ROLE OF HAND HYGIENE IN PREVENTING TRANSMISSION OF INFECTIOUS DISEASES

David Jay Weber, M.D., M.P.H.

Medical Director, Hospital Epidemiology

Professor of Medicine, Pediatrics & Epidemiology

University of North Carolina at Chapel Hill

PRESENTATION TOPICS

Rationale for hand hygiene Link between professional and consumer hand hygiene Indications for hand hygiene in home and community

settings Efficacy of hand hygiene in reducing day care center-

associated infections Uses of hand hygiene products in home health

RATIONALE FOR HAND HYGIENE

Many infectious agents are acquired via hand contact with contaminated surfaces Contact transmission: Healthcare (MRSA, VRE), day care (MRSA),

home (MRSA, “cold viruses”, herpes simplex Fecal-oral transmission: Day care (Shigella, E. coli O157:H7), home

(Salmonella, E. coli O157:H7, Cryptosporidium) Hand hygiene effective in reducing or eliminating transient flora Hand hygiene demonstrated to be effective in preventing

illness (especially fecal-oral diarrheal illnesses) in healthcare facilities, child care centers/homes, and households

EFFECTIVENESS OF HAND HYGIENE IN THE HOSPITAL

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North

Pittet D, et al. Lancet 2000;356:1307-12.

Primary Child Care Arrangements for Children

<6 Years of Age

Parents (8.6 mill)

Center(3.8 mill)

Family Day Care (2.0 mill)

Child’s Home (1.7 mill)

Other (2.5 mill)

(Ralph Cordell, CDC)

INFECTION CONTROL CONCERNS: INFANTS AND TODDLERS

Infants and toddlers Require diapering or assistance in using a toilet Explore the environment with their mouths Have poor control over their secretions and excretions Have immature immune systems Require hands-on contact with health providers

Toddlers Have frequent contact with other toddlers

RELATIVE RISK OF DIARRHEA BY TYPE OF CHILD CARE SETTING

Author Study Design Child Care Center

Child Care Home

Bartlett, 1985 Cohort 2.2* (1.3, 3.5)** 1.3 (0.7, 2.4)

Alexander, 1990 Case control 3.5 (1.0, 4.8) <1.0

Reves, 1993 Case control 2.4 (1.6, 3.7) 2.0 (1.3, 3.1)

Pickering LK & Osterholm MT, 1997* Relative to care at home, ** 95% CI

INFECTIONS ASSOCIATED WITH CHILD CARE CENTERS

Enteric syndromes Diarrheal diseases HepatitisPathogens Hepatitis A Norovirus Rotavirus E. coli O157:H7 Shigella Cryptosporidium

Respiratory Otitis media Sinusitis Pharyngitis PneumoniaPathogens H. influenzae type B S. pneumoniae

Cost (in millions) of child care-associated illness to businesses and families in the U.S.

Haskins.Bull NY Acad Med 1990

Absence from work ($1,300)

Treatment of otitis ($420)

Treatment of Hib infections($17.3)

Long term care ($40)

Treatment of respiratory infections ($78)

RANDOMIZED CONTROLLED TRIALS DEMONSTRATING EFFICACY OF HAND HYGIENE IN CHILD CARE CENTERS

Author, Year DCC Intervention Reduction in DiarrheaKotch J, 1994 24 HH, environmental cleaning,

improved diapering, edReduction severe diarrhea

Uhari M, 1999 20 HH, environmental cleaning, improved diapering, ed

8-9%

Carabin H, 1999 47 HH, ed 27%

Roberts L, 2000 23 HH, ed 50%

Kotch J, 2006 46 New equipment (diapering, handwashing, food preparation)

~50% (diarrheal days)

Ed, education; HH, hand hygiene

MODEL OF ENTERIC DISEASE TRANSMISSION IN DAY CARE

INDICATIONS FOR HAND HYGIENE IN THE HOME

Targeted Hand Hygiene (times & places): Before and after eating or preparing food

>75 million foodborne infections per year (Mead PS, et al. EID 1999;5:607) Before and after using the bathroom Before and after diapering

Per data from child care centers After pet/animal contact

>300 zoonotic diseases; many contact or fecal-oral transmitted Before and after providing health care

Per data from healthcare facilities

HAND HYGIENE STUDIES IN THE HOME

Hand hygiene – home studies No reduction in illness rates in homes randomized to antibacterial cleaning and

handwashing products (Larson EL, et al. AIM 2004;140:397-398) ~50% reduction in secondary diarrheal illnesses in homes randomized to an

alcohol-based hand sanitizer and education (Sandora TJ, et al. Pediatr 2005;116:587-94)

Studies demonstrating efficacy of hand hygiene are problematic Limited number of studies with small sample sizes Design obstacles Multiple routes of exposure and exposures outside the home Efficacy of hand hygiene using soap and water (efficacy of control group)

CONCLUSIONS

Infections acquired in healthcare facilities and day care centers result in substantial morbidity and cost

Infections acquired in healthcare facilities and day care centers often result from person-to-person transmission via the hands of healthcare or day care providers

Hand hygiene may reduce the frequency of nosocomial and day care center infections

Hand hygiene likely provides a benefit with selected (targeted) activities in the home