Download Hand hygiene in home healthcare and everyday life

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
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•
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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