By Thomas OH, Ph.D., Medical & Scientific Affairs for ASIA PACIFIC (Schülke & Mayr)
Limiting transmission of the COVID-19 pandemic in the healthcare setting requires a wide range of infection prevention measures. Standard infection control precautions (SICPs) are the basic steps necessary to reduce the risk of transmission of infectious agents. They should be used by all staff, in all care settings, at all times, for all patients. [DHSC, 2020] A critical and basic element of SICPs is hand hygiene, which is essential to reduce the transmission of infection in hospitals and other healthcare settings.
This article examines hand hygiene guidelines for health workers and considers the role of alcohol based hand rubs (ABHRs) as well as offering guidance on selecting the most suitable ABHRs for use in the healthcare setting.
The latest guidance from the Department of Health and Social Care [DHSC, 2020] reiterates the WHO, 2009 ‘5 Moments for Hand Hygiene’. Hands must be cleaned immediately before and after every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination, waste handling and touching the patient’s surroundings.
Hand hygiene includes the use of ABHR for routine hand hygiene and hand washing with soap and water, including thorough drying, if hands are visibly soiled or dirty. [DHSC, 2020]
The technique for hand washing must be carried out thoroughly and for a time period sufficient to inactivate the virus which is 40 to 60 seconds. [DHSC, 2020]
Recent advice from the US based Centers for Disease Control and Prevention (CDC) states that although ‘hand washing mechanically removes pathogens ….. laboratory data demonstrate that 60% ethanol and 70% isopropanol, the active ingredients in CDC recommended alcohol-based hand sanitizers, inactivates viruses that are genetically related to, and with similar physical properties as, the 2019-nCoV.’ [CDC, 2020]
ABHR must be available for all staff as near to the point of patient care as possible, where this is not practical, personal dispensers should be used. The technique for use of ABHR to decontaminate hands must be carried out thoroughly and for a time period sufficient to inactivate the virus which is usually 30 seconds (but the manufacturer’s instructions should always be followed). [DHSC, 2020]
Since the COVID-19 pandemic, ABHRs have been in short supply due to the surge in demand both from healthcare facilities and the general public. This has led to a plethora of ‘new’ ABHR manufacturers including gin distilleries and breweries. Considerable caution needs to be exercised in selecting an ABHR for hospital use. A substandard hand rub/gel could have undesired consequences, such as sub-optimal antimicrobial efficacy and skin incompatibility for staff and patients, particularly in this current pandemic.
The formulation of an ABHR is critical. The antimicrobial agents within the product need to work in conjunction with added components like moisturiser, without compromising each other. An ABHR for use in hospitals should conform to the stringent testing governed by for example European Norm (EN): EN 1500, EN 12791 and EN 14476.
European Norm (EN) 1500 is utilised in Europe for testing of ABHRs to reduce the level of microbes for normal hand hygiene practices whereas EN 12791 tests for surgical hand hygiene. Both EN tests require healthy test volunteers and the hand rub being tested is challenged against a reference active agent. This is a rigorously defined process to examine the efficacy of a particular hand disinfectant.
The EN 14476 involves testing for efficacy against viruses and is a specific in vitro test of the ABHR formulation against viruses including enveloped viruses, such as SARS-CoV-2 that causes COVID-19.
There are significant differences in efficacy between products that have been certified in accordance with the applicable European standards, compared to non-certified products. A study comparing a certified ABHR with a non-certified one showed that even after participants had been trained to EN 1500 standards in hand hygiene, the bacterial burden was only reduced by 6-fold from baseline using the non-certified product compared to close to 50-fold from baseline with the certified one. [Babulek, 2014]
A useful starting point therefore for selecting an ABHR is to check if it conforms to EN standards. For example, desderman® pure gel meets EN1500 for hygienic hand disinfection in 30 seconds and EN12791 for surgical hand disinfection in 90 seconds as well as EN14476 for virucidal efficacy.
The alcohol component of the hand rub is the main active ingredient to eliminate microorganisms. Besides its rapid killing action, the fast drying time is also an advantage when it comes to hand sanitising. 60 -70% alcohol (commonly ethanol/isopropanol) is the concentration demonstrated to be effective against enveloped viruses, such as those causing COVID-19. [CDC, 2020]
Although non-alcohol hand rubs are available, they need to contain alternative active(s) such as chlorhexidine or benzalkonium chloride. Although these actives are antimicrobial, much longer contact times are required for appreciable efficacy to be achieved. Likewise, drying times are considerably longer than those achieved by ABHRs. However, if a user is allergic to alcohol, the best option is likely to be hand-washing with a gentle soap.
Most hospital-grade ABHRs are formulated with additional moisturisers to help protect the hands. This is essential in the hospital environment where staff cleanse their hands on average at least ten times an hour. [Albright, 2018] It is worth checking if an ABHR manufacturer has conducted dermatological tests to ensure the product is gentle on the skin.
Hand hygiene has long been acknowledged as the single most important measure to prevent nosocomial infections in the healthcare setting. It is universally recognised as a key element in helping prevent the spread of infectious diseases. [WHO, 2009] Never has the importance of effective hand hygiene been more relevant than it is today, in this current pandemic.
References
Albright J, Use patterns and frequency of hand hygiene in healthcare facilities: Analysis of electronic surveillance data, American Journal of Infection Control 2018, 46, 1104-9
Babulek R et al, Hand hygiene–evaluation of three disinfectant hand sanitizers in a community setting, PLoS One. 2014 Nov 7;9(11):
CDC Statement for Healthcare Personnel on Hand Hygiene during the Response to the International Emergence of COVID-19, 14th March 2020
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/hcp-hand-sanitizer.html accessed 27th March 2020
Department Health and Social Care, 24th March 2020, COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0
World Health Organisation, WHO guidelines on hand hygiene in health care, 2009
