The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers Sally F. Bloomfield, BPharm, PhD,a Allison E. Aiello, PhD, MS,b Barry Cookson, FRCP, FRCPath,c Carol O’Boyle, PhD, RN,d and Elaine L. Larson, RN, PhDe Ann Arbor, Michigan; Cheshire and London, United Kingdom; Minneapolis, Minnesota; and New York, New York Infectious diseases (ID) circulating in the home and community remain a significant concern. Several demographic, environmen- tal, and health care trends, as reviewed in this report, are combining to make it likely that the threat of ID will increase in coming years. Two factors are largely responsible for this trend: first, the constantly changing nature and range of pathogens to which we are exposed and, secondly, the demographic changes occurring in the community, which affect our resistance to infection. This report reviews the evidence base related to the impact of hand hygiene in reducing transmission of ID in the home and community. The report focuses on developed countries, most particularly North America and Europe. It also evaluates the use of alcohol-based hygiene procedures as an alternative to, or in conjunction with, handwashing. The report compiles data from intervention studies and considers it alongside risk modeling approaches (both qualitative and quantitative) based on microbiologic data. The main conclusions are as follows: (1) Hand hygiene is a key component of good hygiene practice in the home and community and can produce significant benefits in terms of reducing the incidence of infection, most particularly gastrointestinal infections but also respiratory tract and skin infections. (2) Decontamination of hands can be carried out either by handwashing with soap or by use of waterless hand sanitizers, which reduce contamination on hands by removal or by killing the organisms in situ. The health impact of hand hygiene within a given community can be increased by using products and procedures, either alone or in sequence, that maximize the log reduction of both bacteria and viruses on hands. (3) The impact of hand hygiene in reducing ID risks could be increased by convincing people to apply hand hygiene procedures correctly (eg, wash their hands correctly) and at the correct time. (4) To optimize health benefits, promotion of hand hygiene should be accompanied by hygiene education and should also involve promotion of other aspects of hygiene. (Am J Infect Control 2007;35:S27-64.) There can be no doubt that advances in hygiene improve both the length and quality of our lives. How- during the 19th and 20th centuries, along with other ever, since the middle of the 20th century, following the aspects of modern medicine, have combined to development of vaccines and antimicrobial therapy, From the International Scientific Forum on Home Hygiene, Cheshire, comprising Professor Bloomfield, Dr. Aiello, Professor Elaine Larson, Pro- United Kingdom, and London School of Hygiene and Tropical Medicine,a fessor Barry Cookson, Dr. Michele Pearson, and Dr. Carol O’Boyle met at London, United Kingdom; Department of Epidemiology,b School of Public Columbia University, New York, on March 22, 2007, to review, discuss, Health, University of Michigan, Ann Arbor, MI; Laboratory of Healthcare and develop the review and agree on final content. The information con- Associated Infection,c Centre for Infections, Health Protection Agency tained in this document is based on the database of scientific literature on and Departments of Tropical Medicine and Infectious Disease and Public home hygiene that has been accumulated by the IFH over the past 10 Health Policy, London School of Hygiene and Tropical Medicine, London, years, together with contributions from the knowledge base of all the United Kingdomc; School of Nursing,d University of Minnesota, Minneap- authors. A PubMed search covering 2002 to 2007 was carried out using olis, MN; School of Nursing, Department of Epidemiology, Mailman School the terms ‘‘hygiene,’’ ‘‘home,’’ ‘‘handwashing,’’ and ‘‘alcohol’’ to ensure of Public Health,e Columbia University, New York, NY. that recent literature was not overlooked. The section on intervention studies was based on a systematic review of the relevant Address correspondence to Sally F. Bloomfield, BPharm, PhD, Inter- literature. national Scientific Forum on Home Hygiene, Morningside, Willow Green Lane, Little Leigh, Northwich, Cheshire CW8 4RB, United Kingdom. Supported by McNEIL-PPC, Inc., through an unrestricted educational grant. E-mail: Sallyfbloomfi[email protected]. Disclaimer: The views expressed in this report are the views of the ex- This document has been developed as a special project by the Interna- perts and are endorsed by the IFH. The views should not be considered tional Scientific Forum on Home Hygiene (IFH; www.ifh-homehygiene. representative of the parent institutions of the expert authors. org). IFH is a nongovernmental, not for profit organization that is working 0196-6553/$32.00 to raise awareness of the importance of hygiene in