2019

Manjiri Gajmal
Microbiologist; Bhavan’s Research Center
INSTITUTIONAL HAND HYGINE- REVIEW
11/13/2019
INTRODUCTION

The word hygiene derives from the ancient Greek goddess Hygeia, the goddess of healing. Today,
hygiene is associated with disease prevention and health promotion. The importance of hygiene is
universally accepted and evidence based. Physical contact between people and between people and
objects is a key vehicle for the transmission of pathogens. Therefore, effective hand hygiene has a
key role in disease prevention. Hand hygiene is now regarded as one of the most important element
of infection control activities. Hands play a major role in the transmission of infection in healthcare
institution such as hospitals, in food and hygine industry as well as community settings. Hand
hygiene is the primary measure to reduce infections Improved hand hygiene has the potential to
reduce morbidity and mortality from infections spread by faecal-oral routes and person-to-person
contact. Two leading cause of child morbidity and mortality are pneumoniae and diarrhoea, hand
washing with soap can significantly reduce prevalence of them. Hand hygine is primary measure to
reduce the infection but, lack of compliance with routine practices is problematic now. Therefore,
newer approaches of hand hygiene have been demonstrated. Hence, WHO First Global Patient
Safety Challenge, “Clean Care is Safer Care”, is focusing part of its attention on improving hand
hygiene standards and practices in health care along with implementing successful interventions. (1)
Guidelines on Hand Hygiene in Health Care, were launched in 2009. Hospitals and health care
workers were encouraged to adopt these guidelines, including the “My 5 Moments for Hand
Hygiene” approach, which contribute to a greater awareness and understanding of the importance of
hand hygiene. “Clean Care is Safer Care” was launched in October 2005 as the first Global Patient
Safety Challenge (1st GPSC), aimed at reducing health care-associated infection (HCAI) worldwide.
(1) A key action within “Clean Care is Safer Care” is to promote hand hygiene globally and at all
levels of health care. Hand hygiene, a very simple action, is well accepted to be one of the primary
modes of reducing HCAI and of enhancing patient safety. (1)

HCAI (Health Care Associated Infection) is defined as infection occurring in a patient during the
process of care in a healthcare facility which was not present or incubating at the time of admission.
(3) It is been documented that 1 in 20 patients are affected by health care associated infections and
therefore HCAI is a major problem for patient safety and its prevention must be a first priority.(2) It
has been seen that HCAI causes prolonged hospital stay, long term disability, increased resistance of
microorganisms to antimicrobials, massive additional financial burdens, an excess of deaths, high
costs for the health systems and emotional stress for patients and their families.(1) In developed
countries, HCAI concerns 5–15% of hospitalized patients and can affect 9–37% of those admitted to
intensive care units (ICUs).(1) CDC also stated that HCAI are mainly cause by non-adherence of

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health care worker to standard practise.(4) Importance of hand hygiene in infection transmission is
well demonstrated but due to lack of compliance to it, as low as 40% in health care professionals;
prevalence of HCAI is reduced.(3) In one of the survey study carried out among health care
professionals in hospital in India to understand hand hygine knowledge, attitude and practice, it has
been found out that majority had only moderate knowledge i.e. 90.9%.(3) Hence need for hand
hygiene training program is important. University of Geneva Hospital was the first which reported
that there was significant reduction of nosocomial infection with compliance to hand hygiene. (2)
Many studies have documented that HCWs can contaminate their hands or gloves with pathogens
such as Gram-negative bacilli, S. aureus, enterococci or C. difficile by performing “clean
procedures” or touching intact areas of skin of hospitalized patients. (1) Hand hygiene is one of the
most effective means of preventing infection in developing countries. Knowledge of good hand
hygiene practice and compliance in hand hygiene as per WHO guidelines is essential for lowering
HAIs. (3)

Nurses are mainly exposed to variety of infection due to their nursing activity; student nurses are also
at high risk during their training period as they are in direct contact with the patient. Study conducted
in one of the nursing hospitals in the Jordan to understand the knowledge and attitudes of nurses
towards hand hygine compliance. Average compliance was observed in nursing students with
recommended hand washing practices; which indicates that there is need to enhance attention of
nursing students towards hand washing. This implies that patient safety aspects should be reinforced
during nursing clinical training courses. In this study highest compliance score was observed in after
direct contact with patient, and lowest compliance in hand washing before patient care. Nurses need
to understand hand washing compliance is important before and after care of patients. (4)

