Microbiology Topics.Scott Sutton, Coordinator[

“Microbiology Topics” discusses various topics in microbiology of practical use in validation and compli-ance. We intend this column to be a useful resource for daily work applications.

Reader comments, questions, and suggestions are needed to help us fulfill our objective for this column. Case studies from readers are most welcome. Please send your comments and suggestions to column coordinator Scott Sutton at scott.sutton@microbiol.org or journal coordinating editor Susan Haigney at shaigney@advanstar.com.

KEY POINTSThefollowingkeypointsareaddressedinthisarticle:

•Good personal hygiene is a requirement of allpharmaceuticalactivities,fromoperatingonthelinethroughvalidations.However,studiesshowpoorcomplianceasaruletobasichandwashingtechnique.

•Poorhandwashingtechniquemayresultinincreasedabsenteeism,particularlyintimeofapotentialH1N1pandemic.

•Limitedavailabilitytoadequatefacilitiesmayleadtopoorcomplianceorpoorefficacyofwashingifperformed.Thesefacilitiesincludeappropriatelyconstructedandsourcedwatersupply,soapsupply,andperhapsmostimportantly,adequateprovisionsforthoroughdryingofhands.

•While“antibacterial”labelclaimsdonoharm,theyshouldnotbereliedupontoprotectagainstpoorpractice.

•Jewelrycaninterferewithadequatecleansingand

shouldberemovedbeforewashing.Jewelryshouldbediscouragedinareaswherehandcleanlinessisimportant.

•Trainingforcomplianceinhandwashingisdifficult.Therehavebeennumerousreportsofthedifficultyintrainingandthesubsequentmonitoringofhealthcareworkersforcompliancewithhandwashingrequire-ments.Suggestionsfortrainingandapotentiallyusefulmonitoringtoolareprovided.

•Manystudiesuseextendedperiodsoftimeduringthewash(1.5-2minutesinsome).Thisisnotapracticalregimen.AhandwashingregimentissuggestedforpharmaceuticalmanufacturingworkersbasedontheCentersforDiseaseControl(CDC)handwash-ingprotocol.

•Validationpersonnelshouldcarefullyevaluateper-sonnelpracticeswhenmicrobialtestingisrequiredinvalidationprotocols.Itislikelythatsimplepro-cesses,suchashandwashing,aregenerallyassumedtobeundercontrolwhentheymaybeanundetectedsourceofproductcontamination.

INTRODUCTION Whendevisingvalidationprotocols,whethertheyareprocesssimulationmediafills,environmentalmonitoringqualifications,sanitizerqualificationprograms,orper-sonnelqualificationprograms,wetendtotakethebasicrequirementsforgranted.Handwashingisanactivitythatisundoubtedlytakenforgranted.Whilethefirsttwoactivitiesmentionedabovearemoreaconcernfortheasepticmanufacturer,theremainingenvironmentandpersonnelqualificationstudiesareacurrentgoodmanu-

Hand Washing—A Critical Aspect of Personal Hygiene in PharmaScott Sutton

ABOUT THE AUTHORScott Sutton, Ph.D., is a consultant with Vectech Pharmaceutical Consultants and operates The Microbiology Network (www.microbiol.org), which provides services to microbiology-related user’s groups. Dr. Sutton can be reached at scott.sutton@microbiol.org.

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facturingpractice(CGMP)concernforallmanufacturers.Thesepracticesmustbebasedonsolidfundamentals.Knowledgeandtraininginthesefundamentalsbeginswithadequatepreparationofthepersonnel.Beyondthis,itisaclearrequirementintheCGMP(1)asfollows:

“21CFR211.28PersonnelResponsibilities:“(a)Personnelengagedinthemanufacture,processing,

packing,orholdingofadrugproductshallwearcleanclothingappropriateforthedutiestheyperform.Protec-tiveapparel,suchashead,face,hand,andarmcoverings,shallbewornasnecessarytoprotectdrugproductsfromcontamination.

“(b)Personnelshallpracticegoodsanitationandhealthhabits.

“(c)Onlypersonnelauthorizedbysupervisoryperson-nelshallenterthoseareasofthebuildingsandfacilitiesdesignatedaslimited-accessareas.

