patients. Erythema was typically transient, and in most cases resolved without interruption of therapy. Three cases of edema were reported by patients, and two of these were also identified by visual inspection; all cases of edema occurred in conjunction with erythema. Two cases of acne (facial, shoulders) and one of folliculitis (scalp) were also reported.

CONCLUSIONS

Skin reactions were observed in a minority of patients, were mild or at most moderate in severity, and seldom led to discontinuation.

Hands4U: a multifaceted strategy to implement guideline-based recommendations to prevent hand eczema in health care workers: design of a randomised controlled trial and (cost) effectiveness evaluation

BACKGROUND

Workers in wet work occupations have a risk for developing hand eczema. Prevention strategies exist, but compliance to the proposed recommendations is poor. Therefore, a multifaceted implementation strategy (MIS) is developed to implement these recommendations to reduce hand eczema among health care workers performing wet work.

METHODS/DESIGN

This study is a randomised controlled trial in three university hospitals in the Netherlands. Randomisation to the control or intervention group is performed at department level. The control group receives a leaflet containing the recommendations only. The intervention group receives the MIS which consists of five parts: 1) within a department, a participatory working group is formed to identify problems with the implementation of the recommendations, to find solutions for it and implement these solutions; 2) role models will help their colleagues in performing the desired behaviour; 3) education to all workers will enhance knowledge about (the prevention of) hand eczema; 4) reminders will be placed at the department reminding workers to use the recommendations; 5) workers receive the same leaflet as the control group containing the recommendations. Data are collected by questionnaires at baseline and after 3, 6, 9 and 12 months. The primary outcome measure is self-reported hand eczema. The most important secondary outcome measures are symptoms of hand eczema; actual use of the recommendations; sick leave; work productivity; and health care costs.Analyses will be performed according to the intention to treat principle. Cost-effectiveness of the MIS will be evaluated from both the societal and the employer's perspective.

DISCUSSION

The prevention of hand eczema is important for the hospital environment. If the MIS has proven to be effective, a major improvement in the health of health care workers can be obtained. Results are expected in 2014.

TRIAL REGISTRATION NUMBER

NTR2812.

The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations

The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.

Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group

BACKGROUND

Nurses have a high risk of developing hand eczema due to hand disinfection procedures.

OBJECTIVES

To investigate the perception of nurses regarding the adverse effects of hand washing (HW) and alcoholic disinfection (ADI), and to obtain data on the prevalence of hand dermatitis and sensitization to alcohols and alcohol-based hand rubs (ABHRs).

METHODS

A self-administered questionnaire survey, carried out as a pilot study (PS), followed by a modified multicentre study (MC) in five hospitals. Patch tests to ethanol (80%), 1-propanol (60%), 2-propanol (70%) and ABHRs were performed in a subsample.

RESULTS

The majority (PS 60.1%; MC 69.5%) of nurses considered ADI to be more damaging than HW. Mostly, ADI and HW were suspected to have irritant effects (ADI 79.2%/52.1%; HW 65.5%/36.2%) compared with an allergenic potential (ADI 10.4%/5.8%; HW 7.8%/3.9%). The prevalence of hand dermatitis in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions. In 50 tested individuals no sensitization and only two irritant reactions to alcohols and three single-positive reactions to ABHRs were observed, none of the latter related to alcohols.

CONCLUSIONS

Although ADI is known to cause less skin irritation than HW, nurses perceive ADI as more damaging, resulting in: (i) a low compliance with ADI and (ii) a higher prevalence of hand dermatitis because the more deleterious HW is preferred. This may result in an increase in occupational disease and nosocomial infections. Educational programmes should promote ADI as a procedure with good efficiency and skin tolerability to reduce the prevalence of hand eczema in nurses and to enhance compliance with hand hygiene standards.

Latex glove use by food handlers: the case for nonlatex gloves

There is increasing concern that continued exposure to latex products can predispose individuals, particularly those who are atopic (allergy prone), to latex allergy. Latex allergy as a serious hazard has been well documented in the health care industry. There are also well-documented cases of food handlers who have had allergic reactions after the use of latex gloves. The contamination of food with latex proteins by food handlers using latex gloves can also result in potentially severe allergic reactions in latex-allergic consumers. We review latex allergy and present the case for avoiding latex glove use by food handlers in the food and hospitality industries. Adopting the use of nonlatex gloves has benefits for workers, consumers, and the food industry.

Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection

BACKGROUND

Recent data indicate that full efficacy of a hand rub preparation for hygienic hand disinfection can be achieved within 15 seconds (s). However, the efficacy test used for the European Norm (EN) 1500 samples only the fingertips. Therefore, we investigated hand coverage using sixteen different application variations. The hand rub was supplemented with a fluorescent dye, and hands were assessed under UV light by a blind test, before and after application. Fifteen non-healthcare workers were used as subjects for each application variation apart from one test which was done with a group of twenty healthcare workers. All tests apart from the reference procedure were performed using 3 mL of hand rub. The EN 1500 reference procedure, which consists of 6 specific rub-in steps performed twice with an aliquot of 3 ml each time, served as a control. In one part of this study, each of the six steps was performed from one to five times before proceeding to the next step. In another part of the study, the entire sequence of six steps was performed from one to five times. Finally, all subjects were instructed to cover both hands completely, irrespective of any specific steps ("responsible application"). Each rub-in technique was evaluated for untreated skin areas.

RESULTS

The reference procedure lasted on average 75 s and resulted in 53% of subjects with at least one untreated area on the hands. Five repetitions of the rub-in steps lasted on average 37 s with 67% of subjects having incompletely treated hands. One repetition lasted on average 17 s, and all subjects had at least one untreated area. Repeating the sequence of steps lasted longer, but did not yield a better result. "Responsible application" was quite fast, lasting 25 s among non-healthcare worker subjects and 28 s among healthcare workers. It was also effective, with 53% and 55% of hands being incompletely treated. New techniques were as fast and effective as "responsible application". Large untreated areas were found only with short applications. Fingertips and palms were often covered completely.

CONCLUSION

In clinical practice, hand disinfection is apparently better than practitioners of infection control often anticipate. Based on our data, a high-quality hygienic hand disinfection is not possible within 15 s. A 30 s application time can, however, be recommended for clinical practice. The currently recommended six steps of EN 1500 are not really suitable for clinical practice, because they yield comparably poor results. The most appropriate application procedure may be "responsible application", or one of the other new techniques.

Comprehensive bactericidal activity of an ethanol-based hand gel in 15 seconds

BACKGROUND

Some studies indicate that the commonly recommended 30 s application time for the post contamination treatment of hands may not be necessary as the same effect may be achieved with some formulations in a shorter application time such as 15 s.

METHOD

We evaluated the bactericidal activity of an ethanol-based hand gel (Sterillium Comfort Gel) within 15 s in a time-kill-test against 11 Gram-positive, 16 Gram-negative bacteria and 11 emerging bacterial pathogens. Each strain was evaluated in quadruplicate.

RESULTS

The hand gel (85% ethanol, w/w) was found to reduce all 11 Gram-positive and all 16 Gram-negative bacteria by more than 5 log10 steps within 15 s, not only against the ATCC test strains but also against corresponding clinical isolates. In addition, a log10 reduction > 5 was observed against all tested emerging bacterial pathogens.

CONCLUSION

The ethanol-based hand gel was found to have a broad spectrum of bactericidal activity in only 15 s which includes the most common species causing nosocomial infections and the relevant emerging pathogens. Future research will hopefully help to find out if a shorter application time for the post contamination treatment of hands provides more benefits or more risks.