WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE (ADVANCED DRAFT): A SUMMARY
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WHO GUIDELINES ON
HAND HYGIENE IN HEALTH CARE
(ADVANCED DRAFT): A SUMMARY - extracted text
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WORLD ALLIANCE FOR PATIENT SAFETY
WHO GUIDELINES ON
HAND HYGIENE IN HEALTH CARE
(ADVANCED DRAFT): A SUMMARY
CLEAN HANDS ARE SAFER HANDS
World Health
Organization
WORLD ALLIANCE FOR PATIENT SAFETY
WH© GUSDUUli® ©W
HAND HYGIENE IN HEALTH CARE
BRAIFTJ; A SUMMARY
CLEAN HANDS ARE SAFER HANDS
WHO Guidelines on Hand
Hygiene in Health Care
(Avanced Draft): A Summary
Foreword.............................................................................................................. 5
Introduction..........................................................................................................7
The problem: health care-associated infections are a major cause of
death and disability worldwide............................................................... 9
The economic burden.................................................................................. 12
Interventions are available but are not being used................................. 12
The solution....................................................................................................... 14
Recommendations........................................................................................... 17
1.
Indications for handwashing and hand antisepsis............................ 17
2.
Hand hygiene technique...................................................................... 18
3.
Recommendations for surgical hand preparation............................ 18
4.
Selection and handling of hand hygiene agents.............................. 19
5.
Skin care.................................................................................................. 20
6.
Use of gloves........................................................................................... 20
7.
Other aspects of hand hygiene.............................................................21
8.
Health-care worker educational training and
motivational programmes...................................................................... 21
9.
Governmental and institutional responsibilities................................ 22
Benefits of improved hand hygiene............................................................. 23
Implementation strategies..............................................................................25
The task forces.............................................................................................. 25
The launch..................................................................................................... 26
The pilot testing phase................................................................................... 27
Conclusion: the way forward......................................................................... 29
Selected references.......................................................................................... 30
Acknowledgements.......................................................................................... 31
WHO Guidelines on Hand Hygiene in Health Care
WHO Guidelines on Hand
Hygiene in Health Care
(Avanced Draft): A Summary
Foreword.............................................................................................................. 5
Introduction......................................................................................................... 7
The problem: health care-associated infections are a major cause of
death and disability worldwide............................................................... 9
The economic burden.................................................................................. 12
Interventions are available but are not being used................................. 12
The solution....................................................................................................... 14
Recommendations........................................................................................... 17
1.
Indications for handwashing and hand antisepsis............................ 17
2.
Hand hygiene technique...................................................................... 18
3.
Recommendations for surgical hand preparation............................ 18
4.
Selection and handling of hand hygiene agents.............................. 19
5.
Skin care.................................................................................................. 20
6.
Use of gloves........................................................................................... 20
7.
Other aspects of hand hygiene.............................................................21
8.
Health-care worker educational training and
motivational programmes...................................................................... 21
9.
Governmental and institutional responsibilities................................ 22
Benefits of improved hand hygiene............................................................. 23
Implementation strategies..............................................................................25
The task forces.............................................................................................. 25
The launch..................................................................................................... 26
The pilot testing phase................................................................................... 27
Conclusion: the way forward......................................................................... 29
Selected references.......................................................................................... 30
Acknowledgements.......................................................................................... 31
WHO Guidelines on Hand Hygiene in Health Care
Foreword
Health care-associated infections affect hundreds of millions of patients worldwide
every year. As an unintended result of seeking care, these infections lead to more
serious illness, prolong hospital stays, and induce long-term disability. Not only do
they inflict unexpected high costs on patients and their families, they also lead to a
massive additional financial burden on the health-care system and — last but not
least — contribute to unnecessary patient deaths.
By their very nature, infections have a multifaceted causation related to systems
and processes of health-care provision and political and economic constraints on
health systems and countries, as well as to human behaviour conditioned by educa
tion. Most infections are, however, preventable.
Importantly, there is a large and unfair patient safety gap, with some health-care
institutions and systems managing the risks to patients much better than others. The
level of development and the resources available are not the only critical issues for
success: improvement is reported from both developed and developing countries
and is a source of learning among them.
Let us assess the size and nature of the problem of health care-associated infec
tion and create the basis for monitoring the effectiveness of preventive actions
worldwide. Surveillance and prevention, relying on evidence-based best practice, is
possible. Development of effective solutions to improve patient safety and reduce
risk is also possible. Tools are available, but they should be tested, adapted and
implemented worldwide with a sense of equity and solidarity.
Hand hygiene is the primary measure to reduce infections. Though the action is
simple, the lack of compliance among health-care providers is problematic through
out the world. Following recent understanding of the epidemiology of hand hygiene
compliance, new approaches have proven effective. The Global Patient Safety
Challenge 2005-2006: "Clean Care is Safer Care" is focusing part of its attention on
improving hand hygiene standards and practices in health care and on helping to
implement successful interventions.
As part of this approach, WHO Guidelines for Hand Hygiene in Health Care
(Advenced Draft) prepared with the help of more than 100 international experts, are
in the testing and implementation phases in different parts of the world. Pilot sites
range from modern, high-technology hospitals in developed countries to remote
dispensaries in resource-poor villages. This Challenge is a global reality: no hospital,
no clinic, no health-care system, no dispensary, and no health post can currently say
that compliance with hand hygiene recommendations is not an issue.
Health literacy is the capacity of individuals to obtain, interpret and understand
basic health information and services necessary for appropriate health decision
WHO Guidelines oh Hand Hygiene in Health Care
making. Health literacy links education with health; it also needs leaders and
policy-makers to be aware of the social, economic and environmental determinants
of behaviour. "Clean Care is Safer Care" takes these issues into account throughout
its Challenge.
Countries are invited to adopt the Challenge for their own health-care systems.
Please engage fully the patients and service users as well as health-care providers in
action plans for improvement. Please ensure the sustainability of all actions beyond
the initial two-year period of the Challenge. While system change is required in most
places, sustained change in human behaviour is even more important and this relies
on peer support and political backing.
Let us remind ourselves that "Clean Care is Safer Care" is not a choice, but a
patient's basic right to quality care. Clean hands prevent suffering and save lives.
Thank you for being part of this Challenge.
Professor Didier Pittet
Director, Infection Control Programme
University of Geneva Hospitals, Switzerland
and
Leader, Global Patient Safety Challenge
World Alliance for Patient Safety
World Health Organization
Geneva, Switzerland
Introduction
Confronted with the important issue of patient safety, the Fifty-fifth World Health
Assembly in 2002 adopted a resolution urging countries to pay the closest possi
ble attention to the problem and to strengthen safety and monitoring systems. The
resolution requested WHO to take a lead in building global norms and standards
and supporting country efforts in developing patient safety policies and practices.