“(d)Anypersonshownatanytime(eitherbymedi-calexaminationorsupervisoryobservation)tohaveanapparentillnessoropenlesionsthatmayadverselyaffectthesafetyorqualityofdrugproductsshallbeexcludedfromdirectcontactwithcomponents,drugproductcon-tainers,closures,in-processmaterials,anddrugproductsuntiltheconditioniscorrectedordeterminedbycom-petentmedicalpersonnelnottojeopardizethesafetyorqualityofdrugproducts.Allpersonnelshallbeinstructedtoreporttosupervisorypersonnelanyhealthconditionsthatmayhaveanadverseeffectondrugproducts.“

Inadditiontotheconcernoverthequalityofourvali-dationstudies,thereisapersonnelconsiderationaswell.Properhand-washingtechniqueisthemosteffectivemeanstoslowthespreadofdisease.Properhandwashingisparticularlyimportantinthistimeofincreasedconcernoverglobalpandemic.TherehavebeenascoreofrecentarticlesonthebestwaystominimizethespreadoftheH1N1virustransmission(2,3).Recentworkhasshownthathandwashingmaybeanextremelyeffectiveandeconomicalwaytoslowthespreadofthevirus(4).

Anobviousconsiderationintryingtoestablishtheefficacyofhand-washingregimensisthemethodtodeter-minethatefficacy.Anin-depthreviewofmethodologyisoutsidethescopeofthisarticle,buttheinterestedreaderisreferredtoASTM-E1174-00,Standard Test Method for Evaluation of the Effectiveness of Health Care Personnel,orConsumer Hand Wash Formulations,orthetwoEuropeanstandardsprEN12054(describingsuspensiontests)andprEN12791(describingthein vivotest).Wewillnotdiscussthetestingmethodologiesanyfurther,butthereaderiscautionedthatallresultsreportedbythedif-ferentstudieswill,ofcourse,bedependentonhowtheregimenwastested.

FACILITIESWereturnto theCGMP(1) for the followingbasicrequirements:

“211.52WashingandToiletFacilities.Adequatewashingfacilitiesshallbeprovided,includinghotandcoldwater,soapordetergent,airdriersorsingle-ser-vicetowels,andcleantoiletfacilitieseasilyaccessibletoworkingareas.”

WaterSomeaspectsoftheavailabilityofsoapandwater(intermsofsinks)areself-evident.Firstofall,thereshouldbesoapandwateravailabletothoseenteringandleavingthelabormanufacturingarea.Thewatershouldbeofsufficientquality(atleastpotable).Themechanismtooperatethewaterflowshouldnotencouragetherecon-taminationofthehandsimmediatelyafterwashing.Thisiscommonlyaccomplishedthroughtheuseofelbowleversorfootswitchestoturnthewateronandoff.TheimportanceofthisconsiderationwasemphasizedinthestudyofGriffithet al.(5),whoshowedapositivecor-relationbetweensurfacefilthandrecontaminationofhands—thefaucetswerethemostconsistentlycontami-natedfeatureoftheimmediateenvironment.

Currentbestpracticerecommendssinksbeconve-nientlylocatednearentranceandexitpoints,withsuitablecontrolmechanisms,andtheavailabilityofsoap.

SoapThetypeofsoap,andinparticularthedesignofthesoapdispenser,isanotherimportantaspectoftheeffi-cacyofhandwashing.Wehavethreemajorchoices:Barsoap,refillableliquidsoap,andsealedliquidsoap(forthemomentwewillsetasidethewholequestionofantibacterialsoapsandaddressitlater).Barsoapisnotsuitableasitisaprovenreservoirforbacteria(6).Thisleavesuswithliquidsoap.

Liquidsoapdispenserscomeintwogeneraldesigns.Inthefirst,liquidsoapcanbeaddedtoareservoirwhenrequired.Bestpracticeistocompletelycleanoutthisres-ervoirbeforefillingitagaintopreventbacterialbuildup—Bacteriacanliveinsoap(7,8).Itisnotrecommendedtomerely“top-off”thesoaptorefillthereservoir.So,inchoosingbetweenremovingtheresidualsoapandthoroughlywashingoutthereservoirbeforerefilling,andtheotherchoiceofliftingthelidandtoppingitoff,whichisthemorelikelypractice?Thisdoesnotevenconsiderthenozzlethatgetstouchedbytheuser’shandassoapisdispensed(topreventthatlastdropfromfallingontothecounter).Inaddition,thisfaucetisverylikelytohavedriedsoapcakedtoitsexterior.

