UK: Norovirus Season Starts Early

80% of Norovirus Outbreaks occur between November & April - Credit CDC 

 

# 6710

 

 

Whether you call it Norwalk or Norovirus – the more descriptive `Winter Vomiting Bug’, or the less accurate `stomach flu’  - the virus behind millions of cases of gastroenteritis each year can pack more misery into 72 hours than should be allowed by law.

 

Long the scourge of crowded institutions - like nursing homes, cruise ships, hospitals and schools - the virus also circulates readily in the community, taking advantage of low levels of human immunity and its ease of spread.

 

After exposure and a short incubation period (12-24 hours), the victim usually experiences nausea, frequent vomiting & diarrhea, and stomach pain – and may also experience headache, fever, and body aches.

 

The illness generally runs its course in 1 to 3 (very long) days, and most people recover.

 

But among those who are aged or infirmed, the virus can take a heavy toll. According to the CDC, each year the norovirus:

 

• causes about 21 million cases of acute gastroenteritis (inflammation of the stomach or intestines or both)
• contributes to about 70,000 hospitalizations and 800 deaths, mostly among young children and the elderly

 

Last month in JAMA, a study of 407 norovirus outbreaks across 308 nursing homes showed an 11% increase in fatalities during times when a facility was experiencing an outbreak.

 

JAMA. 2012 Oct 24;308(16):1668-75.

Hospitalizations and mortality associated with norovirus outbreaks in nursing homes, 2009-2010.

Trivedi TK, DeSalvo T, Lee L, Palumbo A, Moll M, Curns A, Hall AJ, Patel M, Parashar UD, Lopman BA.

 

A short (2 minute) video on this paper may be viewed below. Among their recommendations, it is important to identify an outbreak early, take preventative measures, and nursing staff who become infected should not return to work until at least 48 hours after their symptoms have abated.

 

 

 

Already this winter, I’m aware of a couple of outbreaks here in Central Florida, and in the post-hurricane Sandy recovery, we’ve media reports that Viral outbreak at Hurricane Sandy evacuation shelter shuts 3 Brooklyn schools.

 

And from the UK today,  reports that their `winter vomiting bug season’ has gotten off to an early start.

 

Stomach flu earlier, worse in Britain

Published: Nov. 11, 2012 at 12:35 AM

LONDON, Nov. 11 (UPI) -- Norovirus, or the stomach flu, is 27 percent higher in Britain than at the same time last year and six weeks earlier than usual, health officials say.

(Continue . . .)

 

Earlier this week, the HPA posted the following notice on their Syndromic Surveillance site, indicating reports of vomiting were elevated, suggesting `community-based norovirus activity’.

 

 

One of the keys to prevention is good hand hygiene.

 

Unfortunately, unlike with many other bacteria and viruses, alcohol gel doesn’t do a particularly good job of killing the virus, as we discussed last year in  CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus.

 

Which makes a good old fashion hand scrubbing with soap and water the best preventative.

 

The primary method of infection is via the fecal-oral route. The CDC describes it this way:

 

Norovirus and Food

Norovirus is a leading cause of disease from contaminated foods in the United States. Foods that are most commonly involved in foodborne norovirus outbreaks include leafy greens (such as lettuce), fresh fruits, and shellfish (such as oysters). However, any food item that is served raw or handled after being cooked can become contaminated with noroviruses.

Norovirus Spreads Quickly

Norovirus can spread quickly from person to person in crowded, closed places like long-term care facilities, daycare centers, schools, hotels, and cruise ships. Noroviruses can also be a major cause of gastroenteritis in restaurants and catered-meal settings if contaminated food is served.

 

The viruses are found in the vomit and stool of infected people. You can get it by

• Eating food or drinking liquids that are contaminated with norovirus (someone gets stool or vomit on their hands, then touches food or drink).
• Touching surfaces or objects contaminated with norovirus and then putting your hand or fingers in your mouth.
• Having direct contact with a person who is infected with norovirus (for example, when caring for someone with norovirus or sharing foods or eating utensils with them).

People with norovirus illness are contagious from the moment they begin feeling sick until at least 3 days after they recover. But, some people may be contagious for even longer.

 

The role of direct aerosolized human-to-human transmission of norovirus remains a bit murky, although there are numerous anecdotal reports that suggest that it happens.

 

The CDC – in a an MMWR report from 2011 called Updated Norovirus Outbreak Management and Disease Prevention Guidelines describes transmission thusly:

 

Transmission

Norovirus is extremely contagious, with an estimated infectious dose as low as 18 viral particles (41), suggesting that approximately 5 billion infectious doses might be contained in each gram of feces during peak shedding. Humans are the only known reservoir for human norovirus infections, and transmission occurs by three general routes: person-to-person, foodborne, and waterborne.

 

Person-to-person transmission might occur directly through the fecal-oral route, by ingestion of aerosolized vomitus, or by indirect exposure via fomites or contaminated environmental surfaces.

 

The CDC recommends the following steps to protect yourself from the virus.

 

 

 

Good advice, but frankly - having already gone through at least one memorable bout with the virus - if I found myself caring for someone with Norovirus in my household, I’d take a few extra precautionary steps.