School going children are spending more time in school and they are close contact with each other,
sharing school materials everything from chairs to the desk, to crayons, to germs, and touching their
faces. So, hand washing is effective way to prevent the spread of common school illness like cold,
pinkeye and flu. (5) Effective and appropriate hand hygiene practice for schoolchildren is important
in preventing infectious diseases such as diarrhoea, which is the second most common cause of death
among school-age children in sub-Saharan Africa (6) Proper hand washing with soap can reduce the
risk of diarrhoea by 42%–48% . In turn, this can lead to reductions in morbidity and mortality rates,
as well as in school absenteeism among children. (6) For school children the practice is significant,
who might suffer from more severe hygiene related diseases as compared to adults. Teaching
children hand washing is important to keep them clean and healthy. (5) Especially teach the child to
hand wash often, before eating, after blowing nose and after the use of the bathroom. As a matter of

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habit, it is very good idea to make sure washing hand becomes something automatically (5)In one of
the study conducted at school children in rural area of Maharashtra; a statistically significant
difference was detected between the first practice, which was made before training, and the second
and third practices, which were made after training, in terms of hand washing skill development (p <
0.001). The study concludes that post demonstration practice score showed significant difference
than the pre demonstration practice score, which is a net benefit due to the effectiveness of
demonstration of hand hygiene was simple, inexpensive and effective to improve children’s
knowledge and practices regarding hand hygiene. (5)

Children at day care and kindergartens are at higher risk of getting infections. The overcrowded
environment, children’s natural intimacy where body contact is inevitable, lack of understanding on
basic hygiene and lack of natural immunity to viruses and bacteria were among factors attributed to
high rate of infections in the kindergartens.(12) Preventive strategies should be directed at
interrupting the chain of transmission, which hand hygiene is the single most effective and cheapest
measure. Hand hygiene has been shown to reduce the occurrence of acute gastroenteritis (AGE) and
acute respiratory illness (ARI) in childcare setting.(12) Washing hands with correct technique have
been shown to reduce spread of infectious diseases, such as diarrhoea and respiratory infections.
Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic
resistance in healthcare settings. (12)

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A wide array of products is available in the hand hygiene segment viz hand washes, hand rubs and
hand sanitizers. Following are some of the examples

Alcohol Based Hand Wash-

Alcohols are currently the preferred agent for routine hand hygiene. They have excellent activity and
the most rapid bactericidal action of all antiseptics. Of importance from a workflow perspective,
alcohols dry very rapidly, allowing for fast antisepsis at the point of care. In addition, alcohols are
more convenient for hygienic handrub than aqueous solutions given their excellent spreading quality
and rapid evaporation. In most cases, the efficacy of ethanol and isopropanol are comparable, though
ethanol has been found to have better efficacy profile against viruses. Some studies have
demonstrated that ethanol gel formulations, unless they have been specially formulated and tested,
are less efficacious than ethanol solution formulations.

Alcohol-based handrubs (whether isopropyl, ethyl, or n-propanol, in 60-90% vol/vol), when

containing appropriate emollients such as glycerol (1-3%) or other skin-conditioning agents, are less
irritant to healthcare worker’s hands than soap and water.

Alcohol provides its antibacterial activity though desiccation of the target organism. In the presence
of water, it is generally believed that they cause membrane damage and rapid denaturation of
proteins, with subsequent interference with metabolism and cell lysis. Applied to skin, the ethanol
based hand sanitizers are effective in reducing the bioburden of many types of microbes. Nut
alcohols are volatile and can evaporate from the skin’s surface, so the residual antibacterial activity is
limited. (8) certain reports have been shown that certain pathogens are becoming more tolerant to
ethanol exposure.

Benzalkonium Chloride-

Due to shortcomings of traditional alcohol-based hand rub, alcohol free formulation have been
formulated, with the surfactant benzalkonium chloride as the active antibacterial agent.
Benzalkonium chloride belong to the group of quaternary ammonium compounds which are
commonly used as disinfectants, antimicrobials or surfactants both in industrial and house hold
products. (13) This active ingredient acts by disrupting the cell membranes of the target test
organism and is active at relatively low concentration (0.12-0.13%)(8) as this surfactant is not
volatile, it is expected to remain on the skin as the product dries. (8) the effectiveness of
benzalkonium chloride as antibacterial agent on skin has been studied against alcohol based

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sanitizers against various test organism as S. marcescens, S.aureus and E.faecium, it showed that
benzalkonium chloride shows progressive increase in effectiveness as antibacterial agent as
compared to alcohol based hand sanitizers. In one of the study using cup scrub technique has showed
that benzalkonium chloride is more effective than product containing 63% ethanol. (8)

Benzalkonium chloride get absorbed on the cell wall of the organism, it reacts with cytoplasmic
membrane followed by membrane disorganization, which causes leakage of the intracellular low
molecular weight material, degradation of the proteins and nucleic acid and cell wall lysis. There is
thus a loss of structural organization and integrity of the cytoplasmic membrane in bacteria, together
with other damaging effects to the bacterial cell.