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Theothervarietyofpublicarealiquidsoapdispenserhasasealedbagwithanintegralnozzle.Regardlessoftheformulationcontainedwithinthebag,thissystemenablesacleanstartupwitheachrefillofthesoapcontainer.Iwouldurgetheuseofthesealedbagsysteminthelabandmanufacturingarea.Thereisnosenseinriskingthecontaminationofyourhandsbythesoapifthisriskcanbeminimized.

Antibacterial AdditivesTheconceptofantibacterialadditivestosoapsoundsgood.Takesoap,arguablythemostimportantmedi-caladvanceinthelastfewhundredyears,andmakeitbetterbyaddingabiocidetoit.Theproblemwiththisscenarioisthatnooneisactuallyrequiredtoshowthatthebiocideworksinthesoap,onlythatitispresentintheformulation.Thisisnottosaythatreputablemanu-facturersdonoconductappropriatetesting,onlythatthedemonstrationofantimicrobialefficacyisnotrequiredtoputalabelonyourproductthatitisan“Antibacterial”soap.Inaddition,thereisthepossibilityofselectingforbiocideresistanceinsoapsthatmightbeonlymarginallymoreefficaciousthanstandardsoap,ifmoreefficaciousatall(9,10).However,thiscanleadtobettersoapsifformulatedwell.Forexample,Fulset al.(11)foundthatwithaparticularsoapcontainingtriclosan,theuseofagreatervolumeofsoapandlongerwashtimeresultedinamarkedsuperiorityoftheantibacterialsoapoverthetraditional.

Thebiocidesmostcommonlyusedassoapadditivesincludetriclosan,chlorhexidine,EDTA,andalcohols.Triclosanhascomeunderintensescrutinyforpotentialselectionofantibiotic-resistantmutantmicroorganims,particularlyinEurope.ThispromptedtheEuropeanCommission(EC)toformallyexaminethesafetyoftriclosan,andtheScientificSteeringCommitteeoftheEuropeanCommissionadoptedanofficialopinionin2002thattriclosan,usedinbiocidalconcentrations,issafeandeffective(12).Chlorhexidinestillhasaplaceinthesurgicalscrubarena,butisnotamajorcomponentinconsumerproducts.

Tosumthisup,biocidesaddedtosoapmakeananti-bacterialsoap.However,thisisnotaguaranteethattheresultantantibacterialsoapsare,infact,antibacterial.Therehaveevenbeenreportsoftheantibacterialsoapsufferingcontamination(13,14).

HAND JEWELRYHandjewelry(e.g.,rings,bracelets,watches,etc.)shouldberemovedwhenwashinghands.Theseitemsofjewelrymakeitverydifficulttocleanyourhandseffectively.

Alpet al.(15)examinedthehandwashingpracticesoflaboratoryworkers,figuringthatregularexposuretopathogenicorganismswouldmakethemawareofthedangers.Compliancewas100%fortheactitselfaftertraining,but36.7%worearing,46.9%awatch,and6.1%bracelet—allofwhichharboredpathogenicorganismsafterhandwashing.Thiswascorrectedbyrepeatedinterventions.Fagerneset al.(16),inastudyofhealth-careworkers,examinedtheimpactofwearingasingleplainring(ratherliketheweddingringmanyofusarenolongerabletoremove).Thegoodnewsisthatthetotalbioburdenafterwashingwasnotdifferentbetweenringwearingandnoringsubjects,althoughthestudyshowedaclearincreaseinEnterbacteriacaecontaminationwhencomparedtothesubjectswithoutrings.

