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Hand hygiene in home healthcare and everyday life Sally Bloomfield, Chairman, International Scientific Forum on Home Hygiene (IFH) Hon. Professor, London School of Hygiene and Tropical Medicine IFIC Oct 2012 Why is hygiene in home healthcare and everyday life important? • • • Infectious disease circulating in the community - heavy burden on health and healthcare systems Much preventable by good hygiene in homes and everyday lives Hygiene-related disease includes: – Gastrointestinal (food and non-food e.g norovirus) • UK 1 in 4 people pa (Tam et al 2011) • UK norovirus – 3 million – mostly non foodborne – Respiratory infections – Emerging infections – new agents/strains • Influenza “pandemic” strains • Antibiotic resistant strains are also a community problem – CA-MRSA, ESBL & NDM-1-producing strains ID risk in the community is increasing • Increasing “at risk” groups needing special care – Up to 1 in 5 people in the European community – Including - otherwise healthy - elderly, very young, pregnant mums etc, – underlying disease: HIV/AIDS • Increasing healthcare at home – shorter hospital stays – post-surgical care – home-based treatments: chemotherapy, dialysis etc – Reduced health spending - but gains likely to be undermined by inadequate infection control at home Antibiotic resistance • Tackling antibiotic resistance is a global priority • Hygiene can: – reduce the need for antibiotic prescribing, major underlying contributor. – reduce the silent epidemic spread of resistant strains (e.g. MRSA, ESBL and NDM-1-producing strains) in the community. The cycle of infection • • Healthcare workers now accept that reducing infection in healthcare settings cannot be achieved without also reducing circulation of pathogens (norovirus, MRSA etc) in the community. hygiene in home and everyday life settings must not become weak link in the chain? Changes demand new strategies • Increasingly hygiene recognised as a cost effective strategy to reduce ID burden and address problem of antibiotic resistance • To be effective and sustainable – must involve everybody – must be a shared responsibility The International Scientific Forum on Home Hygiene (IFH) www.ifh-homehygiene.org • Established 1997 - not-for profit, non-government organisation. • Need for body to speak from a scientific/medical viewpoint about hygiene in home and everyday life settings Primary objectives: • Raise awareness of the fundamental role of hygiene • Promote understanding of home hygiene practice • Ensure home hygiene is based on the scientific evidence IFH targeted approach to hygiene • IFH has developed a “new” approach to hygiene in the home and community - designed to meet 21st century challenges – known as “targeted hygiene”. • Based on risk management approaches - now the standard approach to control microbial risks in food and pharmaceuticals – and hospitals – means identifying critical points and targeting hygiene at these risk points IFH targeted approach to hygiene breaking the chain of infection Targeted hygiene: the chain of infection Sources of infection swallowed Cuts and grazes faeces Way Way in in Eyes and nose coughs Way Way out out inhaled hands Hand contact surfaces Food cloths contact surfaces Spread Spread baths, Clothing, basins linens air Food particles sneezes Developing a “targeted” approach to home hygiene • Critical control points identified by assessing microbiological data for each site or surface to determine: • Is it likely to be contaminated with pathogens/germs? • Are the pathogens likely to be spread from the site or surfaces such that family members become exposed? • If the answer to both questions is yes, then there is a need for hygienic cleaning to reduce the risk of spread The chain of infection transmission in the home and everyday life settings, and the role of hygiene in reducing the risk of infection. (www.ifh-homehygiene.org) Identifying critical points Hands Hand contact surfaces Food contact surfaces Clothing and household linens Cleaning cloths/ utensils Toilets, baths, sinks,washbasins Floors, walls, furniture etc Increasing risk Targeted hygiene: breaking the chain of infection means “hygienic cleaning” to eliminate pathogens from critical sites before they can spread further What do we mean by “hygienically clean” “a level of germs which is not harmful to health” But • infectious dose varies: – viruses: 1-100 particles – bacteria: may be 10 --> as high as 106 – Salmonella: amplified following transfer to food • Depends on susceptibility - may be lower for “at risk” groups • Without precise data - seems reasonable that : – where there is significant risk of pathogen spread (i.e for critical control points) – aim should be to get rid of as many germs as