 

According to:

 

GUIDELINE FOR THE PREVENTION AND CONTROL OF NOROVIRUS GASTROENTERITIS OUTBREAKS IN HEALTHCARE SETTINGS

Taranisia MacCannell, PhD, MSc ; Craig A. Umscheid, MD, MSCE ; Rajender K. Agarwal, MD, MPH ; Ingi Lee, MD, MSCE ; Gretchen Kuntz, MSW, MSLIS ;Kurt B. Stevenson, MD, MPH 3 and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

(EXCERPT)

PERSONAL PROTECTIVE EQUIPMENT

23. If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material.    (Category IB) (Key Question 1.C.4)

  
24. Use a surgical or procedure mask and eye protection or a full face shield if there is an anticipated risk of splashes to the face during the care of patients, particularly among those who are vomiting. (Category IB) (Key Question 3.C.2.a) 

25. More research is needed to evaluate the utility of implementing Universal Gloving (e.g., routine use of gloves for all patient care) during norovirus outbreaks. (No recommendation/unresolved issue) 

 

One of the reasons I keep a generous supply of exam gloves, and surgical (& N95) masks in my emergency kit. 

 

And finally, earlier this year in Norovirus Sequelae we looked at  a new study appearing in Clinical Infectious Diseases that found a link between norovirus infection and ongoing gastrointestinal complaints.

 

Researchers looked at the records of more than 1700 military personnel who were treated for AGE (acute gastroenteritis) during three known norovirus outbreaks.

 

By comparing them to controls, they determined that those with a history of AGE were at increased risk of developing chronic gastrointestinal disorders.

 

Since this was a fairly small study, and some variability was detected in outcomes across the three outbreaks studied, more research will be needed to confirm their findings and to determine how long these after effects may persist.

 

Still, this is one virus that you want to avoid catching, if at all possible.

»» Read More

Lancet: Public Response To The H1N1 Pandemic Of 2009

 

 

# 6610

 

 

During the opening months of the 2009 H1N1 pandemic – before a vaccine was available – about the only advice that public health departments could offer was that people practice good flu hygiene.

 

The CDC’s Action Steps released in September, 2009.

 

1. Get your family vaccinated for seasonal flu and 2009 H1N1 flu.
2. Cover your mouth and nose with a tissue when you cough or sneeze.  If you don’t have a tissue, cough or sneeze into your elbow or shoulder; not into your hands.
3. Practice good hand hygiene by washing your hands often with soap and water, especially after coughing or sneezing.
4. Stay home if you or your child is sick for at least 24 hours after there is no longer a fever or signs of a fever (without the use of fever-reducing medicine). Keeping sick students at home means that they keep their viruses to themselves rather than sharing them with others.

 

And variations of this advice was promoted pretty much worldwide, including this NHS promotion in the UK:

 

 

While many people did adopt these practices, many did not.  In September of 2009 I wrote of my own encounter with with an unrepentant public sneezer in a blog called  `Being A Sneeze Guard’.

 

And in a blog called And Yet, They Still Call It Wellington, we looked at a New Zealand study that found poor flu hygiene compliance during the 2009 pandemic.

 

Today, The Lancet has published a review of flu compliance that has garnered a good deal of press overnight, particularly in Britain, where compliance was less than sterling.

 

Public response to the 2009 influenza A H1N1 pandemic: a polling study in five countries

Dr Gillian K SteelFisher PhD , Robert J Blendon ScD , Johanna RM Ward MSc , Robyn Rapoport MA , Emily B Kahn PhD , Katrin S Kohl MD

 

 

Although the full text is behind a pay wall, the Fergus Walsh with the  BBC has a report with some of the details.

 

Britons 'kissed through swine flu'

(Excerpt)

Researchers at Harvard School of Public Health in Boston questioned nearly 5,000 people. Just 25% of British people surveyed said they more frequently coughed or sneezed into their elbow or shoulder during the pandemic compared with 82% in Mexico and 84% in Argentina. Some 53% of Britons said they washed their hands or used hand sanitizer more frequently, compared with 89% in Argentina, and 72% in Japan and the US.

 

Just 2% of Britons said they avoided hugging or kissing family or friends compared with 46% of those questioned in Mexico and 21% in the US.

(Continue . . .)

 

 

It wasn’t just the general public displaying a cavalier attitude during the pandemic - something I wrote about in Hand Hygiene Among Doctors Exposed. That concerned an observational study conducted at two scientific conferences on the hand washing habits of doctors.

 

The first was the 26th Meeting of the Scandinavian Society on Antimicrobial Chemotherapy (SSAC) in Tromsø, Norway, and second took place at the International Congress on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco, CA.

 

Both took place in September 2009, during the height of the pandemic.

 

Observers stationed in the men’s and women’s restrooms kept track of the hand washing compliance among the men and women (mostly infectious disease specialists) attending these conferences.

 

The results, while better than others we’ve seen among the general public, were still less than comforting.

 

The study appeared in the  AJIC (American Journal of Infection Control) and was called:

 

Do as I say, not as I do: Handwashing compliance of infectious diseases experts during influenza pandemic

Anu Kantele, MD, PhD, Mari Kanerva, MD, PhD, Mikko Seppänen, MD, PhD, Jussi Sutinen, MD, PhD, Kirsi Skogberg, MD, PhD, Laura Pakarinen, MD, Iiro H.S. Jääskeläinen, MD, Inko Aho, MD, Asko Järvinen, MD, PhD, Taru Finnilä, MD Jukka Ollgren, PhD

 

The bottom line was that in San Francisco only 69% of the men were observed to wash with soap and water, and 86% of the women. Results from the conference in  Tromsø, Norway conference were even more disturbing, with just 38% of the men, and 84% of the women using soap and water.