Chlorohexidine Gluconate-

Chlorohexidine gluconate is one of the main antiseptic agent present in antimicrobial soaps. It has
also been seen that it has prolonged antimicrobial effect. Its broad spectrum activity, acceptable
tolerability, and good safety margin makes it one of the most widely used biocide. (9) CHG has good
in vitro activity against Gram-positive bacteria and enveloped viruses, less activity against Gram-
negative bacteria and non-enveloped viruses, and minimal activity against mycobacteria. (10) In one
of the study it has been found that chlorohexidine scrub is significantly more effective than that of
povidone-iodine scrub.(10) In one of the US based study, ethanol plus chlorohexidine shows
significantly lower aerobic count than that of only ethanol.

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EMERGING ANTIBACTERIAL AGENTS-

Many of the chemical antiseptics are now available in market as alcohol based sanitizers,
benzalkonium chloride products, chlorhexidine products etc. These soaps or solutions help to reduce
health care associated transmission of contagious diseases more effectively but they have some
shortcomings or adverse effects. Their frequent use can lead to skin irritation and also resistant
among pathogens.(12) Organisms such as Staphylococcus aureus, Pseudomonas spp., Klebsiella
pneumonia & Proteus vulgaris are some of the skin pathogens which are now becoming resistant to
the traditional antibacterial products(12) Use of plants as source of medicine has been inherited and
is an important component of the health care system in India.(12) Herbal based hand sanitizers
formulated with natural emollients and moisturizers are equally effective and also have the additional
benefit of safety with negligible rates of skin dryness/irritation, and hence keep the skin free from
germs, and also leaving the skin clean, smooth and safe.

It has been studied that wide range of active phytochemicals such as polyphenols, alkaloids, essential
oils/lipids, terpenoids, peptides etc., are abundantly synthesized by the plant, plant based product
formulation. These diverse classes of bioactive molecules have also been reported to possess wide-
spectrum anti-bacterial activities with a multitude of mechanisms of action. Mode of action is related
to both direct mechanisms such as cytoplasmic membrane damage, inhibition of nucleic acid, cell
wall syntheses and; indirect mechanisms including interference with and modulation of bacterical
virulence factors including enzymes, toxins and signal receptors.(15)

The finding of study, in which antibacterial activity of the Guava leaves has been studied shows that
it has inhibitory activity against S.aureus when it was formulated into hand sanitizer gel. Guava
leaves (Psidium guajava L) have active chemical compounds such as saponins, flavonoids, tannins,
eugenol, and triterpenoids. Tannin and flavonoids are polyphenolic compounds (1.4%) that dominate
guava leaves. Tannin in Guava, inhibits the phosphorylation activity of the bacteria, which causes
cell lysis.(15)

Various parts of the Neem tree have been used as traditional Ayurvedic medicine in India.
Azadirachta indica A. Juss, (Neem tree), from the Meliaceae family, also known as Margosa or
Indian lilac. Various parts of the Neem tree have been used as traditional Ayurvedic medicine in
India. Neem oil, the bark and leaf extracts have been therapeutically used as folk medicine to control

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leprosy, intestinal helminthiasis, respiratory disorders and constipation and also as a general health
promoter. Neem leaves possesses a wide spectrum of antibacterial action against gram-negative and
gram-positive microorganisms.(12) One of the study shows that formulated hand wash using mint
and neem shows good antibacterial activity against S.aureus and E.coli. Extracts of mint and neem in
this study demonstrated a broad-spectrum activity due to the identified alkaloids; diterpenoids,
flavonoids and tannins further confirm its use as a health remedy in popular medicine.(11) Lemon
juice which is obtained from fruits of Citrus limon L. belonging to the family Rutaceae is
traditionally used for the purpose of cleaning due to its disinfectant properties. Lemon juice is also
used as a short term preservative in some food preparations. Lemon juice is used in Indian medicinal
systems because of the anti microbial properties of lemon. It is also used to add taste to many food
preparation.(12) Mimosa pudica L. (Mimosaceae) also referred to as touch me not, live and die,
shame plant and humble plant is a prostrate or semi-erect subshrub of tropical America and
Australia, also found in India. It majorly possesses antibacterial, antivenom, antifertility,
anticonvulsant, antidepressant, aphrodisiac, and various other pharmacological activities. The herb
has been used traditionally for ages, in the treatment of urogenital disorders, piles, dysentery, sinus,
and also applied on wounds.(12) One of the study showed extract of Azadiracta indica, Mimosa
pudica and their combinations with lemon water are capable of giving superior zone of inhibition to
protect against the skin pathogens. This might be rational basis for use of herbs in preparation of
hand wash and use of these compounds in making antiseptic lotions or soaps in place of chemicals.
(12)