In May 2004, the Fifty-seventh World Health Assembly approved the creation of an
international alliance to improve patient safety as a global initiative, and the World
Alliance for Patient Safety was launched in October 2004. For the first time, heads
of agencies, policy-makers and patient groups came together from all corners of
the globe to advance the patient safety goal of "First, do no harm" and to reduce
the adverse health and social consequences of unsafe health care. The Alliance
is focusing its actions on the following areas: the Global Patient Safety Challenge;
Patients for Patient Safety; Taxonomy; Research; Solutions for Patient Safety; and
Reporting and Learning. Together, the combined efforts of all these components
have the potential to save millions of lives and, through the improvement of basic
procedures, to halt the diversion of a significant amount of resources from other
productive uses.
The Global Patient Safety Challenge, a core element of the Alliance, creates an
environment where safety of care brings together the expertise of leading special
ists in the fields of hand hygiene and the safety of injections, surgical procedures,
blood use, and the care environment. The topic chosen for the first Global Patient
Safety Challenge is health care-associated infection. Such infections occur world
wide in both developed, transitional and developing countries and are among the
major causes of death and increased morbidity for hospitalized patients; they will
be addressed through the Global Patient Safety Challenge 2005-2006: "Clean Care
is Safer Care".
A key action within the Challenge is to promote hand hygiene in health care
globally as well as at country level through the campaign "Clean Care is Safer Care".
Hand hygiene, a very simple action, reduces infections and enhances patient safety
across all settings, from advanced health-care systems in industrialized countries to
local dispensaries in developing countries. In order to provide health-care workers,
hospital administrators and health authorities with the best scientific evidence and
recommendations to improve practices and reduce health care-associated infec
tions, WHO has developed Guidelines on Hand Hygiene in Health Care (Advanced
Draft).
The development of the advanced draft Guidelines followed the WHO recom
mended process for guidelines. The process began in autumn 2004 and included
two international consultations (in December 2004 and April 2005) attended by
experts from all over the world and technical specialists from WHO. A core group
WHO Guidelines on Hand Hygiene in Health Care
of experts coordinated the work of reviewing the available scientific evidence, writ
ing the document and fostering discussion among authors. It is noteworthy that
more than 100 international experts contributed to the document's preparation. At
present, pilot tests in each of the six WHO regions are being conducted to help
provide local data on the resources required to carry out the recommendations and
generate information on the feasibility, validity, reliability and cost-effectiveness of
the interventions concerned. This piloting is an essential part of the Challenge.
Development of the WHO Guidelines
on Hand Hygiene in Health Care
WHO recommended steps in technical guideline development
Action taken
Define the specific issues to be addressed by the guidelines
Completed
Undertake a systematic search for evidence
Completed
Review the evidence available
Completed
Develop recommendations linked to the strength of the evidence
Completed
Draft guidelines
Completed
Discuss and incorporate, where relevant, comments of external reviewers
Completed
Draft final version of the guidelines
Completed
Make recommendations on dissemination strategy
Completed
Document the process of guideline development
Completed
Test the guidelines through pilot evaluations
Work in progress
The problem: health care-associated infections are
a major cause of death and disability worldwide
"Hospitals are intended to heal the
sick, but they are also sources of
infection. Ironically, advances in
medicine are partly responsible
Health care-associated infections occur worldwide and affect both developed and
resource-poor countries. Infections acquired in health-care settings are among the
major causes of death and increased morbidity in hospitalized patients. They repre
sent a significant burden for both the patient and his or her family and for public
for the fact that, today, hospital
health. A prevalence survey conducted under the auspices of WHO in 55 hospitals
infections are a leading cause of
of 14 countries representing four WHO regions (South-East Asia, Europe, the Eastern
death in some parts of the world."
Mediterranean and the Western Pacific) revealed that, on average, 8.7% of hospital
The World Health Report 7996
—
Fighting disease, fostering
development.
patients suffer nosocomial infections. At any time, over 1.4 million people world
wide suffer from infectious complications associated with health care.
Health care-associated infections rank as major killers of patients of all ages, par
ticularly among the most vulnerable members of the population. The more sick the
patient, the higher the risk of acquiring a health care-associated infection and dying
Each
year,
at
least
patients
in
the
USA and over
320 000
patients
2 000 000
in
the
UK
from it.
In developed countries, about 5-10% of patients admitted to acute care hos
pitals acquire an infection that was not present or incubating on admission. Such
acquire one or more health care-
hospital-acquired infections add to the morbidity, mortality and costs that would be
associated infections during their
expected from the patient's underlying disease alone. In the USA, one in 136 hospi
stay in hospital.
tal patients becomes seriously ill as a result of acquiring an infection in hospital. This
is equivalent to 2 000 000 cases a year — about 80 000 deaths annually. In England
health care-associated infection causes 5 000 deaths each year
Every day, 247 people die in the
USA as a result of a health careassociated infection.
Among the critically ill, even in highly resourced units, at least 25% of patients
admitted develop a health care-associated infection. In some countries, this propor
tion may be much higher; for example, in Trinidad and Tobago as many as two-thirds
of patients admitted to intensive care suffer at least one health care-associated
infection.
Worldwide, at least 1 in 4 patients
in
intensive
care
will
acquire
an infection during their stay in
In resource-poor countries, where the health system needs to deliver care to a
population with lower health status and to cope with the lack of human and techni
cal resources, the burden of health care-associated infections is even more important.
hospital. In developing countries,
As an example, in Mexico, health care-associated infections are the third most
this estimate may be doubled.
common cause of death for the entire population. Although estimates of preventable
health care-associated infections vary, the proportion may be as high as 40% or
more in developing countries.
WHO Guidelines on Hand Hygiene in Health Care
9
Causes of mortality in Mexico
In
overcrowded
and
understaffed
health services, the incorrect use of
medical technology is commonplace,
and increases the risk of infection asso
ciated with the process of care. This is a
frequent scenario in resource-poor set
tings, and adds to the health-care gap
between
developed
and
developing
countries. The impact is larger among
the more vulnerable patients. The rate
of infections associated with vascular
devices among neonates is 3-20 times
higher in developing countries than in
developed ones. In Brazil and Indonesia,
more than half of the neonates admitted
to neonatal units acquire a health careassociated infection, with a fatality rate
between 12% and 52%. In contrast, in
developed countries, the rate of hospital-
associated infection among neonates is
12-fold lower.