the home and to develop and promote a strategy for home hygiene based on sound scien- Copyright ª 2007 by the Association for Professionals in Infection tific principles. The first draft of this document was prepared by Professor Control and Epidemiology, Inc. Sally Bloomfield and Dr. Allison Aiello. An expert group convened by IFH, doi:10.1016/j.ajic.2007.07.001 S27 S28 Vol. 35 No. 10 Supplement 1 Bloomfield et al and with serious epidemics of the ‘‘old’’ infectious en- their impact on health and well-being. The review also emies such as diphtheria, tuberculosis, and others ap- evaluates the use of alcohol-based hand hygiene proce- parently under control, hygiene has tended to lose its dures as an alternative to, or in conjunction with, hand- prominent position, and the focus of concern has washing. These products are defined by a number of shifted to degenerative and other chronic diseases. No- different terms in Europe and North America (hand san- where has the decline in concern about hygiene been itizers, handrubs, and others). For the purposes of this more evident than in the home and community. report, we will refer to them as alcohol-based hand san- However, whereas advances in medicine and public itizers (ABHS). Although this report focuses primarily on health seemed, at one time, to offer the possibility that the home, it is recognized that the home forms a contin- infectious diseases (ID) might soon be a thing of the uum with public settings such as schools, offices, and past, it is now clear that this is not the case. In the public transport and cannot be considered totally in iso- past 20 years, concern about ID and the need for pre- lation. Nevertheless, the hand hygiene practice frame- vention through home and community hygiene has work proposed in this review is largely also applicable moved steadily back up the health agenda. Between to ‘‘out of home’’ settings. 1980 and 1992, deaths attributable to ID increased by This report compiles data from intervention studies 22% in the United States alone, representing the third and considers it alongside risk modeling approaches leading cause of death among US residents.1 Two fac- based on microbiologic data. Currently, there is a ten- tors are largely responsible for this trend: first, the con- dency to demand that, in formulating evidence-based stantly changing nature and range of pathogens to policies and guidelines, data from intervention studies which we are exposed and, secondly, the changes oc- should take precedence over data from other ap- curring in the community, which affect our resistance proaches. Although there are those who still adhere to infection. To what extent our more relaxed attitudes to this, it is accepted increasingly that, as far as hygiene to hygiene practice have contributed to these trends is is concerned, because transmission of pathogens is not known, but poor hygiene is a significant factor for a highly complex and involves many different pathogens large proportion of the gastrointestinal (GI), skin, and each with multiple routes of spread, decisions regard- respiratory tract (RT) infections, which make up the ing infection control must be based on the totality of greatest part of the ID burden. evidence including microbiologic and other data. Prior to approximately 1980, common pathogens This document is intended for infection control and such as rotavirus, campylobacter, Legionella, Esche- public health professionals who are involved in devel- richia coli (E coli) O157, and norovirus were largely un- oping hygiene policies and promoting hygiene practice heard of. Whereas methicillin-resistant Staphylococcus for home and community settings, including those in- aureus (MRSA) and Clostridium difficile (C difficile) were volved with food and water hygiene, care of domestic once considered largely hospital-related problems, this animals, pediatric care, care of elderly adults, and is no longer the case. Now, community-associated care of those in the home who may be at increased MRSA (CA-MRSA) strains are a major public health con- risk for acquiring or transmitting infection. The pur- cern in North America and, increasingly, in Europe. pose of the review is to provide support for those Most recently, the severe acute respiratory syndrome who work at the interface between theory and practice, (SARS) outbreak and concerns about avian flu have particularly those involved in developing policies for raised awareness of the potential for transmission of the home and community, by providing a practical respiratory viruses via hands and surfaces. Demo- framework for hand hygiene practice together with a graphic trends mean that the proportion of the popula- comprehensive review of the evidence base. tion in the community who are more vulnerable to In recent years, a significant amount of research has infection is increasing, whereas trends toward shorter been done to identify strategies for changing hygiene hospital stays and care in the community also demand behavior.