 

You’ll find a lot more on this subject in Giving Germs A Helping Hand, which looked at low handwashing compliance among doctors and other healthcare providers.

 

To try to encourage better hand hygiene among health care providers, the CDC has a hand hygiene website  with  many resources, including a link to a new iPad/iPhone application called iScrub.

 

»» Read More

Norovirus Sequelae

 

 

# 6404

 

 

Last month I wrote a blog called Norovirus: The Gift That Keeps On Giving, about an outbreak of this nasty gastrointestinal malady among a group of teenage girls at a soccer tournament in 2010.  

 

It now appears that the above title may have been more appropriate than I imagined, as a new study appearing in Clinical Infectious Diseases finds a link between norovirus infection and ongoing gastrointestinal complaints.

 

According to the CDC norovirus sickens more than 20 million Americans every year, hospitalizes up to 70,000, and contribute to 800 deaths.  The CDC maintains an extensive Norovirus webpage where they describe the illness, how it is spread, and how to avoid infection.

 

 

As if enduring 24 to 48 hours of vomiting and diarrhea wasn’t enough, today’s study suggests that those who experience a norovirus infection are at substantially greater risk of developing chronic dyspepsia, constipation and GERD (Gastroesophageal reflux disease).

 

In the following study researchers looked at the records of more than 1700 military personnel who were treated for AGE (acute gastroenteritis) during three known norovirus outbreaks. 

 

By comparing them to controls, they determined that those with a history of AGE were at increased risk of developing chronic gastrointestinal disorders.

 

Since this was a fairly small study, and some variability was detected in outcomes across the three outbreaks studied, more research will be needed to confirm their findings and to determine how long these after effects may persist.

 

 

 

Post-infectious gastrointestinal disorders following norovirus outbreaks

Chad K. Porter1, Dennis J. Faix, Danny Shiau, Jennifer Espiritu, Benjamin J. Espinosa, and Mark S. Riddle

Results. We identified 1,718 subjects from three outbreaks. After controlling for important demographic covariates, the incidence of constipation, dyspepsia and GERD was approximately 1.5 fold higher (p<0.01) in AGE exposed subjects than matched subjects. We also noted variability in outcome incidence across outbreaks.

Conclusions. It appears that the risk of dyspepsia, constipation and GERD are higher among those who have AGE during a confirmed norovirus outbreak. While these findings need confirmation, they suggest that dysmotility may result subsequent to these infections. If confirmed, the costs and morbidity associated with the chronic consequences of norovirus should be considered.

Dysmotility is a generic medical term to describe diseases of the GI tract (esophagus, stomach, small and large intestines) where the muscles do not function properly.

 

The primary route of infection is the fecal-oral route (although there is evidence it can also be airborne), and the best intervention is . . . you guessed it . . .  washing your hands.

 

Unfortunately, unlike with many other bacteria and viruses, alcohol gel doesn’t do a particularly good job of killing the virus, as we discussed last year in  CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus.

 

For more information, the CDC’s hand hygiene website provides many useful resources, including a link to a new iPad/iPhone application called iScrub.

 

»» Read More

Global Clean Your Hands Day: 2012

 

 

 

Five steps to 5 May 2012 - What's YOUR plan?

 

# 6316

 

 

Tomorrow, May 5th, is being promoted by the World Health Organization as global  CLEAN YOUR HANDS DAY - to encourage HCWs (Healthcare workers) to improve and sustain hand hygiene practices around the world.

 

While exact numbers are unknown, it is estimated that tens . . . perhaps hundreds of millions of people around the world are adversely affected by what are largely preventable  health care-associated infections (HCAI) each year.

 

Most of these infections could be prevented by HCWs maintaining good hand hygiene – cleaning their hands properly, and at the appropriate time.

 

Last year we saw the introduction of the 5 moments for hand hygiene campaign.

 

 

This from the World Health Organization.

WHO Save lives: clean your hands global annual campaign

Date: 5 May 2012

Each year, hundreds of millions of patients all around the world are affected by health care-associated infections (HCAI). Although HCAI is the most frequent adverse event in health care, its true global burden has been unknown because of the difficulty in gathering reliable data. However, recent work by WHO and others highlights that developing countries are more affected. Most health care-associated infections are preventable through good hand hygiene – health-care workers cleaning hands, at the right times and in the right way.

The Save Lives: clean your hands global annual campaign, launched in 2009, is a day in which WHO is committed to 'bringing people together to improve and sustain hand hygiene'. Overall it is an opportunity to:

• be part of a global movement to improve hand hygiene and receive acknowledgement of this from WHO;
• be one of the leaders helping to prevent HCAI in your country; subsequently saving lives;
• receive support for moving from commitment to action at the point of patient care;
• share your knowledge and successes with others;
• join a network of countries that have already committed to sustained hand hygiene campaigning; and
• demonstrate your commitment to making patient safety a priority.

Related links

• More about Save lives: clean your hands
• More about the burden of health care-associated infections and the evidence for clean hands
• More about country or area campaigns
• More about sharing your knowledge

 

 

 

Lest anyone think that this is just a problem in developing countries, the CDC reports that every year about 2 million Americans get a hospital associated infection (HAI), and as many as 100,000 people die each year as a result.

 

A point driven home repeatedly by Maryn McKenna in her book, Superbug: The Fatal Menace of MRSA which I reviewed here.