Source: S. Ponce de Leon. The needs of developing countries and the resources
required. Journal of Hospital Infection, 1991, 18 (Suppl A):376-381.
The last two decades have seen the
greatest increase in nosocomial infec-
tions in hospitals in developing countries where infectious diseases remain the
leading cause of death. Among health care-associated infections, surgical site infec
tions are leading causes of illness and death in certain hospitals in sub-Saharan
Africa. This is happening at a time when the arsenal of drugs available to treat infec
tions is being progressively depleted because of increasing resistance of the microbes
to antimicrobial drugs. Thus the list of already scarce effective agents is further
shortened.
4384 children die every day of
health care-associated infections
in developing countries.
Health care-associated infection during neonatal care is a leading cause of seri
ous illness and death. Prevalence rates for Brazil, European countries and the USA
are shown in the map below.
WHO Guidelines on Hand Hygiene in Health Care
The economic burden
Added to the considerable human misery caused by health care-associated infec
tions is their economic impact. In the USA, the risks of acquiring these infections
have risen steadily over the last decades with accompanying extra costs estimated
at USS 4500-5700 million a year. In England, health care-associated infections are
estimated to cost £1000 million annually to the National Health Service.
The costs of health care-associated infections vary from country to country, but
are substantial everywhere. In Trinidad and Tobago they represent 5% of the annual
budget of a country hospital, and in Thailand some hospitals spend 10% of their
annual budget on the management of infections. In Mexico, these costs represent
70% of the entire budget of the ministry of health.
Interventions are available but are not being used
Most patient deaths and suffering attributable to health care-associated infections
can be prevented. Low-cost and simple practices already exist to prevent these
infections. Hand hygiene, a very simple action, remains the primary measure to
reduce health care-associated infection and the spread of antimicrobial resistance,
enhancing patient safety across all settings. Yet compliance with hand hygiene is
very low throughout the world and governments should ensure that hand hygiene
promotion receives enough attention and funding to succeed.
Knowledge of measures to prevent health care-associated infections has been
widely available for years. Unfortunately, for a number of reasons, preventive meas
ures are often not being used. Poor training and adherence to proven practices on
hand hygiene is one reason.
Failure to apply infection control measures favours the spread of pathogens. This
spread may be particularly important during outbreaks, and health-care settings
can act as multipliers of disease, with an impact on both hospital and community
health. The emergence of life-threatening infections such as severe acute respiratory
syndrome (SARS), viral haemorrhagic fevers (Ebola and Marburg viral infections)
and the risk of a new influenza pandemic highlight the urgent need for efficient
infection control practices in health care. In the recent Marburg viral haemorrhagic
fever event in Angola, transmission within health-care settings played a major role
in the amplification of the outbreak. Uneven application of policies and practices
across countries is another concern, as usage may vary largely between hospitals
and countries. This variation was reflected during the SARS pandemic, in which
the proportion of health-care workers affected ranged from 20% to 60% of cases
worldwide.
Severe acute respiratory syndrome (SARS): total number of cases and
percentage of health-care workers affected, four countries.
r health workers
Percentage of hea'1
China
„
e
laiwo..
(mainland) IH«rovin«)
WHO Guidelines on Hand Hygiene in Health Care
The solution
Clear, effective and applicable guidance on measures to control the spread of infec
tions is needed. Although hand hygiene is considered the most important measure
to prevent and control health care-associated infections, ensuring its improvement is
a complex and difficult task. The WHO Guidelines on Hand Hygiene in Health Care
Care (Advanced Draft) provide health-care workers, hospital administrators and
health authorities with a thorough review of different aspects of hand hygiene and
in-depth information to overcome potential barriers. These guidelines are intended
for use in any situation where health care is delivered.
The guidelines provide a comprehensive review of scientific data on hand hygiene
rationale and practices in health-care settings. This extensive review brings together
in one document sufficient technical information to support training materials and to
help plan implementation strategies. The subjects developed in the review are:
• definition of terms;
• historical perspective on hand hygiene in health care;
• normal bacterial flora on hands;
• physiology of normal skin;
• transmission of pathogens on hands, including the available evidence
on the steps of transmission from either patient's skin or inanimate
environments to other patients or health-care workers through
contaminated hands;
• experimental and mathematical models of hand transmission of
microorganisms;
• relation between hand hygiene and acquisition of health care-associated
pathogens;
• critical review of methods to evaluate the antimicrobial efficacy of
hand rub and handwashing agents and formulations for surgical hand
preparation; this review comprises current methods, shortcomings of
traditional test methods, and perspectives of coming methods;
• agents used for hand hygiene, including water, non-antimicrobial
and antimicrobial soaps, alcohols, chlorhexidine, chloroxylenol,
hexachlorophene, iodine and iodophors, quaternary ammonium
compounds, and triclosan;
• activity of antiseptic agents against spore-forming bacteria and reduced
susceptibility of organisms to antiseptics;
Availability
of
alcohol-based
hand rubs is critical to promote
effective hand hygiene practices,
in particular in settings without
access
to
running
water.
Introduction of an alcohol-based
hand rub has led to increased hand
hygiene compliance among health
care workers and decreased health
care-associated infections.
Factors influencing
adherence to
recommended hand
hygiene practices
• relative efficacy of plain soap, antimicrobial soap and detergents, and
alcohols;
• safety issues related to hand hygiene products;
• a WHO waterless formulation for hand hygiene. To achieve optimal
compliance with hand hygiene among health-care workers, products
A. Observed risk factors for poor
adherence
should be easily accessible; the Guidelines suggest two formulations for
an alcohol-based hand rub, taking logistic, economic and cultural factors
into consideration;
•
Working in intensive care
•
Working during the week (vs. week-end)
•
Wearing gowns/gloves
•
Automated sink
of product selection for surgical hand preparation, and surgical hand
•
Activities with high risk of cross-transmission
antisepsis using either medicated soap and water or an alcohol-based
"
Understaffing or overcrowding
•
High number of opportunities for hand
hygiene per hour of patient care
•
Nursing assistant status (rather than a nurse)
•
Physician status (rather than a nurse)
B. Self-reported factors for poor
adherence
•
Hand-washing agents cause irritations and
• surgical hand preparation, including review of evidence, objectives
hand rub;
• frequency and pathophysiology of skin reactions related to hand hygiene,
and methods for reducing adverse effects;
• factors to consider when selecting hand hygiene products, and guidance
on pilot testing before purchase;
8 hand hygiene practices among health-care workers, adherence to
dryness
•
recommended measures, and review of factors affecting adherence;
Sinks are inconveniently located or shortage
of sinks
•
Lack of soap, paper, towel
•
Often too busy or insufficient time
•
Patient needs take priority
•
Hand hygiene interferes with health-care
8 religious and cultural aspects of hand hygiene;
8 behavioural considerations regarding hand hygiene practices and review
of the application of behavioural sciences to help promotion strategies;
8 organization of education programmes to promote hand hygiene;
worker-patient relationship
•
Low risk of acquiring infection from patients
•
Wearing of gloves or belief that glove use
obviates the need for hand hygiene
•
Lack of knowledge of guidelines and protocols
•
Not thinking about it, forgetfulness
•
No role model from colleagues or superiors
•
Scepticism about the value of hand hygiene
•
Disagreement with the recommendations
•
Lack of scientific information of definitive
8 strategies for hand hygiene promotion, with review of components so far
applied in promotion strategies, and assistance on developing a strategy
for guideline implementation;
• glove-wearing policies worldwide, their impact on hand hygiene, and
special concerns regarding glove use in developing countries;
• other policies related to the effectiveness of hand hygiene procedures,
such as the care of fingernails and the use of jewellery and artificial nails.
