"I wash my hands of it!?" – Trends in hand hygiene over the past decades

"I wash my hands of it!?" – Trends in hand hygiene over the past decades

"Ich wasche meine Hände in Unschuld" !? – Entwicklungen der Händehygiene in den letzten Dezennien

Abstract

Hand hygiene is the most important measure to protect against the spread of nosocomial infections. With the development ofin vitround

Manfred L. Rotter

in vivotest methods for evaluation of the effect of hand hygiene, there

1 Clinical Institute for Hygiene and Medical Microbiology at has been a sharp increase over the past 50 years in the body of know-

ledge relating to effective methods for removal from the hands or killing

the University of Vienna, Vi- enna, Austria

and inactivation of pathogens. In 1958 the German Society of Hygiene and Microbiology (DGHM) published a first “Guidelines for Testing Chemical Disinfectants” and included only those hand disinfection products on its “List of Tested Chemical Disinfectants Found To Be Ef- fective” that had been tested as per the methods cited in the guidelines.

The American Society of Testing and Materials (today: ASTM Internation- al) was next, with the first test protocols for hand disinfection products, which in 1974 were adopted by the US Food and Drug Agency as

“Guidelines” in a “Tentative Final Monograph” (TFM) and in 1994, having revised it to incorporate new insights, it was published once again.

Where the user is concerned, guidelines for hand disinfection containing information on indication and implementation are of course more im- portant than methods dealing with efficacy testing of products. Such guidelines are compiled within the hospitals by the infection control teams set up during the 1970s. Written guidelines were also published by several healthcare institutions, scientific societies and associations.

The guidelines formulated by the World Health Organisation (WHO), in an expert committee under the direction of Didier Pittet, proved to be the most successful of the attempts undertaken at global level to en- hance hand hygiene. The most remarkable changes appear to be the efforts aimed at improving compliance among medical personnel and the increasing international acceptance of hand disinfection by using alcohols in the form of rubs; whether this will be with lotions or gels re- mains to be seen.

Zusammenfassung

Die Händehygiene ist die wichtigste Maßnahme zur Verhütung der Ausbreitung von Krankenhausinfektionen. Mit der Entwicklung von Testmethodenin vitroundin vivozur Evaluierung des Effektes hat sich seit der Mitte des letzten Jahrhunderts das Wissen über wirksame Me- thoden der Entfernung von Krankheitserregern von den Händen, deren Abtötung und Inaktivierung in den letzten 50 Jahren sprunghaft erwei- tert. 1958 veröffentlicht die Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM) die ersten „Richtlinien für die Prüfung chemischer Desinfektionsmittel“ und nahm Produkte zur Händedesinfektion in ihre

„Liste der geprüften und für wirksam befundenen chemischen Desin- fektionsmittel“ nur auf, wenn diese nach den darin enthaltenen Metho- den geprüft worden waren. Es folgte die American Society of Testing and Materials (heute: ASTM International), mit den ersten Testprotokol- len für Produkte zur Händedesinfektion, die 1974 von der US Food and

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Original Contribution

OPEN ACCESS

Drug Agency als „Guidelines“ in einem „Tentative Final Monograph“

(TFM) übernommen und 1994 überarbeitet erneut herausgegeben wurden.

Für den Anwender sind Richtlinien zur Händehygiene, die über Indikation und Durchführung informieren wichtiger als Methoden zur Wirksamkeits- prüfung der Produkte. Derartige Richtlinien werden innerhalb von Krankenhäusern von den in den 1970er-Jahren formierten Hygiene- Teams erstellt. Schriftliche Richtlinien wurden auch von zahlreichen im Gesundheitswesen tätigen Institutionen, wissenschaftlichen Gesellschaf- ten und Vereinen publiziert. Als bedeutender Erfolg sind die globalen Richtlinien zur Händehygiene durch die Weltgesundheitsorganisation (WHO) durch ein Expertenkomitee unter Leitung von Didier Pittet zu werten. Am wichtigsten aber scheinen alle Bemühungen um die Verbes- serung der Compliance des medizinischen Personals und die interna- tional zunehmende Akzeptanz der Händedesinfektion durch Verwendung von Alkoholen in Form von Einreibverfahren – ob mit Lotionen oder Gelen wird die Zukunft zeigen.

Text

While for millennia handwashing has been practiced not only in an attempt to remove physical contamination but also to rid oneself of guilt and evil, it was only some 200 years ago that, thanks to the insights of physicians such as Alexander Gordon, Oliver Wendell Holmes and Ignaz Philipp Semmelweis and to Semmelweis’ ability to draw the right conclusions, that people became aware of the fact that diseases could be spread via the hands and, vice versa, that this pathway could be interrupted through hand hygiene.

Today, hand hygiene is seen as the most important measure to protect against the spread of nosocomial in- fections, but is it being practiced such that it does justice to its assigned role? Evidence of shortcomings here came to light in the middle of the past century, giving rise to scientific research, which in turn meant a sharp increase over the past 50 years in the body of knowledge relating to effective methods for removal from the hands or killing and inactivation of pathogens which were not even dis- covered 200 years ago and of which many more are still not known. This has been made possible above all thanks to the development of in vitro und in vivo laboratory test methods for evaluation of the effect of hand hygiene methods.

The German Society of Hygiene and Microbiology (DGHM) published already back in 1958 the first “Guidelines for Testing Chemical Disinfectants” [1] and included only those hand disinfection products on its “List of Tested Chemical Disinfectants Found To Be Effective” (e.g. [2]) that had been tested as per the methods cited in the guidelines. Somewhat later the American Society of Testing and Materials (today: ASTM International) pub- lished the first test protocols for hand disinfection products [3], which in 1974 were adopted by the US Food and Drug Agency as “Guidelines” in a “Tentative Final Monograph” (TFM) and in 1994, having revised it to incor- porate new insights, it was published once again [4].