 

Remarkably, Maryn points out that 50% of health care workers fail to consistently wash their hands between patients.

 

 

Whether you work in a healthcare setting or not, today would be a good day to visit the CDC’s hand hygiene website, where you will find many resources, including a link to a new iPad/iPhone application called iScrub.

 

 

To round out this entry, some oldies but goodies from the AFD archives.

 

Doing The Hand Jive

Referral: Maryn McKenna On Hand Hygiene

Gonna Wash Those Germs Right Off Of My Hands

 

A collection of Hand Washing posters can be found at:

 

http://www.cdc.gov/handhygiene/Resources.html

 

And lastly, a return engagement by that consummate entertainer, one that Maryn McKenna  introduced me to a few years ago . . .  the one you all know and  love . . give it up for GERMY, in the award winning all singing, all dancing production of Soapacabana!

»» Read More

A Barrier To Good Hand Hygiene

 

 

 

# 5939

 

 

It sounds counter-intuitive. 

 

That the use of latex (or vinyl) gloves could contribute to reduced hand hygiene compliance in health care settings. 

 

But that is exactly what a study - published in the December issue of Infection Control and Hospital Epidemiology – has uncovered.

 

The study, which was conducted at 15 hospitals in the UK, found that hand hygiene compliance – even in this age of heightened awareness of infection control - was `disappointingly low’.

 

Overall hand hygiene compliance was observed to be just 47.7%, while the use of gloves was associated with a further decrease to just 41%.

 

It would appear that the use of gloves can lead to a false sense of security, and the result is a reduction in hand hygiene.

 

The following press release comes from SHEA, the  Society for Healthcare Epidemiology of America. 

 

Latex gloves lead to lax hand hygiene in hospitals, study finds

CHICAGO -- Healthcare workers who wear gloves while treating patients are much less likely to clean their hands before and after patient contact, according to a study published in the December issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. This failure of basic hand hygiene could be contributing to the spread of infection in healthcare settings, the researchers say.

 

Glove use is appropriate for situations when contact with body fluids is anticipated or when patients are to be managed with contact precautions. However, use of gloves should not be considered a substitute for effective hand hygiene practices taking place before and after patient contact. Although gloves can reduce the number of germs transmitted to the hands, germs can sometimes still get through latex. Hands can also be contaminated by "back spray" when gloves are removed after contact with body fluids.

 

The researchers, led by Dr. Sheldon Stone of the Royal Free Hospital NHS Trust, observed more than 7,000 patient contacts in 56 intensive care and acute care of the elderly wards in 15 United Kingdom hospitals, making this one of the largest and most detailed studies on gloves and their impact on hand hygiene. Overall, the study found that hand hygiene compliance was "disappointingly low," at just 47.7 percent. Compliance was even lower in instances where gloves were worn, dipping to just over 41 percent.

 

"The chances of hands being cleaned before or after patient contact appear to be substantially lower if gloves were being worn," said Dr. Stone, the principal investigator. "We call this the phenomenon of the 'Dirty Hand in the Latex Glove.'"

(Continue . . . )

 

Cite: Christopher Fuller, Joanne Savage, Sarah Besser, Andrew Hayward, Barry Cookson, Ben Cooper, Sheldon Stone. The Dirty Hand in the Latex Glove: A Study of Hand-Hygiene Compliance When Gloves Are Worn. Infection Control and Hospital Epidemiology 32:12 (December 2011)

 

Given the huge burden of HAIs (Hospital Acquired Infections), the subject of hand hygiene comes up frequently in this blog. 

 

You’ll find a lot more on this subject in last month’s Giving Germs A Helping Hand, which looked at low handwashing compliance among doctors and other healthcare providers.

 

On May 5th of this year the World Health Organization promoted a CLEAN YOUR HANDS DAY  to encourage HCWs to improve and sustain hand hygiene practices around the world.

 

Clean Care is Safer Care

First Global Patient Safety Challenge
Clean Care is Safer Care

 

Additionally, the CDC’s hand hygiene website  has many resources, including a link to a new iPad/iPhone application called iScrub.

 

 

To round out this entry, some oldies but goodies from the AFD archives.

Doing The Hand Jive

Hand Hygiene Among Doctors Exposed

Gonna Wash Those Germs Right Off Of My Hands

»» Read More

Before You Ask To Borrow Someone’s Cell Phone . . .

 

 

# 5898

 

 

Just in time for Global Handwashing Day – which is tomorrow, October 15th – we’ve a report from the London School of Hygiene & Tropical Medicine that should give one pause before asking to borrow another person’s cell phone.

 

Contamination of UK mobile phones and hands revealed

One in six mobile phones in the UK is contaminated with fecal bacteria, researchers found

 

One in six mobile phones in Britain is contaminated with faecal matter, according to new research released ahead of Global Handwashing Day.

 

Experts say the most likely reason for the potentially harmful bacteria festering on so many gadgets is people failing to wash their hands properly with soap after going to the toilet.

 

The findings of the UK-wide study by scientists from the London School of Hygiene & Tropical Medicine and Queen Mary, University of London also reveal a tendency among Britons to lie about their hygiene habits.

 

Although 95% of people said they washed their hands with soap where possible, 92% of phones and 82% of hands had bacteria on them. Worryingly, 16% of hands and 16% of phones were found to harbour E. coli – bacteria of a faecal origin. Harmful E. coli (Escherichia coli) is associated with stomach upsets and has been implicated in serious cases of food poisoning such as the fatal O157 outbreak in Germany in June.