impact of improved hand hygiene on health
care-associated infection rates
C. Additional perceived barriers to
•
appropriate hand hygiene
of implementation campaigns. Methods for monitoring hand hygiene performance
Lack of active participation in hand hygiene
are reviewed, and quality indicators related to hand hygiene in health care are pro
promotion at individual or institutional level
posed.
•
Lack of role model for hand hygiene
•
Lack of institutional priority for hand hygiene
•
Crucial topics to help design and evaluate implementation strategies are addressed
in the Guidelines, which include key outcome measurements to assist the evaluation
Lack of administrative sanction of noncompliers/rewarding of compliers
•
Lack of institutional safety climate
WHO Guidelines on Hand Hygiene in Health Care
Consensus Recommendations
Ranking system for evidence
It was agreed that the CDC/H1CPAC system for categorizing recommendations be
adapted as follows:
• Category 1A. Strongly recommended for implementation and strongly
supported by well designed experimental, clinical, or epidemiological
studies.
• Category IB. Strongly recommended for implementation and supported
by some experimental, clinical, or epidemiological studies and a strong
theoretical rationale.
• Category IC. Required for implementation, as mandated by federal and/
or state regulation or standard.
• Category II. Suggested for implementation and supported by suggestive
clinical or epidemiological studies or a theoretical rationale or a
consensus by a panel of experts.
Recommendations
1 .Indications for handwashing and hand antisepsis
Wash hands with soap and water when visibly dirty or contaminated with
A.
proteinaceous material, or visibly soiled with blood or other body fluids, or if
exposure to potential spore-forming organisms is strongly suspected or proven
(IB) or after using the restroom (II).
Preferably use an alcohol-based hand rub for routine hand antisepsis in all other
B.
clinical situations described in items Ca to Cf listed below if hands are not visibly
soiled (IA). Alternatively, wash hands with soap and water (IB).
Perform hand hygiene:
C.
a)
before and after having direct contact with patients (IB);
b)
after removing gloves (IB);
c)
before handling an invasive device (regardless of whether or not gloves are
used) for patient care (IB);
d)
after contact with body fluids or excretions, mucous membranes, non-intact
skin, or wound dressings (IA);
e)
if moving from a contaminated body site to a clean body site during patient
care (IB);
f)
after contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient (IB);
D.
Wash hands with either plain or antimicrobial soap and water or rub hands with
an alcohol-based formulation before handling medication and preparing food
(IB).
E.
When alcohol-based hand rub is already used, do not use antimicrobial soap
concomittently (II).
WHO Guidelines on Hand Hygiene in Health Care
Hand Hygiene Technique with Alcohol-Based Formulation
2. Hand hygiene technique
Apply a palmful of the product and cover all sur
A.
faces of the hands. Rub hands until hands are dry
(IB).
B.
When washing hands with soap and water, wet
Apply a palmful of lhe product in a cupped hand and
cover all surfaces.
Rub hands palm to palm
hands with water and apply the amount of product
necessary to cover all surfaces. Vigorously perform
rotational hand rubbing on both palms and inter
lace fingers to cover all surfaces. Rinse hands with
water and dry thoroughly with a single use towel.
Use running and clean water whenever possible.
Use towel to turn off faucet (IB).
right palm ov er left dorsum
with interlaced fingers and
palm to palm with fingers
interlaced
backs of fingers to opposing
palms with lingers interlocked
vice versa
C.
Make sure hands are dry. Use a method that does
not recontaminate hands.
Make sure towels are
not used multiple times or by multiple people (IB).
Avoid using hot water, as repeated exposure to hot
water may increase the risk of dermatitis (IB).
D.
Liquid, bar, leaflet or powdered forms of plain
soap are acceptable when washing hands with a
rotational rubbing of left
thumb clasped in right palm
and vice versa
rotational nibbing, backwards ...once dry, your hands are
and forwards w uh clasped
safe.
fingers of right hand in left
palm and vice versa
non-antimicrobial soap and water. When bar soap
is used, small bars of soap in racks that facilitate
drainage should be used (II).
3. Recommendations for surgical hand preparation
A.
If hands are visibly soiled, wash hands with a plain soap before surgical hand
preparation (II). Remove debris from underneath fingernails using a nail cleaner,
preferably under running water (II).
B.
Sinks should be designed to decrease the risk of splashes (II).
C.
Remove rings, watches, and bracelets before beginning surgical hand prepara
tion (II). Artificial nails are prohibited (IB).
D.
Surgical hand antisepsis should be performed using either an antimicrobial soap
or an alcohol-based hand rub, preferably with sustained activity, before donning
sterile gloves (IB).
Modified according to EN1500
Handwashing Technique with Soap and Water
E. If quality of water is not assured in the operating
theatre, surgical hand antisepsis using an alcohol-
based hand rub is recommended before donning
sterile gloves when performing surgical procedures
(ID.
F. When performing surgical hand antisepsis using an
Wet hands with water
apply enough soap to cover
all hand surfaces
rub hands palm to palm
antimicrobial soap, scrub hands and forearms for
the length of time recommended by the manufac
turer, 2 to 5 min. Long scrub times (e.g. 10 min) are
not necessary (IB).
C. When using an alcohol-based surgical hand rub
product with sustained activity, follow the manufac
right palm over left dorsum
with interlaced fingers and
vice versa
palm to palm with fingers
interlaced
backs of fingers to opposing
palms with lingers interlocked
turer's instructions. Apply the product on dry hands
only (IB). Do not combine surgical hand scrub and
surgical hand rub with alcohol-based products
sequentially (II).
