The WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft) will be issued as a final version in 2007. At present it is important for countries and organisations to note that the Guidelines rep- resent a consensus of international experts and up to date technical information on hand hygiene improvement within a health care context across the world. The Guidelines are being pilot tested and it is likely that changes will be made to some of the technical content of the chapters in light of pilot test results. The Advanced Draft status offers WHO the opportunity to review and update the literature during the life of the Global Patient Safety Challenge to ensure that evidence is as contem- poraneous as possible on final publication. It is unlikely that the fundamental principles behind the guideline recommendations will change by the time the Guidelines are finalized in 2007. We welcome formal feedback on these guidelines. 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Printed by WORLD ALLIANCE FOR PATIENT SAFETY WHO Guidelines on Hand Hygiene in Health Care (ADvanced Draft) Global Patient Safety Challenge 2005–2006: “Clean Care is Safer Care” April 2006 CONTENTS IntrOduction . 7 Part I . revIeW Of scIentIfIc data related tO Hand HygIene . 9 1 . definition of terms . .9 2 . Historical perspective on hand hygiene in health care . .11 3 . ormaln bacterial flora on hands . .12 4 .Physiology of normal skin . .13 5 . transmission of pathogens on hands . .14 5.1 Organisms present on patients’ skin or in the inanimate environment . 14 5.2 Organisms transferred to heatlh-care workers’ hands. .14 5.3 Organisms capable of surviving on hands. .16 5.4 Defective hand cleansing resulting in hands remaining contaminated. 16 5.5 Cross-transmission of organisms by contaminated hands. 17 6 . Models of hand transmission . .18 6.1 Experimental models . 18 6.2 Mathematical models. 18 7 . relationship between hand hygiene and the acquisition of health care-associated pathogens . .19 8 . Methods to evaluate the antimicrobial efficacy of handrub and handwash agents and formulations for surgical hand preparation .21 8.1 Current methods. 21 8.2 Shortcomings of traditional test methods. 24 8.3 New methods for the future. .26 9 . review of preparations used for hand hygiene . .27 9.1 Water. 27 9.2 Plain (non-antimicrobial) soap. 30 9.3 Alcohols. 30 9.4 Chlorhexidine. 33 9.5 Chloroxylenol . .34 9.6 Hexachlorophene. .35 9.7 Iodine and iodophors. 35 9.8 Quaternary ammonium compounds. .36 9.9 Triclosan. 37 WHO Gudelnes On Hand Hygiene n HealtH Care (advanCed draft) 9.10 Other agents. 38 9.11 Activity of antiseptic agents against spore-forming bacteria . 38 9.12 Reduced susceptibility of microorganisms to antiseptics. 39 9.13 Relative efficacy of plain soap, antiseptic soap and detergents, and alcohols. .39 9.14 Safety issues related to alcohol-based preparations . 41 10 . a WHO alcohol-based formulation . .42 10.1 General remarks. .42 11 . surgical hand preparation . .46 11.1 Evidence for surgical hand preparation . 46 11.2 Objectives of surgical hand preparation. 47 11.3 Selection of products for surgical hand preparation. .48 11.4 Surgical hand antisepsis using medicated soap. .48 11.5 Surgical hand preparation with waterless, alcohol-based handrub. 50 11.6 Steps for surgical hand preparation. .51 11.7 Surgical hand scrub with medicated soap or surgical handrub with alcohol-based formulations. .52 12 skin reactions related to hand hygiene . .52 12.1 Frequency and pathophysiology of irritant contact dermatitis. 53 12.2 Allergic contact dermatitis related to hand hygiene products. 54 12.3 Methods to reduce adverse effects of agents. 54 13 . factors to consider when selecting hand hygiene products . .56 13.1 Pilot testing. .56 13.2 Selection factors. .57 14 . Hand hygiene practices among health-care workers and adherence to recommended practices . 60 14.1 Hand hygiene practices among health-care workers . 60 14.2 Observed adherence to hand cleansing. 61 14.3 Factors affecting adherence. .61 15 . religious and cultural aspects of hand hygiene . .62 15.1 Hand hygiene in different religions . .63 15.2 The concept of “visibly dirty” hands. 66 15.3 Hand gestures. .66 15.4 Prohibition of alcohol use. 67 16 . Behavioural considerations . .70 16.1 Social sciences and health behaviour . .70 16.2 Behavioural aspects of hand hygiene . .71 17 . Organizing an education programme to promote hand hygiene . .75 17.1 Implementation process. 76 17.2 Reviewing the guideline for implementation . 76 17.3 Steps in guideline implementation. 78 17.4 The infection control link health-care worker. 79 18 . formulating strategies for hand hygiene promotion . .80 18.1 Elements of promotion strategies. .80 18.2 Developing a strategy for guideline implementation . 82 19 . Impact of improved hand hygiene . .83 20 . Other policies related to hand hygiene . .84 20.1 Gloving policies. .84 20.2 Glove use in settings with limited resources . 87 20.3 Importance of hand hygiene for safe blood and blood products . 91 20.4 Jewellery . 92 20.5 Fingernails and artificial nails . .93 21 . Hand hygiene research agenda . .94 Part II . Consensus recommendations . 95 1 . Indications for handwashing and hand antisepsis . .95 2 . Hand hygiene technique . .96 3 . recommendations for surgical hand preparation . .96 4 . selection and handling of hand hygiene agents . .97 5 . skin care . .98 6 . use of gloves . .98 7 . Other aspects of hand hygiene . .98 8 . educational and motivational programmes for health-care workers . .99 9 . governmental and institutional responsibilities . .99 9.1 For hospital administrators . 99 9.2 For national governments. .99 Part III . Outcome MeasureMents . 103 1 . Monitoring hand hygiene compliance . 103 1.1 Direct observation . .103 1.2 Indirect monitoring. .104 1.3 Electronic monitoring. .104 WHO Gudelnes On Hand Hygiene n HealtH Care (advanCed draft) III 2 . Hand hygiene as a quality indicator for patient safety . .105 3 . cost–effectiveness of hand hygiene . .107 3.1 Financial strategies to support national programmes . 110 Part Iv . PromotIng Hand HygIene On a large scale . 111 1 . countrywide issues . 111 2 . the national Patient safety agency “cleanyourhands” campaign 112 3 . Benefits of national programmes . 112 4 . risk management . 113 5 . Barriers to national programmes . 114 6 . Principles of countrywide hand hygiene improvement . 115 Part v . PrOvIdIng InfOrMation tO tHe PuBlIc . 117 1 . the importance of informing the public . 117 2 . documenting public information campaigns . 117 3 . examples of WHO public information campaigns . 118 4 . examples of national public information campaigns . 118 5 . the public information component of national campaigns to prevent health care-associated infection . 119 6 . documenting lessons learnt . .120 references . 123 taBles . 155 AppendIces . 191 1 . definitions of health-care settings and other related terms . .193 2 .Hand and skin self-assessment tool . .195 3 . example of a spreadsheet to estimate costs . .197 AbbrevIations . 201 acknowledgeMents . 205 WHO Gudelnes On Hand Hygiene n HealtH Care (advanCed draft) v INTRODUCTION The WHO Advanced Draft Guidelines on Hand Hygiene in Health Care provide health- care workers (HCWs), hospital administrators and health authorities with a thorough review of evidence on hand hygiene in health care and specific recommendations to improve practices and reduce transmission of pathogenic microorganisms to patients and HCWs. The present guidelines are intended to be implemented in any situation in which health care is delivered either to a patient or to a specific group in a population. Therefore, this concept applies to specific health-care facilities, to community settings and to other settings where health care is occasionally