 

(Continue . . .)

 

 

BBC News has a short (2 minute) video on this story, showing how the testing of mobile phones was accomplished.

 

 

While cell phones were the subject of this study, in truth anything and everything we touch can harbor bacteria.  Door knobs, computer keyboards, shopping cart handles, elevator buttons, credit cards, cash . . . .

 

And as the movie `Contagion’ pointed out so effectively, we touch our faces 3 to 5 times every waking minute, and in between we are touching hundreds of other (likely contaminated) surfaces every day.

 

The opportunities for introducing pathogens into your body via your eyes, nose or mouth are abundant, and your only real defense is washing your hands as often as possible.

 

And it isn’t just bacteria, like Staph, MRSA, or E. coli that can contaminate surfaces. Viruses can live for hours – and under the right condition, sometimes days – on inanimate surfaces.

 

With cold and flu season upon us, it is all the more reason to carry (and use) a bottle of alcohol sanitizer and to seek out opportunities to wash your hands with soap and water as often as possible.

 

Although better than nothing, hand sanitizers are not always enough. In CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus we saw how these handy sanitizers are not always effective against C. Diff and Norovirus.

 

In Fomite to Fingers To Face: A Triple Play Combination, we looked at how long some of these pathogens could remain viable on surfaces and act as a vehicle of transmission.

 

The 2007 study Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease by Stephanie A. Boone,& Charles P. Gerba found that most viruses survived longer on nonporous surfaces (metal or plastic), and that respiratory viruses (RSV, HPIV, influenza virus, coronavirus, and rhinovirus) could remain viable for hours or even days.

 

Under the right conditions, enteric viruses - like Rotavirus, Norovirus, and Hepatitis A - have been known to survive on fomites from weeks to months.

 

We live in a germy world. 

 

Which is why public health agencies and organizations push hand washing so vigorously.  They know it literally saves lives.

 

As an inveterate hand washer from way back (I was a paramedic during the 1970s, before wearing latex gloves became de rigueur), I’m certainly a believer.

 

I had my hands in an untold number of unspeakable messes, but washed (well . . actually scrubbed) my hands more than a dozen times each day, and managed to stay healthy.

 

For more on all of this I’d invite you to visit:

 

 http://www.globalhandwashingday.org/

 

And the CDC’s hand hygiene website, where you will find many resources, including a link to a new iPad/iPhone application called iScrub.

 

»» Read More

Giving Germs A Helping Hand

 

 

 

# 5892

 

One hundred and sixty-three years ago, a Hungarian physician named Ignaz Semmelweis published a controversial medical book called Etiology, Concept and Prophylaxis of Childbed Fever.

 

At the time, childbed - or puerperal fever - was a common cause of mortality and morbidity among postpartum women. Semmelweis demonstrated that it could be greatly reduced by simply having doctors wash their hands before performing gynecological exams.

 

Sure, that makes sense today, but at the time his theories were considered radical (Pasteur wouldn’t come up with his `germ theory’ for another 17 years).

 

Besides, it was outrageous to suggest that doctors might actually be causing disease and death among their patients.

 

Semmelweis was ridiculed, ostracized and eventually forced to leave his hospital post. He died at the age of 47 in an asylum, a broken man.

 

More than 160 years later, infection control professionals continue to drum the message of proper hand hygiene into HCWs (Health Care Workers), yet lapses remain common.

 

A discouraging report from the Irish Independent.

 

 

Doctors 'worst' at basic hand hygiene

By Eilish O'Regan Health Correspondent

Wednesday October 12 2011

Nearly one in four doctors fails to clean their hands between patients -- increasing the risk of passing on potentially life-threatening infection, a damning report revealed yesterday.

 

The survey of hand hygiene in 36 acute hospitals revealed that doctors were the worst offenders (61pc) and that, overall, nearly three in 10 staff were not following the basic rule of infection control.

(Continue . . .)

 

  
The actual audit report is available on the HPSC (Health Protection Surveillance Center) website.

 

June 2011: Hand Hygiene Audit Results (Period 1)

File Size: (278kB)
Publication Date: 11 October 2011

Frequently Asked Questions on Hand Hygiene Audit Results

File Size: (167kB)
Publication Date: 11 October 2011

 

The `good news’ is that nurses – who likely have the greatest direct contact with patients – were the best at hand hygiene, with a compliance rate of just over 80%.

 

 

The `bad news’ is that this survey may not accurately reflect the level of compliance when auditors are not present.   The report explains:

 

 

3.  Limitations of Auditing Hand Hygiene with Direct Observation 

The results may not be reflective of healthcare worker compliance at all times. Compliance with hand hygiene is measured by auditors observing healthcare workers undertaking patient care. It is well recognised that workers will change their behaviour, if aware that they are being observed (Hawthorne effect).

 

However, it is also known that this effect wears off over time and that healthcare workers under observation may not be aware (due to the many competing demands on their attention) of the presence of the auditor. In addition, the purpose of auditing is to improve practice, therefore any action that improves compliance increases patient safety. Auditors are requested to give immediate feedback to ward staff following an audit, thereby increasing awareness and knowledge of hand hygiene. 

 

While overall compliance was just under 75%, the goal is to raise that to 90% by 2013.