H. When using an alcohol-based product, use suffi
cient product to keep hands and forearms wet with
rotational rubbing of left
thumb clasped in right palm
and vice versa
rotational rubbing, backwards rinse hands with water
and forwards with clasped
fingers of right hand in left
palm and vice versa
the hand rub throughout the procedure (IB).
I.
After application of the alcohol-based product,
allow hands and forearms to dry thoroughly before
donning sterile gloves (IB).
dry thoroughly with a single
use towel
use towel to turn off faucet
...and your hands are safe.
4. Selection and handling of
hand hygiene agents
Modified according to EN1500
A. Provide health-care workers with efficacious hand
hygiene products that have low irritancy potential
(IB).
B. To maximize acceptance of hand hygiene products by health-care workers, solicit
their input regarding the feel, fragrance, and skin tolerance of any products under
consideration. In some settings, cost may be a primary factor (IB).
C. When selecting hand hygiene products:
- determine any known interactions between products used to clean hands,
skin care products, and the types of gloves used in the institution (II);
WHO Guidelines on Hand Hygiene in Health Care
-
solicit information from manufacturers about risk of contamination (pre-mar
keting and in-use) (IB);
-
ensure that dispensers are accessible at the point of care (IB);
-
ensure that dispensers function adequately and reliably, and deliver an appro
priate volume of the product (II);
-
ensure that the dispenser system for alcohol-based formulations is approved
for flammable materials (IC);
-
solicit information from manufacturers regarding any effects that hand lotions,
creams, or alcohol-based hand rubs may have on the effects of antimicrobial
soaps being used in the institution (IB).
D. Do not add soap to a partially empty soap dispenser. If soap dispensers are
reused, follow recommended procedures for cleansing (IA).
5. Skin care
A.
Include information regarding hand care practices designed to reduce the risk of
irritant contact dermatitis and other skin damage in health-care workers educa
tion programmes (IB).
B.
Provide alternative hand hygiene products for health-care workers with allergies
or adverse reactions to standard products used in the health-care setting (11).
C.
When needed to minimize the occurence of irritant contact dermatitis associated
with hand antisepsis or handwashing, provide health-care workers with hand
lotions or creams (IA).
6. Use of gloves
A.
The use of gloves does not replace the need for hand cleansing by either handrub
bing or handwashing (IB).
B.
Wear gloves when it can be reasonably anticipated that contact with blood or
other potentially infectious materials, mucous membranes, and non-intact skin
will occur (IC).
C.
Remove gloves after caring for a patient. Do not wear the same pair of gloves for
the care of more than one patient (IB).
D.
When wearing gloves, change or remove gloves during patient care if moving
from a contaminated body site to a clean body site within the same patient or to
the environment (II).
E.
Avoid reuse of gloves (IB). If gloves are re-used, implement reprocessing methods
to ensure glove integrity and microbiological decontamination (II).
7. Other aspects of hand hygiene
A.
Do not wear artificial fingernails or extenders when having direct contact with
patients (IA).
B.
Keep natural nails short (tips less than 0.5 cm long) (II).
8. Health-care worker educational training
and motivational programmes
A.
In hand hygiene promotion programmes for health-care workers, focus specifi
cally on factors currently found to significantly influence behaviour, and not
solely on the type of hand hygiene products. The strategy must be multifaceted
and multimodal and include education and senior executive support for imple
mentation (IB).
B.
Educate health-care workers about the type of patient-care activities that can
result in hand contamination and about the advantages and disadvantages of
various methods used to clean hands (II).
C.
Monitor health-care workers' adherence to recommended hand hygiene prac
tices and provide them with performance feedback (IA).
D.
Encourage partnerships between patients, their families and health-care workers
to promote hand hygiene in health care (II).
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09703
WHO Guidelines on Hand Hygiene in Health Care
9. Governmental and institutional responsibilities
Critical factors for the
success of large-scale
hand hygiene promotion
9.1 For hospital administrators
•
A.
Provide health-care workers with access to sate continuous water supply at all
faucets and access to necessary facilities to perform handwashing (IB).
B.
Provide health-care workers with a readily accessible alcohol-based hand rub at
•
Presence of drivers for improvement
•
Adaptability of the programme
•
Political commitment
•
Make improved hand hygiene adherence an institutional priority and provide
appropriate leadership, administrative support and financial resources (IB).
D.
•
Availability of finance
•
Coalitions and partnerships
•
Local ownership
•
Presence of external support agencies
•
Capacity for rapid dissemination and active
Assign health-care professionals with dedicated time and training for the insti
tutional infection control activities, including the implementation of a hand
hygiene promotional programme (II).
learning
•
•
Implement a multidisciplinary, multifaceted and multimodal programme designed
to improve adherence of health-care workers to recommended hand hygiene
practices (IB).
F.
With regard to hand hygiene, ensure that the water supply within the health-care
setting is physically separated from drainage and sewerage, and provide routine
system monitoring and management (IB).
9.2 For national governments
A. Make improved hand hygiene adherence a national priority and consider provi
sion of a funded, coordinated and implemented programme for improvement
(ID.
B. Support strengthening of infection control capacities within health-care settings
(11).
C.
Promote hand hygiene at the community level to strengthen both self-protection
and protection of others (II)-
Links to health-care regulation
Economies of scale that can be achieved
through central production
•
E.
Policies and strategies that enable spread and
sustainability
the point of patient care (IA).
C.
Combined expertise of many professional
groups
Capacity for public-private partnership
working.
Benefits of improved hand hygiene
Can hand hygiene promotion help to reduce the
burden of health care-associated infections?
Convincing evidence demonstrates that improved hand hygiene can reduce the
frequency of health care-associated infections. Failure to comply with hand hygiene
is considered the leading cause of health care-associated infections, contributes to
the spread of multiresistant organisms, and is recognized as a significant contributor
to outbreaks of infection.
Improved hand hygiene practices are temporally related to the decreased fre
quency of health care-associated infections and spread of multiresistant organisms.
In addition, reinforcement of hand hygiene practices helps to control epidemics in
health-care facilities.
The beneficial effects of hand hygiene promotion on the risk of cross-transmis
sion are also present in schools, day care centres and the community setting. Hand
hygiene promotion improves child health as it reduces upper respiratory pulmonary
infection, diarrhoea and impetigo among children in the developing world.
Is hand hygiene promotion cost-effective?