DRYINGSeveralteamshavelookedatpapertowelsvs.hotairdryerinregardstocleaningandtransmissionofcontamination.MatthewsandNewsom(17)comparedhotairdriersandpapertowelsforthepotentialtospreadairbornemicroorganismsduringthedryingprocess.TheirdesignfocusedonairsamplingusingCasellaslit-to-agarsamplerforairbornebacteriaduringdrying(inthesomewhatcontrolledenvironmentofabiologicalsafetycabinet).Theyfoundminordifferencesinairborneviablecountsinacomparisonbetweenonemodelofdryerandpapertowels,significantlylessairborneviablecountsfortwoothermodelsincomparisontopapertowels.Blackmoreexpandedthiscomparison,conductingastudy(18)ontheeffectofdryingbyairblower,bypapertowel,andfinallybyclothtowelonacontinuousroller.Thefingertipsofthelefthandweresampledbytouchingtonutrientagarandthenthehandswerewashed.Afterwashing,thehandsweredriedbyoneofthethreemethodsandsampledagain.Theexpelledairfromtheairdrierswassampledbyblowingitonto“nutrientagar”from6inchesforacontrolledperiodoftime(differingbycycletimeofthemodelofairdrier).Thepaperandclothtowelsweresampledbytouchplates.Blackmorereportsthattheairblowerstested(inpubliclocations)harboredbacteriaandcouldserveasasourceforrecontaminationofhandsafterwashing.Thesituationwithcontinuousclothdryingwasnotencouragingeither.Theclothrollertowelswereverygoodwhennewbutoverthecourseofthreemonths(thelengthoftimestudied)theybecamecontaminated.Inaddition,shefound(in1989)thatthesecontinuousclothtowelsarelaunderedandre-used.Thelaunderedmaterialwascontaminatedaswell(rangeof10-60CFU/touchplate)asinstalledintherollerdispenser.Oneexplanationfortheapparentcontradictionintheresultsisofferedby

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MeersandLong(19)whodidalimitedstudytoevalu-atethepurchaseofhot-airdryersfortheirhospitalandsampledtheairbefore,during,andafterdrying,findinganincreaseincountsonlyafterdrying.Theyconcludedthatitwasdifficultforsmallparticlestoescapefromskinwhilemoist(coveredwithwater).Whatwasimportantwasthattheskinbethoroughlydried.

Harrisonet al.(20)tookacloserlookattransmissionofbacteriabetweenhandsandpapertowels.Theylookedatbothdirectionsoftransmission,reasoningthattheconcernoveracontaminatedtoweltransmittingtothehandisclear,butthereisalsoapossibilityforacontami-natedhandtotransferbacteriatothedispenserwhilefreeingjammedtowels.Usingawall-mountedpapertoweldispenserandarangeofpapertowels,volunteers(witheithercleanorcontaminatedhands)wereaskedtoclearjammedtowelsfromthedispenser(thedispensereithercleanorcontaminated).Theyfoundthatwhilethecontaminatedhandsonlymarginallycontaminatedthedispenser(0.01%-0.64%)thedispenserwasfairlyeffectiveatcontaminatinghands(12.4-13.1%).

Inlookingatthepotentialfordirtyhandstocontami-natesurfacesweshouldalsoconsiderdryness.Patricket al.(21)instudyingthisissueconcludedthat,“…bacte-rialnumberstranslocatingontouchcontactdecreasedprogressivelyasdryingwithanairorclothtowelsystemremovedresidualmoisturefromthehands...Carefulhanddryingisacriticalfactordeterminingtheleveloftouch-contact-associatedbacterialtransferafterhandwashinganditsrecognitioncouldmakeasignificantcontributiontowardsimprovinghandcarepracticesinclinicalandpublichealthsectors.”

ReinforcingthisconsiderationistherecentstudyofYamamotoet al.(22)wholookedatdryingbypapertowel,byhotair,andbyhotairsupplementedwithUVlight.Inaddition,thehotairdryingwasperformedeitherbyholdingthehandsstationaryorbyrubbingthehandstogether.Afterlookingatallvariablestheyconcludedthatthehotairdryeriseffectiveifthehandswereheldmotionless(i.e.,notrubbed)untildry.TheUVlightalsoseemedtohelpindecreasingresidualviablecellsforthehotairdryer.Papertowelswereshowntobemoreeffec-tivewhenmeasuredbyfingertipsampling,butequivalentbyothermeasures.

TRAINING AND MONITORINGAllbudgetaryresourcesspentonapersonnelhygieneprogramwillbeineffectiveiftrainingandmanagementattentionisincompleteorindifferent.Complianceisuniversallythemajorprobleminhand-washingprograms(23).Thefirstproblemtoaddressistodetermineasuit-

ableprocedureforhandwashing.Severalareavailable;although,nonearespecificallydirectedtothepharma-ceuticalworker.Apotentiallyusefulmethodispresentedinthenextsection.