 

Given the heavy burden of HAIs (Hospital Acquired Infections), on May 5th of this year the World Health Organization promoted a CLEAN YOUR HANDS DAY  to encourage HCWs to improve and sustain hand hygiene practices around the world.

 

 

Clean Care is Safer Care

First Global Patient Safety Challenge
Clean Care is Safer Care

The goal of Clean Care is Safer Care is to ensure that infection control is acknowledged universally as a solid and essential basis towards patient safety and supports the reduction of health care-associated infections and their consequences.

 

As a global campaign to improve hand hygiene among health-care workers, SAVE LIVES: Clean Your Hands is a major component of Clean Care is Safer Care. It advocates the need to improve and sustain hand hygiene practices of health-care workers at the right times and in the right way to help reduce the spread of potentially life-threatening infections in health-care facilities.

• Find out more about SAVE LIVES: Clean Your Hands
• More about Clean Care is Safer Care
• The Clean Care is Safer Care team

Below you’ll find some resources from the WHO, including posters, PDF files, and articles.

Five Moments for Hand Hygiene

The newly developed Five Moments for Hand Hygiene has emerged from the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) to add value to any hand hygiene improvement strategy. Quite simply, it defines the key moments for hand hygiene, overcoming misleading language and complicated descriptions. It presents a unified vision and promotes a strong sense of ownership.

 

Not only does the Five Moments align with the evidence base concerning the spread of HAI but it is interwoven with the natural workflow of care and is designed to be easy to learn, logical and applicable in a wide range of settings. Find out more about your Five Moments by clicking the links below.

 

Whether you work in a healthcare setting or not, today would be a good day to visit the CDC’s hand hygiene website, where you will find many resources, including a link to a new iPad/iPhone application called iScrub.

 

To round out this entry, some oldies but goodies from the AFD archives.

 

Doing The Hand Jive

Hand Hygiene Among Doctors Exposed

Gonna Wash Those Germs Right Off Of My Hands

 

And finally a collection of Hand Washing posters can be found at:

 

Suitable For Framing

»» Read More

CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus

 

 

Photo Credit – CDC

 

# 5747

 

While dispensers of alcohol-based hand sanitizers have become ubiquitous in many health care facilities over the past few years, there remain serious questions over just how effective they may be in killing some particularly hearty pathogens.

 

In recent years it has become apparent that alcohol based hand cleansers are not effective at killing the spores of the Clostridium difficile bacteria, and so the CDC offers this advice:

 

How can Clostridium difficile infection be prevented in hospitals and other healthcare settings?

• Use gloves when entering patients’ rooms and during patient care.
• Perform Hand Hygiene after removing gloves.
• Because alcohol does not kill Clostridium difficile  spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. diffile spores is more challenging than the removal or inactivation of other common pathogens.
• Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message.

 

And more recently, we’ve seen increased evidence that these handy hand sanitizers may be `suboptimal’ at killing some nonenveloped viruses (including norovirus), as well.

 

In March of this year, the CDC’s MMWR published a lengthy report that called into question the efficacy of alcohol based products against norovirus:

 

Updated Norovirus Outbreak Management and Disease Prevention Guidelines

(Excerpt)

Overall, studies suggest that proper hand washing with soap and running water for at least 20 seconds is the most effective way to reduce norovirus contamination on the hands, whereas hand sanitizers might serve as an effective adjunct in between proper handwashings but should not be considered a substitute for soap and water handwashing.

 

Today, the CMAJ has an early release news item that summarizes the findings of a couple of recent studies that showed that health care facilities that relied more heavily on alcohol-based sanitizers were more apt to experience outbreaks of norovirus.

 

 

Hand sanitizers may increase norovirus risk

August 10, 2011

 

Alcohol-based hand sanitizers may not be the panacea for hand hygiene they were once supposed, as mounting research indicates they may not be effective substitutes for soap and water, and in some cases may actually increase the risk for outbreaks of highly contagious viruses in health care settings.

 

Public health experts, however, say more rigorous investigations will be necessary to trump the convenience of using hand sanitizers, among other benefits, or substantially alter existing recommendations that strongly encourage their use by health care professionals.

(Continue . . . )

 

You can read the abstract to one of these studies in the May 2011 edition of the  AJIC.

 

Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007

 

David D. Blaney, MD, MPH , Elizabeth R. Daly, MPH , Kathryn B. Kirkland, MD ,Jon Eric Tongren, PhD, MSPH , Patsy Tassler Kelso, PhD , Elizabeth A. Talbot, MD

 

Lead author Dr. David Blaney of CDC’s  Epidemic Intelligence Service is quoted in the CMAJ article as saying that alcohol-based hand sanitizers might be, “suboptimal in controlling the spread of noroviruses.”

 

For now, the efficacy of alcohol based hand sanitizers against norovirus remains controversial at best. More, and better studies will be needed before any firm conclusions can be drawn.

 

None of this is to suggest that hand sanitizers are without value.

 

They are fast and easy - which promotes their frequent use - and when used properly they appear effective against a wide variety of bacteria and enveloped viruses, including colds and influenzas.

 

 

But when dealing with a norovirus outbreak, for now the best policy appears to be washing your hands thoroughly with soap and water.

»» Read More

Fomite to Fingers To Face: A Triple Play Combination

 

 

 

 Photo Credit – CDC 

# 5741

 

Fomites are any surface or object that can become contaminated with viral or bacterial pathogens and that can act as a vehicle of transmission. 