possible Methods for “hygiene cleaning” Detergent/soap-based hygienic cleaning - removal • To be effective as a hygiene measure it must be applied in conjunction with a thorough rinsing process - to wash germs away from hands • Wiping hands is not sufficient Microbiocidal hygiene products – inactivation in situ • In some cases a product or process which inactivates/ kills pathogens in situ is required – Microbiocidal product (disinfectant, alcohol hand sanitizers) – AHS for consumer use mostly 60-70%v/v ethanol – Antibacterial hand soaps and handwash products Hygiene procedures to prevent cross contamination from and via hands In vivo tests* - efficacy of HWWS and alcohol hand sanitizers in removal of bacteria from hands (from Bloomfield et al. 2007) Agent Hand washing with soap Ethanol 60 –70% Test organism applied to hands E. coli S. aureus E. coli, S. aureus Contact time Average log reduction 15-30 secs 1 min 30 secs 1 min 0.5 – 2.8 2.6 - 3.2 3.4 - 3.7 3.8-4.3 *Studies, based on European and US standard methods Efficacy against viruses - HWWS • In home and everyday life settings, efficacy against viruses key - many common infections transmitted in the home are viral (rotavirus, norovirus, rhinovirus and adenovirus). • Assumed that HWWS is effective in removing viruses from hands, surprisingly little data to support this. • Study show viruses can be transferred from person to person via hand soap. (JHI 2000;46:61-6.) In vivo* efficacy of ethanol formulations against non enveloped viruses 70% ethanol formulations 60-62% ethanol formulations Sattar 2000 Lages 2008 Sattar 2011 Mbithi 1993 Ansari Gehrke 2004 1989 Kampf 2005 Paulman 2011 Contact 10sec 30sec 20sec 10sec 10sec 30sec 30sec 30sec Rotavirus >3 Adenovirus >3 Rhinovirus >3 3.78 2.66 2.4 Hep A FCV MNV 0.89 0.5 <1 apprx 3 Efficacy HWWS against bacterial strains 0.5-2.8 log in 30 secs *finger pad method Sattar or ASTM 1174 panel test method 4.69 Efficacy of new AHS formulations (Macinga et al 2008) Log reduction – in vitro assay 62% ethanol handrub Log reduction on hands – in vivo assay 70% ethanol + synergistic blend of polyquaternium‐37/citric acid. 30 sec 30 sec Rotavirus >5.7 >4.7 >3.6‐>4.3 Adenovirus 0.5 2.7 >3.1 Poliovirus 0 3.5 3.0 FCV 1 >4.2 >4.7 MNV 1.2 >3.6 >3.6 Hep A 0 1.7 1.3 potentiation by acids virus specific :greater activity against HAV when acid absent. IFH concludes AHS use advisable where one of more of the following apply: • Hygiene failure carries a risk of serious consequences e.g handling raw contaminated food in the kitchen • Surface rinsing is not possible (no access to soap and water) • Microbes are strongly attached to the surface e.g hands after handling of raw poultry • infectious source (people, domestic animals) or “at risk” groups present in the home LR maximised by HWWS followed by AHS Systematic review of Intervention studies impact of hand hygiene on RT and GI infections Type of infection Area of study Risk reduction from HWWS AHS (No. of studies w. significant result) Gastrointestinal Respiratory Developed countries Developing countries Developed and Developing (No. of studies w. significant results 48-57% 20-50% (3/5 studies) (3/4 studies) - 26% to 79% (7/11 studies) 20%-51% 13–26% (2/6 studies) (2/4 studies) (from Bloomfield et al 2007) How de we assess the impact of hygiene on health (infection rates)? QMRSA - Infection risks from hand-to-mouth contact after handling raw beef contaminated with E. coli O157 (US population 100 million) Median risk reduction Intervention Log reduction on hands No of infections per year No handwashing 0 0.7 HW c. soap 0.7 0.014 98% (cf no HW) Use of alcohol handrub 4.3 0.00005 99.9996% (cf HW) QMRA data shows health benefit from an increased log reduction may be insignificant for an individual, but translate into a significant decrease in disease burden in national population. Haas et al 2002 Could we improve effectiveness of hand hygiene procedures? • Efficacy of HWWS – optimising impact of: – Soap formulation – Hand rubbing – Rinsing – Drying • Efficacy of AHS Promoting hygiene practice in the home and community - putting theory into practice Major needs are: • A more integrated approach – Food, respiratory, healthcare etc hygiene is dealt with/ptomoted by separate agencies – Need to develop approach which looks at hygiene from point of view of the family – A lead agency to co-ordinate hygiene in home and everyday life • Develop hygiene promotion programmes – Achieving attitude and behaviour change – Supporting hygiene professionals working in the community – Hygiene education in schools IFH communications strategy • IFH communication materials : – Guidelines and training materials – Home Hygiene Training Resource produced in collaboration with IPS – including section on where there is