Trainingbecomesthenextissue.Trainingbyroteisalwaysanoption,butthisisnotaparticularlyeffectiveoneas“everyoneknows”howtowashtheirhandsandanychangesmadesolelytomeetstandardoperatingprocedure(SOP)requirementswillbetransitoryatbest.Thereareseveraltoolsavailableforassistanceintraining,particularlyintheevaluationofcleaningefficacy.Acom-monmethodistouseafluorescentgelasamarker.Afterwashing,thehandsareheldunderUVlighttodetermineefficacyofcleaning.OnesuchactivityisavailableontheInternetathttp://www.bam.gov/teachers/activities/epi_4_hand_wash.pdf(downloaded9/27/09).Thisactivityguideisusefulinsupplyingateachingresourceforhandwashingthatincludesalessonoutlineandthreeseparatesourcesofthefluorescentgeltouseasamarker.

Thefinalissueismonitoringcompliance.Thisispar-ticularlydifficultasself-assessmentisnotoriouslyinac-curate,atleastamonghealthcareworkerswhoconsistentlyself-reportmoreconscientioushygienebehaviorthanwhatisobservedindependently(24-27).Ontheotherhand,Stevensonet al.(28)reportatoolforself-report-ingthatisdirectedatthegeneralpopulationthatmighthaveuseasamonitoringmethod,perhapscoupledwithobservation.Observationofbehaviorshouldbeincludedinanyevaluationhoweverelsecomplianceismeasuredinyourfacility.

A SUGGESTED HAND WASHING PROTOCOLThefollowingstepwiseprocedureisrecommendedforhandwashinginthepharmaceuticalenvironment.ThefollowingprotocolisbasedonaCentersforDiseaseCon-trol(CDC)handwashingprotocol:

•Removejewelryfromhandsandwrists•Considerthesink,includingthefaucetcontrols,

contaminated.Avoidtouchingthesinkandfaucetcontrolswithyourhands.

•Turnwateronusingelbowcontrols(orfootcontrol).Ifthesearenotavailable,useapapertowelandthenwetyourhandsandwrists.

•Applysoapfromadispenser(donotusebarsoapwhichwillcertainlybemicrobiallycontaminated).Assumethecontrolleverforthesoapiscontaminated.Worksoapintoalather.

•Vigorouslyrubtogetherallsurfacesofthelatheredhandsforatleast20seconds.Frictionhelpsremovedirtandmicroorganisms.Washaroundcuticles,

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inthefingerwebbing,thebackofthehandsandunderfingernailsinadditiontorubbingthepalmstogether.

•Rinsehandsthoroughlyunderastreamofwater.Runningwatercarriesawaydirtanddebris.Pointfingersdownsowaterandcontaminationwon’tdriptowardelbows.

•Dryhandscompletely(leavewaterrunning):•Useacleandrypapertowel.Beawarethatif

thetoweljamsandyouneedtoworktoreleaseityoushouldre-washyourhandsifyoutouchthedispenser.

•Useahot-airblower(preferablyonethathasanintegralUVlight).Starttheunitwithyourelbow(notyourwethands).Donotrubyourhandstogetherwhiledryingthemcompletelyunderthehotairflow.

•Useelboworfoottoturnfaucetoff.Ifappropriatefaucetcontrolsarenotavailable,useacleanpapertoweltoturnoffthefaucet.

•Donottopoffthesoapdispenser.Thisleadstocon-taminatedreservoirsinadditiontothecontamina-tioninthenozzle.Ifpossible,useasoapdispenserthatisrefilledinasealedcontainerthatincludesthesoapinaplasticbagandafreshnozzle.

•Donotassumeantibacterialsoapsareefficacious.Treatallsoapsaspotentiallycontaminatedandexercise sanitarypractices in regularly cleaningdispensers.