 

Surfaces like the touch screen on your bank’s ATM, the door knob to a public restroom, or the the handle of a shopping cart are touched by scores of people every day.  

 

And some of those people, undoubtedly, are leaving behind bacteria and viruses you really don’t want to get.

 

Last June (see Firefighters & MRSA Revisited) I wrote of a study by researchers from the University of Washington that looked for – and found – MRSA (Methicillin-resistant Staphylococcus aureus) contaminated surfaces at fire houses in Snohomish county.

 

MRSA was detected in 4% of samples taken from places such as kitchens, bathrooms, and rescue vehicles – and researchers also found 30% of firefighters who volunteered to be tested were colonized with either MRSA or S. aureus in their noses.

 

While fomites have long been suspected of playing a significant role in the transmission of diseases, it has only been in recent years that we’ve learned how remarkably resilient many of these pathogens are once they are deposited on an inanimate surface.

 

The 2007 study Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease by Stephanie A. Boone,& Charles P. Gerba found that most viruses survived longer on nonporous surfaces (metal or plastic), and that respiratory viruses (RSV, HPIV, influenza virus, coronavirus, and rhinovirus) could remain viable for hours or even days.

 

Under the right conditions, enteric viruses - like Rotavirus, Norovirus, and Hepatitis A - have been known to survive on fomites from weeks to months

 

It’s a germy world out there, and most people touch their face 10 to 20 times each hour, providing ample opportunities for pathogens to move from fomite to fingers to face.

 

All of which serves as prelude to a study that appears in the August issue of the American Journal of Infection Control that surveyed the hand hygiene knowledge and beliefs of 71 nurses, infection preventionists and hospital environmental services managers.

 

Individual differences in judgments of hand hygiene risk by health care workers

Anne Collins McLaughlin, PhD Fran Walsh, PhD

 

Participants were asked to assess their perceived risk of contracting or spreading an infection in 16 real-life situations. 

 

The authors found that across all levels, healthcare workers perceived surfaces as safer to touch than a patient’s skin, despite studies that have implicated fomites in the chain of disease transmission. 

 

The authors comment:

"Despite the dangers that fomites present, this knowledge may not be common enough among HCWs for them to understand the level of risk when touching surfaces and then touching patients."

 

Studies have shown that although compliance rates are improving, 50% of health care workers in the United States fail to consistently wash their hands between patients (cite).

 

Hospital acquired infections (HAIs) remain a huge problem, and exact a terrible toll on patients and their families.

 

This from the HHS.

 

HHS Action Plan to Prevent Healthcare-Associated Infections: Introduction

Healthcare-associated infections exact a significant toll on human life. They are among the top ten leading causes of death in the United States, accounting for an estimated 1.7 million infections and 99,000 associated deaths in 2002.

 

Of course, this isn’t just a problem in the United States, but also around the world. 

 

So this year the World Health Organization designated May 5th as global  CLEAN YOUR HANDS DAY - to encourage HCWs (Healthcare workers) to improve and sustain hand hygiene practices around the world (see A Movement With Five Moments).

 

 

 

For some earlier blogs on the importance of fomites in the transmission of disease, and the value of hand hygiene you may wish to revisit:

 

CMAJ: Infectious Risks In Family Doctor’s Offices

Hand Hygiene Among Doctors Exposed

MDs Behaving Badly

Suitable For Framing

 

And lastly . . . to start your week off with a smile, a return engagement by that consummate entertainer, one that Maryn McKenna  introduced me to a couple of years ago . . .  the one you all know and  love . . give it up for GERMY, in the award winning all singing, all dancing production of Soapacabana!

Stick around for the outtakes!

»» Read More

A Movement With Five Moments

 

 

# 5540

 

 

Studies have shown that although compliance rates are improving, 50% of health care workers in the United States fail to consistently wash their hands between patients (cite).

 

Compliance rates in many developing countries are even lower, and these lapses in good hand hygiene no doubt lead to hundreds of thousands of HAIs (Hospital Acquired Infections) every year (see HAI: Hospital Acquired Infections).

 

So today, May 5th, is promoted by the World Health Organization as global  CLEAN YOUR HANDS DAY - to encourage HCWs (Healthcare workers) to improve and sustain hand hygiene practices around the world.

 

 

 

Clean Care is Safer Care

First Global Patient Safety Challenge
Clean Care is Safer Care

The goal of Clean Care is Safer Care is to ensure that infection control is acknowledged universally as a solid and essential basis towards patient safety and supports the reduction of health care-associated infections and their consequences.

 

As a global campaign to improve hand hygiene among health-care workers, SAVE LIVES: Clean Your Hands is a major component of Clean Care is Safer Care. It advocates the need to improve and sustain hand hygiene practices of health-care workers at the right times and in the right way to help reduce the spread of potentially life-threatening infections in health-care facilities.

• Find out more about SAVE LIVES: Clean Your Hands
• More about Clean Care is Safer Care
• The Clean Care is Safer Care team

 

 

Below you’ll find some resources from the WHO, including posters, PDF files, and articles on today’s activities.

 

 

 

Five Moments for Hand Hygiene

 

The newly developed Five Moments for Hand Hygiene has emerged from the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) to add value to any hand hygiene improvement strategy. Quite simply, it defines the key moments for hand hygiene, overcoming misleading language and complicated descriptions. It presents a unified vision and promotes a strong sense of ownership.