more risk – Plain language “fact/advice” sheets • All available to download from www.ifh-homehygiene.org Hygiene education in schools • EU-funded e-Bug project • (www.e-bug.eu) • Teaching pack for primary and secondary schools • Aim – ensure all children in Europe leave school with basic understanding of hygiene and antibiotic resistance – chain of infection, hand, respiratory and food hygiene • Translated into 27 European languages IFH Scientific Advisory Board • • • • • • • • Sally F. Bloomfield, London School of Hygiene and Tropical Medicine Elizabeth Scott, Simmons College, Boston , USA Martin Exner, University of Bonn, Germany Gaetano Fara, Sapienza University of Rome, Italy KJ Nath , Sulabh International Social Service Organization, Calcutta, Carlo Signorelli, University of Parma, Italy Rijkelt Beumer, University of Wageningen, NL Carolien van der Voorden, Water Supply and Sanitation Collaborative Council, Geneva Food hygiene - Risks associated with preparation of a meal using a chicken contaminated with Salmonella or Campylobacter No of participants in each group = 20 After Meal Preparation Chopping bd Utensils Hands Dishcloth Taps Sink Surround Sink Rim Condiments 60 5 35 25 5 30 10 5 Door handles – cupboard, fridge, oven, etc 10 TOTAL 17.3 UK and US data: • up to 50% of raw chicken in the US market carries either Salmonella or Campylobacter • In UK - 1 in 25 homes prepare a meal with a Salmonella and/or Campylobacter contaminated chicken every day Infectious dose: •Salmonella: 102 to 106cfu - but risk amplified by transfer to food or wet cloths •Campylobacter: 100-500cfu Cogan, Bloomfield and Humphries, Letts in Appl.Micro. 1999, 29,354-358 Hand hygiene - Transmission of bacteriophage X174* from hands following person to person contact and handwashing Phage re-isolation - Log count Volunteer 0 1 2 3 4 5 6 Horizontal transmission from contaminated door knob 7.0 4.6 2.6 1.0 1.0 1.3 0 Vertical transmission - hand to hand 7.0 4.4 3.7 2.9 2.7 1.0 - Infectious dose: norovirus: 6-10 particles rhinovirus:1 particle Evidence shows that: • flu and cold virus can be spread via hands and hand contact surfaces (reviewed by Eccles - IFH website. • rhinovirus - “self inoculation by rubbing nasal mucosa can lead to infection” (Hendley et al. 1973) * model virus c. resistance properties similar to polio- or parvoviruses Rheinbaben et al. 2000, J. Hosp Infection, 46, 61-66 In vitro - efficacy of alcohol-based hand sanitizers against bacteria and fungi Microorganism Type Species Gram-Positive and GramNegative Bacteria Clostridium difficile; Corynebacterium diphtheriae; E. faecalis (vancomycinresistant); E facecium (vancomycinresistant); Listeria monocytogenes; Staph.aureus (methicillin-resistant); Streptococcus pneumoniae; Staph. pyogenes; Pseudomonas aeruginosa; E. coli (including O157;H7); Salmonella enteritidis; Salmonella typhimurium; Serratia marcescens; Shigella dysenteriae; Shigella sonne Aspergillus flavus; Aspergillus niger; Candida albicans; Candida tropicalis; Epidermophyton floccosum; Penicillium citrinum; Trichophyton mentagrophytes Fungi Log10 Reduction Reference >4.20 to >5.00 Hammond et in 30 secs al 2000 >3.92 to >6.4 in 30secs Hammond et al. 2000 In vitro tests - efficacy of alcohol-based hand sanitizers against viruses Type Species Product Contact Log10 time Reduction 30 secs >5 Reference Enveloped HIV herpes type A; viruses influenza type A2 Ethanol 62% parainfluenza type 2&3; type 1; hepatitis A; influenza type A2; herpes type 1 NonAdenovirus type 2; enveloped rhinovirus type 14 & viruses 37; coxsackie B3 Ethanol 62% 30 secs >4.1 to>5.0 Fendler et al. 2002 Ethanol 62% 30 secs Ethanol 62% 30 secs Rhinovirus type 16 calicivirus (surrogate for norovirus) 30 secs n propanol 50% 0.5 - 3 Ethanol mins 50% Hammond et a 2000 1.25 to 2.75 Fendler et al 2002 >4.25, Hammond et a 2000, Fendler et al 2002 >4 2.19 to >4 Gehrke et al 2004 In vivo (panel test) efficacy of new AHS formulations against non enveloped viruses Log reduction on hands Various studies Macinga et al 2008 62‐75% ethanol Rotavirus Adenovirus Rhinovirus Poliovirus Hep A FCV MNV 10‐30 sec 2.4 ‐ >3 >3 >3 0.9 0.5‐3.8 3‐ 4.7 75% 70% ethanol + synergistic blend ethanol of polyquaternium‐37/citric acid. 30 sec 15sec >4.3 >3.1 30sec >3.8 >3.1 2.9 1.3 0.9 2.5 potentiation by acids virus specific :greater activity against HAV when acid absent. In vivo (panel test) efficacy of new AHS formulations Log reduction – in vitro assay 62% ethanol handrub 70% ethanol + synergistic blend of polyquaternium‐37/citric acid. 30 sec Rotavirus Adenovirus Poliovirus FCV MNV Hep A >5.7 0.5 0 1 1.2 0 Log reduction on hands – in vivo assay >4.7 2.7 3.5 >4.2 >3.6 1.7 30 sec >3.6‐>4.3 >3.1 3.0 >4.7 >3.6 1.3 potentiation by acids virus specific :greater activity against HAV w