The potential benefit of successful hand hygiene promotion outweighs its costs,
and widespread promotion should be supported. Multimodal interventions are more
likely to be effective and sustainable than single-component interventions; although
they are more resource-intensive, they are proved to have greater potential.
The cost saving achieved by reducing the occurrence of health care-associated
infections should be considered in the evaluation of the economic impact of hand
hygiene promotion programmes. The excess use of hospital resources associated
with only four or five health care-associated infections of average severity may equal
Hand hygiene promotion reduces
infections. As a result, it saves lives
and reduces morbidity and costs
related to health care-associated
infections.
the entire annual budget for hand hygiene products used in inpatient care areas. A
single severe infection of a surgical site, lower respiratory tract, or bloodstream may
cost the hospital more than its entire annual budget for antiseptic agents used for
hand hygiene. In a neonatal intensive care unit in the Russian Federation, the excess
cost of one health care-associated bloodstream infection (USS 1100) would cover
3265 patient-days of hand antiseptic use (US$ 0.34 per patient-day). The alcohol-
based hand rub applied for hand hygiene in this unit would be cost-effective if its
use prevented only 8.5 pneumonias or 3.5 bloodstream infections each year. Savings
achieved by reducing the incidence of multiresistant bacterial infections far exceed
the additional cost of promoting the use of hand hygiene products such as alcoholbased hand rubs.
The hand hygiene promotion campaign at the University of Geneva Hospitals,
Switzerland, constitutes the first reported experience of a sustained improvement in
WHO Guidelines on Hand Hygiene in Health Care
compliance with hand hygiene, coinciding with a reduction of nosocomial infections
and multiresistant Staphylococcus aureus cross-transmission. The multimodal strat
egy that contributed to the success of the promotion campaign included repeated
monitoring of compliance and hand hygiene performance feedback, communication
and education tools, constant reminders in the work environment, active participa
tion and feedback at both individual and organizational levels, senior management
support and involvement of institutional leaders. The promotion of alcohol-based
hand rub at the point of care largely contributed to enhanced compliance. Including
both direct costs associated with the intervention and indirect costs associated with
health-care workers' time, the promotion campaign was cost-effective: the total cost
of hand hygiene promotion corresponded to less than 1% of the costs associated
with health care-associated infections.
An economic analysis of the United Kingdom's "cleanyourhands" hand hygiene
nationwide promotional campaign concluded that the programme would be cost-
beneficial even if health care-associated infection rates were decreased by as little
as 0.1%.
Interventions designed to improve hand hygiene throughout a country may require
significant financial and human resources, particularly for multifaceted campaigns.
Despite the fact that some studies strongly suggest a clear benefit of hand hygiene
promotion, budget constraints are a reality, particularly in developing countries.
Cost-effectiveness analysis might be necessary to identify the most efficient strate
gies. Given that the burden of health care-associated infections is more significant
in developing and transitional countries, the benefits of hand hygiene promotion
campaigns may be even greater than those already documented in industrialized
countries.
Implementation strategies
The implementation strategies of the Global Patient Safety Challenge and, in par
ticular, the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) are
designed to achieve maximum dissemination of the Guidelines and to impact on the
burden of disease. The strategies include several steps and components.
The task forces
Task forces of experts have been established to foster ongoing discussion on some
key topics included in the Guidelines which require further development and practi
cal solutions. The work of these groups is planned to continue until the issue has
been completely analysed and practical solutions developed. Key topics for which
work is underway include:
• patient involvement in infection prevention, and hand hygiene in
particular: theoretical reasons for patient involvement, potential
advantages and obstacles, and practical actions for patient involvement;
• water quality for handwashing: characteristics of water needed to ensure
a level of quality adequate to guarantee the efficacy of hand washing;
• global implementation of the WHO hand hygiene formulation:
production, procurement and distribution issues at country level;
• glove use and re-use: safe practice of glove use and possible re-use in
settings with limited resources, including effective and standardized
procedures for reprocessing to ensure glove integrity and microbiological
decontamination;
• religious, cultural and behavioural aspects of hand hygiene: possible
solutions to overcome religious and cultural barriers for the use of
alcohol-based hand rubs; understanding behavioural aspects underlying
health-care workers' attitudes towards hand hygiene so as to facilitate
promotion;
• communication and campaigning: essential elements to build up a global
campaign to promote the critical role of hand hygiene in health care
worldwide;
• national guidelines on hand hygiene: comparison of currently available
guidelines, to evaluate the background of national recommendations and
foster uniform standards worldwide;
WHO Guidelines on Hand Hygiene in Heaith Care
• frequently asked questions: summary of critical questions that could arise
during the practical implementation of the Guidelines in the field.
As the implementation phase is an ongoing process, other topics of discussion
will be dealt with in additional working groups and expert task forces as they arise.
The launch
The launch of the Global Patient Safety Challenge and the presentation of the WHO
Guidelines on Hand Hygiene in Health Care (Advanced Draft) at WHO Headquarters
in Geneva, Switzerland, on 13 October 2005 are intended to mark the beginning of
a new era of awareness and improvement in patient safety in health care.
The launch aims to:
• highlight the critical role of hand hygiene to control and prevent the
spread of health care-associated infections and multiresistant pathogens;
• strengthen commitment of interested WHO Member States in the Global
Patient Safety Challenge.
On this occasion, ministers of health and major associations of health-care pro
fessionals are invited to pledge formally that they will tackle health care-associated
infections, give priority to hand hygiene, and share results and knowledge interna
tionally. The pledge includes a signed public statement by the country's minister of
health giving priority to reducing health care-associated infections, in particular by:
• considering the adoption of WHO strategies and guidelines;
• developing campaigns at national or sub-national levels for improving
hand hygiene among health care providers;
• committing to work with health professional bodies and associations
and research and educational institutions in the country to promote the
highest standards of practice and behaviour, to foster collaboration and to
encourage senior management support and role modeling from key staff.
National or sub-national campaigns to promote hand hygiene among health
care workers are intended to be harmonized with the Global Awareness Raising
Campaign and the Global Patient Safety Challenge 2005-2006: "Clean Care is Safer
Care" spearheaded by the World Alliance for Patient Safety. Visual messages, slo
gans and press material — such as fact sheets, media advisory and press releases
— and other tools are available for the development of the campaign worldwide.
The process of advertising the launch of this initiative and the dissemination of the
Guidelines benefits from the support of numerous societies and institutions consti
tuting a network to link globally.
The pilot testing phase
The procedure to obtain the final innovative WHO Guidelines on Hand Hygiene in
Health Care includes a last, essential step: the pilot testing phase. This phase con
sists of implementing simultaneously the different components of the Global Patient
Safety Challenge 2005-2006: "Clean Care is Safer Care" in pilot sites located within
each of the six WHO regions, with a particular emphasis on the Guidelines.