Ozonated water -

Ozone (O3) is a highly reactive gas with a broad spectrum of antimicrobial effects on bacteria,
viruses and protozoa. It can easily be produced locally in small generators, and dissolved in tap
water, and quickly transmits into ordinary O2 in the surrounding air. (14) Ozone is produced from
electric generators when an electrical discharge (a spark) splits an oxygen molecule into two oxygen
atoms, and then the unstable ozone molecule is formed according to the reaction O + O2 → O3.
According to the balanced equation 2O3 ⇋ 3O2, where ozone quickly decomposes into O2 (t½ = 20–
30 min), requires that it must be produced in the location where it is used. When it decomposes, O 3
acts as an oxidant with release of free radicals. Being an oxidant, ozone has antimicrobial properties
against bacteria, viruses and protozoa Ozone leads to the destruction of both bacteria and viruses by
interfering with metabolism, most likely by inhibiting enzymes. Some ozone breaks through the
bacterial cell membrane, and this leads to cell death. Ozone destroys viruses by diffusing through the
protein coat into the nucleic acid core, resulting in damage to the viral RNA. At higher

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concentrations, ozone destroys the capsid by oxidation. One of the study of ozonated water indicates
that ozonized water on average eradicates E. coli from artificially contaminated fingers as effectively
as 85% alcohol. The ozone hand disinfection method is simple, cheap and leaves no residual waste,
and when dissolved in water ozone also seems to be safe. (14)

CONCLUSION-

In developing countries, hand haygiene is one of the effective means of preventing infection.
Improved hand hygiene has been shown to reduce HCAI spread by 40% and full compliance can
reduce the risk of acquiring methicillin-resistant Staphylococcus aureus (MRSA)which is a common
cause of severe infections in HCFs, by 24%. Hence, knowledge of hand hygiene and compliance of it
as per WHO guidelines, is very important. It has been seen that noncompliance with guidelines and
recommendations of hand hygiene are due to many factors like lack of time, forgetfulness, lack of
adequate facilities, lack of institutional commitment, lack of motivation, and skin irritation to hand
hygiene products. It can be overcome by emphasizing the importance of hand hygiene and
encouraging people to follow good hand hygiene practices by displaying infection prevention
notices, easy access to hand hygiene. (3) In developing countries, there is also need for governments
and other stakeholders to make provision of adequate water and materials for sanitation and hygiene
in the health care facilities a top priority.
Hand hygiene, either by hand disinfection or hand washing remains to be most pivotal in controlling
infection in healthcare settings.(6) The importance of hand hygiene is been continuously exemplified
and it has been proved that training sessions on hand hygiene has resulted in sustained improvement.
Various antimicrobial agents are present including from tradition alcohol rub also benzalkonium
chloride to new emerging antibacterial agents like plant extracts and ozonated water.
Benzalkonium chloride shows persistent antibacterial activity, which is may be beneficial in the
patients care settings to reduce the chances of incidental contamination of the hands and subsequent
transfer to the patient.(8) Due to extensive use of Benzalkonium chloride, it has been detected in
municipal waste water at concentration ranging from 20-300 µg/l. Its toxicity to humans has been
described for specific targets such as corneal and nasal epithelia. It has also been reported to induce
genotoxicty to mammalian cellas and plant cells. In one of the study conducted on nematode
C.elegans it has been reported that benzalkonium chloride showed more toxicity to C.elegans as
compared to trichlosan.(13)

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According to recently revised handhygiene guidelines, the use of an herbs based hand rubbing is the
preferred method of hand hygiene.(11) Ozonized water could be an alternative to traditional fluid
hand disinfectants with alcohol, for example in institutions. Research should also focus on the
possibility of using ozone as an alternative to soap washing and alcohol disinfection for persons with
contact dermatitis.(14)

Having workshops and hand hygiene focused programmes have shown success in a s0ustained
improvement in compliance with hand hygiene. It also helps to motivate the patients to be aware and
follow measures of hand hygiene. Hand hygiene reminders in the form of flyers, mailers, posters and
standees play a pivotle role in motivating individuals to adhere to etiquettes. An advanced level of
hand hygiene program with elements of infection control should be offered to the all the
professionals working in healthcare setting, once at the time of employment and then yearly
thereafter. There should also be national campaigns at all levels to enable implementation,
adaptability and sustainability of hand hygiene improvement efforts.

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