IMPLICATIONS FOR VALIDATION AND COMPLIANCEProperlytrainingpersonnelregardingroutinecleanlinessisanobviousneedforallmanufacturingandtesting.Thisneedisheightenedinhigh-riskmanufacturingsuchasinasepticprocessing.Thisneedisalsoheightenedinsituationswhereinmicrobialtestingispartofvalidationtestingbutisnotusuallyconductedinroutinemanufac-turing.Forexample,preparationofgranulatingliquidsforsolidproductsdoesnotusuallyincludemicrobialtesting.Preparationofaqueouscoatingliquidsdoesnotusuallyincludemicrobialtesting.Cleanequipmentstor-agedoesnotusuallyincludemicrobialtesting.Alloftheseexampleswouldlikelyincludemicrobialtestingforprocessvalidationorcleaningvalidation.Thetwoafore-mentionedformulationexampleslikelydonotcontainpreservativesintheirrespectiveformulations.Dependingontheformulation,microbialgrowthcouldbeeasilysupportedinthesesituations.Cleanequipmentholdtimevalidationshouldincludemicrobialtesting.Drugdispensingpracticesmaynotroutinelyincludemicro-

bialtestingeventhoughliquidmaterialsthatsupportmicrobialgrowthmayberoutinelydispensedforuseinmanufacturingcommercialproduct.Validationperson-nelshouldcarefullyevaluatepersonnelpracticeswhenmicrobialtestingisrequiredinvalidationprotocols.Itislikelythatsimpleprocesses,suchashandwashing,aregenerallyassumedtobeundercontrolwhentheymaybeanundetectedsourceofproductcontamination.

SUMMARYHandwashingisanactivitythatisfrequentlytakenforgranted.Everypharmaceuticalprocessthatincludessomeaspectofhumaninterventionissubjecttocon-tamination,andtheintegrityofwell-designedandcon-trolledpharmaceuticalprocessesmaybecompromisedbycarelesshandwashing.Employeeawarenessofthispotential,coupledwitheffectivetraining,willminimizeinadvertentcontaminationduetocarelesshand-wash-ingtechniques.

Thereareseveralkeypointstoensureeffectivehand-washing.Itisimportanttousepropertechniqueinstor-ingthesoapinacleanmanner(topreventexcessivecontamination),removealljewelry,touseenoughsoaptodothejob,washthoroughly(timeandapplication),andtocompletelydryyourhandswhilepreventingrecontamination.

Asfordryingmethod,theredoesnotseemtobestrong,unambiguousdatashowingsuperiorityforeitherpapertoweldryingorhotairdrying(althoughUVirradiationwhenusedwithhotairseemspreferable).

Techniqueandprocedureareparamountinminimiz-ingtransmission.Oncetrained,ongoingcompliancewiththehand-washingprocedureshouldbemonitoredaspartofanongoingcontaminationcontrolprogramforthefacility,andanaidtominimizeemployeeabsenceduetoillness.

REFERENCES1.FDA,Title21—FoodAndDrugs,ChapterI—FoodAnd

DrugAdministration,DepartmentOfHealthAndHumanServices,SubchapterC—Drugs:General,Part211,CurrentGoodManufacturingPracticeForFinishedPharmaceuti-cals.

2.Gallaher,W.R.,“TowardsaSaneandRationalApproachtoManagementofInfluenzaH1N12009,”Virology6:51-57,2009.

3.Hellemans,A.,“BeatingtheFluinaSingleShot,”Sci Amer.June:104–107,2008.

4.Grayson,M.,et al.,“EfficacyofSoapandWaterandAl-cohol-BasedHand-RubPreparationsAgainstLiveH1N1InfluenzaVirusontheHandsofHumanVolunteers,”Clin

Microbiology Topics.

54 Journal of Validation technology [Autumn 2009] i v t home.com

gxpand jv t .com

Infect Dis48:285–291,2009.5.Griffith,C.J.,et al.,“EnvironmentalSurfaceCleanlinessand

thePotentialforContaminationDuringHandwashing,”Amer J Infect Control31(2):93-96,2003.

6.Hegde,P.,et al.,“MicrobialContaminationof‘inuse’BarSoapinDentalClinics,”Ind J Dent Res.,17(2):70–73,2006.

7.Buffet-Bataillon,S.,et al.,“OutbreakofSerratiamarcescensinaNeonatalIntensiveCareUnit:ContaminatedUnmedi-catedLiquidSoapandRiskFactors,”J Hosp Infect.72:17–22,2009.