The main goals of this phase are to ensure the feasibility of the Challenge overall
and to learn practical lessons for the applicability of the Guidelines in real field
situations.
Pilot sites are representative of the widest range of existing health-care facilities,
and the results will be reviewed to assess the practicability of the implementation
of the Guidelines. The final version of the WHO Guidelines on Hand Hygiene in
Health Care will take into account and reflect this analysis. The pilot studies are
focused on the implementation of the Guidelines integrated with some interven
tions related to other areas of the Challenge: Clean Products: blood safety; Clean
Practices: safe clinical procedures; Clean Equipment: injection and immunization
safety; Clean Environment: safe water and sanitation in health care.
WHO Guidelines on Hand Hygiene in Health Care
Conclusion: the way forward
Health care-associated infection is of paramount importance throughout the world;
it affects the quality of care and patient safety and adds tremendous and needless
costs to health care.
The commitment of the World Alliance for Patient Safety to reduce health
care-associated infections, by selecting this topic as the first Global Patient Safety
Challenge, is an unprecedented event. The combined efforts within the Challenge
have the potential to save millions of lives and to halt the diversion of major resources
from other productive use, through improvement of basic procedures and a greater
attention to hand hygiene among health-care providers.
Given the importance of this goal, the Alliance has chosen the most rigorous and
ambitious process to produce the WHO Guidelines on Hand Hygiene in Health
Care and to plan and realize a stepwise implementation strategy. For this purpose,
the Guidelines gathered the expertise of the most renowned experts from around the
world; the Guidelines are now being tested in a pilot phase to obtain the most reli
able and adaptable final strategy to be used worldwide. This work should become
the standard for health-care providers determined to put an end to the distress of
millions of patients who have suffered from health care-associated infections.
With hand hygiene as the cornerstone to prevent the transmission of patho
gens, the objective of reducing health care-acquired infections is strongly tackled by
all the actions within the Challenge. Let us all pledge to achieve the Global Patient
Safety Challenge 2005-2006: "Clean Care is Safer Care".
WHO Guidelines on Hand Hygiene in Health Care
Selected references
Boyce |M, Pittet D. Guideline 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. Society for Healthcare Epidemiology of America/
Association
for
Professionals
in
Control/
Infection
Infectious Diseases Society of America. Morbidity and
Mortality Weekly Report Recommendations and Reports,
2002, si(RR-16):1-45
Pittet D et al. Effectiveness of a hospital-wide programme
to improve compliance with hand hygiene. The Lancet,
2000, 356:1307-1312.
Pittet
D
et
al.
Hand
hygiene
among
physicians:
performance, beliefs, and perceptions. Annals of Internal
Medicine, 2004,141:1-8.
Pittet D. Improving compliance with hand hygiene in
hospitals. Infection Control and Hospital Epidemiology,
2000, 21:381-386.
Brown SM et al. Use of an alcohol-based hand rub and
Pittet D. The Lowbury lecture: behaviour in infection
quality improvement interventions to improve hand
control. Journal of Hospital Infection. 2004, 58:1-13.
hygiene in a Russian neonatal intensive care unit. Infection
Control and Hospital epidemiology, 2003, 24:172-179.
infections occurring in patients admitted to selected
Ducel G. Prevention of hospital-acquired infections:
a practical guide, 2nd ed. Geneva, World
Plowman R el al. The rate and cost of hospital-acquired
Health
specialties of a district general hospital in England and the
national burden imposed. Journal of Hospital Infection,
Organization. 2002.
2001, 47:198-209.
Duckro AN et al. Transfer of vancomycin-resistant
Raymond j, Aujard Y. Nosocomial infections in pediatric
enterococci via health care worker hands. Archives of
patients: a European, multicenter prospective study
Internal Medicine, 2005, 165:302-307.
European Study Group. Infection Control and Hospital
Gopal Rao G et al. Marketing hand hygiene in hospitals - a
Epidemiology, 2000, 21’260-263.
case study. Journal of Hospital Infection, 2002, 50:42-47.
Seto WH. Staff compliance with
Hart CA, Kariuki S. Antimicrobial resistance in developing
practices: application of behavioural sciences. Journal of
countries. British Medical Journal, 1998, 317:647-650.
Hospital Infection, 1995, 30(Supph:107-115.
Khan MU. Interruption of shigellosis by handwashing.
Seto WH et al. Effectiveness of precautions against droplets
Transactions of the Royal Society of Tropical Medicine
and contact in prevention of nosocomial transmission of
infection control
and Hygiene, 1982, 76:164-168.
severe acute respiratory syndrome (SARS). The Lancet,
Lam BC, Lee J, Lau YL. Hand hygiene practices in a
2003, 361:1519-20.
neonatal intensive care unit: a multimodal intervention
Sohn AH et al. Prevalence of nosocomial infections in
and impact on nosocomial infection. Pediatrics, 2004,
neonatal intensive care unit patients: results from the first
114:565-571.
national point-prevalence survey. Journal of Pediatrics,
Larson EL et al. An organizational climate intervention
2001,139:821-827.
associated with increased handwashing and decreased
Shahid NS et al. Hand washing with soap reduces diarrhoea
nosocomial infections. International Journal of Behavioral
and spread of bacterial pathogens in a Bangladesh village.
Medicine, 2000, 26:14-22.
Journal of Diarrhoeal Disease Research, 1996, 14:85-89.
Luby SP et al. Effect of handwashing on child health:
a
randomised
controlled
trial.
The
Lancet,
2005,
hand
A
hygiene,
decontaminant,
newly
altering water-sanitation behaviors to reduce childhood
diarrhea in urban Bangladesh. American Journal of
366:225-33.
MacDonald
Stanton BE, Clemens JD. An educational intervention for
affected
et
al.
Performance
as
the
skin
Starfield B. Is US health really the best in the world?
number
of
inpatients
Journal of the Amercian Medical Association, 2000,
alcohol
reduces
the
MRSA
Epidemiology, 1987, 125:292-301.
gel
using
by
of
feedback
and
antibiotic
costs.
Journal of Hospital Infection, 2004, 56:56-63.
284:483-485.