 

Not only does the Five Moments align with the evidence base concerning the spread of HAI but it is interwoven with the natural workflow of care and is designed to be easy to learn, logical and applicable in a wide range of settings. Find out more about your Five Moments by clicking the links below.

Tools for 5 Moments - English

Leaflet 1
pdf, 529kbLeaflet 2
pdf, 668kbHow to handrub: How to handwash
pdf, 659kbHow to handrub
pdf, 620kbHow to handwash
pdf, 630kb5 moments pocket leaflet
pdf, 968kb

 

 

Semmelweis Revisited

(excerpted from an earlier blog)

 

One hundred and sixty-four years ago, a Hungarian physician named Ignaz Semmelweis published a controversial medical book called Etiology, Concept and Prophylaxis of Childbed Fever.

 

Childbed, or puerperal fever, was a major cause of mortality and morbidity among postpartum women, and Semmelweis demonstrated in his Viennese hospital that its incidence could be greatly reduced by having doctors wash their hands before performing gynecological exams.

 

His theories were considered radical (Pasteur wouldn’t come up with his `germ theory’ for another 17 years), and went against all currently accepted medical science.  Diseases, as everyone knew, were caused by imbalances in one of the `four humours’ in the body, to be cured by bloodletting, and had nothing at all to do with washing one’s hands.

 

Besides, it was outrageous to suggest that doctors might actually be causing disease and death among their patients.

 

Semmelweis was ridiculed, ostracized and eventually forced to leave his hospital post.  He moved to Pest, and frustrated by the lack of acceptance of his theories, often denounced the medical community.

 

His fortunes and reputation suffered greatly due to his unrelenting advocacy of hand hygiene.

 

Eventually, he was committed to an asylum, a broken man, where he died at the age of 47.  It was only in the years after his death, with the addition of Pasteur’s findings, that his theories became universally accepted.

 

Incredibly, and despite 150 years of evidence of proven efficacy, doctors and health care professionals around the world are still not as diligent with hand washing as they should be.

 

And those lapses cost thousands of lives, and billions of dollars in additional medical expenses, every year.

 

This from the CDC on HAI’s (Hospital Acquired Infections)

CDC strives to understand how healthcare-associated infections happen and to develop appropriate interventions. A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

And this is just  the United States, globally the numbers are much, much higher.

Sadly, many of these complications could have been prevented by more stringent hand hygiene.

 

»» Read More

CMAJ: Infectious Risks In Family Doctor’s Offices

 

 

# 5165

 

 

I didn’t used to be a germaphobe.

 

In fact, as a paramedic in the 1970s, I worked without gloves 99% of the time (everyone did) - had my hands in some truly awful messes - and hardly gave it a second thought.  

 

A vigorous application of Betadine scrub (fingertips up to the elbows) was the universal cure-all after every call.

 

Of course, this was before HIV, MRSA, and Hepatitis became threats.

 

Looking back at those days, the lackadaisical attitude over infection control in hospitals, ambulances, and yes . . .  even the morgue  . . .  seems reckless and difficult to fathom now.

 

Fast forward almost (ahem) 40 years, and I now carry a little bottle of alcohol sanitizer in my car, and often in my pocket, where ever I go.  I cringe at the thought of sitting in a crowded doctor’s waiting room, and I wash my hands at least 10 times a day.

 

I even keep some surgical masks and exam gloves in a baggie in my car (and in both of my first aid kits), just in case I’m called upon to help out in a car wreck or other emergency.

 

I admit, I’m somewhat more germ conscious after having read Maryn McKenna’s superb Superbug: The Fatal Menace of MRSA, but I can’t place all the blame on her. Penning over 5,000 blogs on infectious diseases over the past five years has no doubt had an effect, as well.

 

And for awhile, during the pandemic, it seemed that many in the general public shared my, err . .  fastidiousness (a much nicer word than `mania’) about hand hygiene and cough and sneeze etiquette.

 

Doctor’s offices routinely handed out surgical masks in the waiting room for those with respiratory symptoms.  Big bottles of hand sanitizer sat on every desk, and signs were everywhere to stay home if you were sick.

 

But the pandemic is now gone, and so are most of those little bottles of hand sanitizer. 

 

Many of the hygienic practices taken by the public – and in doctor’s offices – last year, have slowly eroded, or have slipped out of use entirely.

 

And according to an article that appears in the CMAJ this week, that is a big mistake. 

 

Follow the link to read:

 

December 20, 2010

 

Infectious risks in family doctor’s offices

 

Although the value of hand washing in the prevention of influenza is debatable (see The Flaw In The Ointment  and Sanitized For Your Protection ) there is no doubt that good hand hygiene and respiratory etiquette can significantly reduce the spread of many illnesses.

 

Recently a study appeared in  BMC Infectious Diseases, which suggests hand hygiene can be effective even against the `common cold’.

 

Effectiveness of alcohol-based hand disinfectants in a public administration: Impact on health and work performance related to acute respiratory symptoms and diarrhoea

Nils-Olaf Hubner , Claudia Hubner , Michael Wodny , Gunter Kampf  and Axel Kramer

 

 

The bottom line to the CMAJ article is that infection control policies and procedures not only belong in acute care settings - like hospitals and ambulances – they also need to be reinforced, and maintained, in doctor’s offices as well.

 

Otherwise, we risk letting a lot of preventable illnesses slip through our fingers.

»» Read More