Besides, ASTM International has also published other standards of relevance to hand disinfectants:

• E 2276 (Bacteria-Eliminating Effectiveness of Hygiene Handwash and Handrub Agents Using the Fingerpads of Adult Subjects),

• E 1838 (Virus-Eliminating Effectiveness of Liquid Hy- gienic Handwash and Handrub Agents Using the Fin- gerpads of Adult Volunteers),

• E 2011 (Handwashing Formulations for Virus-Eliminat- ing Activity Using the Entire Hand) und

• E 1115 (Evaluation of Surgical Hand Scrub Formula- tions).

Where the user is concerned, guidelines for hand disin- fection containing information on indication and imple- mentation are of course more important than methods dealing with efficacy testing of products. Such guidelines are therefore being compiled increasingly more commonly within the hospitals by the infection control teams set up during the 1970s. Formal, written guidelines were ulti- mately also published by several relevant healthcare in- stitutions, scientific societies and associations. These include for example those of the Centers for Disease Control (CDC 1975 [5], 1986 [6] and 2002 [7]), of the Association for Professionals in Infection Control (APIC 1988 [8] und 1995 [9]) or of the Hospital Infection Con- trol Practices Advisory Committee (HICPAC 1995 [10], 1996 [11]).

The WHO Guidelines for Hand Hygiene in Healthcare Settings, formulated under the direction of Didier Pittet, within the framework of the WHO World Alliance for Pa- tient Safety, proved to be the most successful of the at- tempts undertaken at global level to enhance hand hy- giene. These guidelines contain detailed information and recommendations on hand hygiene, while also taking account of facilities available in developing countries.

Publication of this important document is expected in 2005/2006.

The most remarkable changes to hand hygiene strategies in recent years were no doubt the efforts aimed at improv- ing compliance among medical personnel and the increas-

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Rotter: "I wash my hands of it!?" – Trends in hand hygiene ...

ing international acceptance of hand disinfection by using alcohols in the form of rubs; whether this will be with lo- tions or gels remains to be seen.

Curriculum Vitae

Univ. Prof. Dr. med. habil Manfred Rotter

Figure 1

Figure 1: Manfred Rotter

Specialist for Hygiene and Microbiology.

Chairman of the Clinical Institute for Hygiene and Medical Microbiology of the University of Vienna.

After successfully ending his study of Medicine at the University of Vienna in 1965 Manfred Rotter became as- sistant doctor at the Hygiene Institute there. He gets a further Diploma in Bacteriology at the London University and habilitated at the University of Vienna for the subject of Hygiene and Microbiology in 1976.

In 1984 and 1987 he took on a visiting professorship in South Africa and became Head of the Clinical Department for Clinical Microbiology of the Hygiene Institute at the Vienna General Hospital, one of the biggest in Europe, in 1991. Additionally he was appointed Chairman of the Clinical Institute for Hygiene and Medicinal Microbiology of the University of Vienna in 1995.

Professor Rotter is a worldwide acknowledged specialist in the area of alcoholic hand disinfection. More than 400 publications and numerous scientific honours do not only document his expertise but also the absolute acknowledg- ment thereof. Tongue in cheek – but nevertheless meant seriously – he is often being called „the direct successor of Semmelweis“.

References

1. DGHM. Richtlinien für die Prüfung chemischer

Desinfektionsmittel. Zbl Bact Hyg Abt I Orig. 1958;173:307-17.

2. DGHM. IV. Liste der nach den "Richtlinien für die Prüfung chemischer Desinfektionsmittel" geprüften und von der DGHM als wirksam befundenen Desinfektionsmittel. Uelzen: Neuer Hygiene Verlag; 1974.

3. ASTM International. E 1174 - Standard Test Method for Evaluation of the Effectiveness of Health Care Personnel or Consumer Handwas Formulations. Federal Register 46 (17).

4. Food and Drug Administration. Tentative final monograph for healthcare antiseptic drug products; proposed rule. Federal Register. 1994;59:31441-52.

5. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med. 1975;83(5):683-90.

6. Garner JS, Favero MS. CDC Guideline for Handwashing and Hospital Environmental Control. Infect Control. 1986;7(4):231-43.

7. Centers for Disease Control and Prevention, Boyce J, Pittet D.

Guidelines for Hand Hygiene in Health-Care settings:

Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene task Force. MMWR. 2002;51(RR-16):1-48.

8. Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control. 1988;16(6):253-66.

9. Larson EL, APIC Guidelines Committee. APIC Guideline for Handwashing and Hand Antisepsis in Health Care Settings. AM J Infect Control. 1995;23:251-69.

10. Hospital Infection Control Practices Advisory Committee (HICPAC).

Recommendation for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol. 1995;16:105-13.

11. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Epidemiol. 1996;17:53-80.

Corresponding author:

Univ. Prof. Dr. Manfred L. Rotter

Klinisches Institut für Hygiene und Medizinische Mikrobiologie der Universität Wien, Kinderspitalgasse 15, 1095 Wien, Österreich, Tel.: ++43 1 404 90 79401, Fax:

++43 1 404 90 9794

Manfred.rotter@meduniwien.ac.at

Please cite as

Rotter ML. "I wash my hands of it!?" – Trends in hand hygiene over the past decades. GMS Krankenhaushyg Interdiszip. 2007;2(1):Doc07.

This article is freely available from

http://www.egms.de/en/journals/dgkh/2007-2/dgkh000040.shtml

Copyright

©2007 Rotter This is an Open Access article distributed under the terms of the Creative Commons Attribution License

(http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share — to copy, distribute and transmit the work, provided the original author and source are credited.

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