Tikhomirov E. WHO Programme for the Control of
McDonald et al. SAR5 in healthcare facilities, Toronto and
Hospital Infections. Chemiotherapia, 1987, 3:148-151
Taiwan. Emerging Infectious Diseases, 2004,10:777-81
Webster J, Faoagali JL, Cartwright D. Elimination of
Ng PC et al. Combined use of alcohol hand rub and gloves
methicillin-resistant
reduces the incidence of late onset infection in very low
neonatal intensive care unit after hand washing with
Staphylococcus
aureus
from
a
birthweight infants. Archives of Disease in Childhood,
tridosan. Journal of Paediatrics and Child Health, 1994,
Fetal and Neonatal Edition, 2004, 89:336-340.
30:59-64.
NPSA/PASA Hand Hygiene Project 2004 (http://www.
Won SP et al. Handwashing program for the prevention
npsa.nhs.uk/cleanyourhands/resources/documents )
of nosocomial infections in a neonatal intensive care
Pessoa-Silva CL et al. Healthcare-associated infections
unit. Infection Control and Hospital Epidemiology, 2004,
among neonates in Brazil. Infection Control and Hospital
25:742-746.
Epidemiology, 2004, 25:772-777.
Zaidi et al. Hospital-acquired neonatal infections in
Pittet D. Clean hands reduce the burden of disease. The
developing countries. The Lancet, 2005, 365:1175-88.
Lancet, 2005,366:185-7.
Acknowledgements
Authors:
John Boyce
Saint Raphael Hospital, New Haven; United States of
Pascale Herrault
Geneva's University Hospitals; Switzerland
Lindsay Grayson
Austin and Repatriation Medical Centre; Australia
Annette Jeanes
Lewisham Hospital; United Kingdom
William Jarvis
Centre Hospitalier Lyon Sud; France
Axel Kramer
Ernst-Moritz-Arndt Umversitat Greifswald; Germany
America
Don Goldmann
Children's Hospital Boston; United States of America
Anna-Leena Lohiniva
US Naval Medical Research Unit; Egypt
Elaine Larson
Columbia University School of Nursing and Joseph
Mailman School of Public Health; United States of
Jann Lubbe
Geneva's University Hospitals; Switzerland
America
Raphaelle Girard
America
Mary Louise McLaws
Faculty of Medicine, University of New South Wales,
Sidney; Australia
Geeta Mehta
Lady Hardinge Medical College, New Delhi; India
Ztad Memish
King Fahad National Guard Hospital, Riyadh; Kingdom
of Saudi Arabia
Didier Pittet
Geneva's University Hospitals and Faculty of Medicine;
Switzerland
Manfred Rotter
Klintsches Institut fur Hygiene und Medizinische
Microbiologie der U niversitat Wien; Austria
Syed Sattar
University of Ottawa; Canada
Hugo Sax
Geneva's University Hospitals; Switzerland
Wing Hong Seto
Queen Mary Hospital, Hong Kong; China
Julie Storr
National Patient Safety Agency; United Kingdom
Michael Whitby
Princess Alexandra Hospital, Brisbane; Australia
Andreas F. Widmer
Facharzt fur Innere Medizin und Infektiologie
Kantonsspital Basel Universitatskliniken;
Switzerland
Andreas Voss
Canisius-Wilhelmina Hospital (CWZ); The Netherlands
Technical contributors:
Charanjit Ajit Singh
International Interfaith Centre; Oxford, United Kingdom
Jacques Arpin
Geneva; Switzerland
Barry Cookson
Health Protection Agency, London; United Kingdom
Izhak Dayan
Communaute Israelite de Geneve; Switzerland
Institute Nacional de Ciencias Medicas y Nutricidn S.Z.;
Mexico
Victor D. Rosenthal
Medical College of Buenos Aires; Argentina
Robert C, Spencer
Nana Kobina Nketsia
Traditional Area Amangyina, Sekondi; Ghana
Bristol Royal Infirmary; United Kingdom
Barbara Soule
Florian Pittet
Geneva; Switzerland
Joint Commission Resources; United States of America
Anantanand Rambachan
Saint Olaf College; Northfield, United States of America
Ravin Ramdass
South African Medical Association; South Africa
Paul Ananth Tambyah
National University Hospital, Singapore
Editor:
Didier Pittet, Geneva's University Hospitals and Faculty
Susan Sheridan
Consumers Advancing Patient Safety; United States of
of Medicine; Switzerland
America
Special thanks:
Parichart Suwanbubbha
Mahidol University, Thailand
Rosemary Sudan, Geneva's University Hospitals
Gail Thomson
North Manchester General Hospital; United Kingdom
Members ol the Infection Control Programme, Geneva's
University Hospitals
WHO Collaborating Departments:
Hans Ucko
World Council of Churches; Switzerland
WHO Lyon Office for National Epidemic Preparedness
Garance Upham
People’s Health Movement; Switzerland
and Response
Gary Vachtcouras
Orthodox Center of Ecumenical Patriarchate; Chambesy-
Communicable Diseases
Communicable Disease Surveillance and Response
Geneva, Switzerland
Blood Transfusion Safety
Constanze Wendt
Hygiene Institut, University of Heidelberg; Heidelberg,
Essential Health Technologies
Germany
Clinical Procedures
Editorial Contributions:
Essential Health Technologies
Rosemary Sudan
Geneva's University Hospitals; Switzerland
Health Technology and Pharmaceuticals
Health Technology and Pharmaceuticals
Policy, Access and Rational Use
Special acknowledgment for technical
contribution and project management:
Essential Drugs and Medicines Policy
Benedetta Allegranzi
University of Verona; Italy
Vaccine Assessment and Monitoring
Health Technology and Pharmaceuticals
Immunization, Vaccines and Biologicals
Overall support and advice:
Sir Liam Donaldson, Department of Health; United
Kingdom
Family and Community Health
Water, Sanitation and Health
Didier Pittet, Geneva's University Hospitals and Faculty
Protection of the Human Environment
of Medicine; Switzerland
Sustainable Development and Healthy Environments
External Reviewers:
Carol O'Boyle
Cesare Falletti
Monastero Dominus Tecum, Pra'd Mill; Italy
Geneva, Switzerland
Martin J. Hatlie
Partnership for Patient Safety; United States of America
Samuel Ponce de Leon Rosales
Peter Mansell
National Patient Safety Agency; United Kingdom
Sasi Dharan
Geneva's University Hospitals; Switzerland
William Griffiths
Geneva's University Hospitals; Switzerland
Emory University School of Medicine; United States of
World Health Organization
Center for Child and Family Health Promotion Research;
P.J. van den Broek
Leiden Medical University Centre; The Netherlands
Victoria J. Fraser
Washington University School of Medicine; United States
J] - I O O
09 703
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WHO Guidelines on Hand Hygiene in Health Care
i
Health System Policies and Operations
Evidence and Information for Policy
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