8.Sartor,C.,et al.,“NosocomialSerratiamarcescensInfectionsAssociatewithExtrinsicContaminationofaLiquidNon-medicatedSoap,”Infect Control Hosp Epidemiol.21(3):196–199,2000.

9.Aiello,A.E.,Larson,E.L.,Levy,S.B.,“ConsumerAntibacte-rialSoaps:EffectiveorJustRisky?”Clinical Infectious Dis-eases,45Suppl2:S137-47,2007.

10.Kampf,G.andKramer,A.,“EpidemiologicBackgroundofHandHygieneandEvaluationoftheMostImportantAgentsforScrubsandRubs,”Clin Microbiol Rev17(4):863–893,2004.

11.Fuls,J.,Rodgers,N.,et al.,“AlternativeHandContaminationTechniquetoComparetheActivitiesofAntimicrobialandNonantimicrobialSoapsunderDifferentTestConditions,”Appl Envir Microbiol,74(12):3739–3744,2008.

12.EC,Opinion of the Scientific Committee on Cosmetic Products and Non-Food Products Intended for Consumers,2002,http://ec.europa.eu/health/ph_risk/committees/sccp/documents/out182_en.pdf.(accessed10/20/2009).

13.Archibald,L.K.,et al.,“Serratiamarcescensoutbreakas-sociatedwithextrinsiccontaminationof1%chlorxylenolsoap,”Infect Control Hosp Epidem.19(7):704–709,1997.

14.Dolan,S.A.,et al.,“BubblestoWubbles:AnInvestigationInvolvingtheContaminationofSoapBubbleProductsataPediatricHospital,”JSPN 11(3):189-95,2006.

15.Alp,E.,et al.,“HandHygieneAmongLaboratoryWorkers,”Infect Control Hosp Epidemiol27(9):978-980,2006.

16.Fagernes,M.,et al.,“ImpactofaSinglePlainFingerRingontheBacterialLoadontheHandsofHealthcareWorkers,”Infect Control Hosp Epidemiol.28(10):1191–1195,2007.

17.Matthews,J.A.andSWBNewsom,“HotAirElectricHandDriersComparedwithPaperTowelsforPotentialSpreadofAirborneBacteria,”J Hosp Infect.9:85-88,1987.

18.Blackmore,M.A.,“AComparisonofHandDryingMeth-ods,”Catering and Health.1:189-109,1989.

19.Meers,PDandKYLeong,“Hot-airHandDriers,”J Hosp Infect.14:169-181,1989.

20.Harrison,W.A.,et al.,“BacterialTransferandCross-contam-inationPotentialAssociatedwithPaper-towelDispensing,”Amer J Infect Control.31(7):387-391,2003.

21.Patrick,D.R.,et al.,“ResidualMoistureDeterminestheLevelofTouch-contactAssociatedBacterialTransferFollowingHandWashing,”Epidemiol Infect.119:319-325,1997.

22.Yamamoto,Y.,et al.,“EfficiencyofHandDryingforRemov-ingBacteriaFromWashedHands:ComparisonofPaperTowelDryingwithWarmAirDrying,”Infect Control Hosp Epidemiol.26(3):316-320,2005.

23.Jumaa,P.A.,“Handhygiene:simpleandcomplex,”Intl J Infect Dis9:3-14,2005.

24.Jenner,E.,Fletcher,B.,et al.,“DiscrepancyBetweenSelf-Re-portedandObservedHandHygieneBehaviourinHealth-careProfessionals,”J Hosp Infect63:418–422,2006.

25.Haas,J.P.andE.L.Larson,“Measurementofcompliancewithhandhygiene,”J Hosp Infect66:6-14.,2007.

26.Larson,E.andELusk,“EvaluatingHandwashingTech-nique,”J Adv Nursing.53(1):46-50,2008.

27.Cole,M.,“ExploringtheHandHygieneCompetenceofStudentNurses:ACaseofFlawedSelfAssessment,”Nurse Education Today29:380–388,2009.

28.Stevenson,R.,et al.,“AScaleforMeasuringHygieneBehav-ior:Development,Reliability,andValidity,”Amer J Infect Control.37(7):557-564,2009.JVT

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