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LETTERS: Juhani Ojajarvi, Arti Thakerar, and Collin Goodbourn Alcohol handrubs v soap BMJ 2003; 326: 50a [Full text]

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Handwashing experience

Phillip J. Colquitt   (3 January 2003)

handwashing not entirely out

Dr Saroj Kumar Patnaik   (3 January 2003)

Hand rubs having antiviral properties

Rajendra P Deolankar   (10 May 2005)

Handwashing experience 3 January 2003
Phillip J. Colquitt, Independent Technical Advisor Independent Send response to journal: Re: Handwashing experience	Editor, Please allow me to refer to my 25 years experience with hand washing, at some length. The alcohol handrub I use[Hexol-Sigma], whilst currently working in Australian public hospitals, is similar in composition to that used in the study by Girou et al[1]. The label on the 500 ml. bottle states…”Each 100 ml contains one gram chlorhexidine gluconate, in and alcoholic solution containing 42 ml isopropyl alcohol, 26.5 ml ethanol, and skin conditioners.” I find hand-rub superior to washing with water and detergent/anti- septic, for the following reasons: 1) ease of use 2) portability – can be taken around by caregivers, or can be installed literally at the bedside on a per bed basis 3) does not “de-fat” the skin because it is not rinsed off, or wiped away by paper towel 4) can be used by the patient who may be confined to bed and who thus can’t get to bowl and sink-eg. before meals, and after interventions for hygiene. 5) can be used by visiting relatives 6) saves time and money Claims heard over the years, that alcohol hand rub “wrecks your skin” have not been found true in my case, nor in others to my awareness, though the pharmacist I bought my last bottle from [at$10 AUD] held to those claims. My experience is that the handrub leaves a residue which feels anything but dry, yet allows manual dexterity. I have seen cases of nurses so skin reddened as to be almost bleeding between the fingers(“webs”), and this was when detergent, not alcohol, was being used. Successful implementation of a new hand wash detergent anti-septic solution by infection control staff, is affected by season, inclusion of staff, and circumstance. In one instance I recall, the same 2% Chlorhexidine detergent with a Tartrazine colorant(additive code number 102) introduced in a season of low-humidity, had 60% of nurses in one ward complaining of reddening of the skin. But the same detergent anti-septic introduced in a subsequent season of high-humidity, in the same institution, and at a time of other major institutional change, produced no complaints. In another instance, a private Australian hospital, where I recently visited a patient for ten consecutive days, handrub was at the foot of each bed, but only one of dozens of staff who visited the patient’s single room, used the handrub. The suggestion is, that alcohol handrub, so supplied, creates an excuse to not hand wash at all. The points made about fire and other risk by previous responses to Girou et al[2] are valid and I would have liked a response from the authors. Alcohol is a dangerous substance, is inhaled as a therapeutic means[3], and to not respond may only serve to create confusion and non- compliance. The reasoning should never be…”it’s good for the patient, it’s good for the hospital, so it’s got to be good for the staff.” Phillip J. Colquitt Independent Technical Advisor. Refs: [1] Girou E, Loyeau S, Legrand P, Oppein F, Brun-Boisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002; 325: 362(17 August.) [2] Electronic responses to Girou et al. http://bmj.com/cgi/eletters/325/7360/362. [3] Merritt BA, Okyere CP, Jasinski DM. Isopropyl alcohol inhalation: alternative treatment of postoperative nausea and vomiting. Nurs Res. 2002 Mar-Apr;51(2):125-8. Competing interests:   None declared
handwashing not entirely out 3 January 2003
Dr Saroj Kumar Patnaik, Postgraduate Resident (Paediatrics) AFMC,Pune-411040, India Send response to journal: Re: handwashing not entirely out	EDITOR- This refers to the handwashing vs alcoholic handwash protocols (1,2). Undoubtedly handrubs with alcohoilc solutions are easier and perhaps less allergenic. However, compliance and technique are significant determinants of efficacy of either protocols especially for handwashing. I would like to share my experiences with both of these protocols while working in the same neonatal intensive care unit under 2 different consultants with two different philosophies. For initial one year under the eagle eye of a consultant who believed in handwashing only (3 minutes initial till including the forearms with subsequent minimum half minute wash between babies or after any perceived breach of sterility protocol), the philosophy was ingrained in us and the compliance was excellent (undoubtedly also because of the surreptitious observation of our adherence to the protocols by the consultant).With the change of neonatologist, we were exposed to the idea of retention of the initial handwash but the interbaby handwashes were eliminated and instead replaced by alcoholic handrubs (sterilium/ medicated spirit or a combination of chlorhexidine and alcohol) between the babies. With the handwash only protocol, the average resident and nursing staff used to endup with dryskin and hand dermatitis (especially in winters) by the end of a 3 month rotation if not earlier. In winters, with occasional power failures, the prospect of coldwater was not too exciting. Nonetheless we used to follow the protocol displayed besides the tap scrupulously. At the end of two years (one each under each consultant protocols), however, there was no change of rates of sepsis under either of the protocols. However, there were 05 cases of Necrotizing enterocolitis while working under the alcoholic rub philosophy . Could this have been a result of change of protocols resulting in breach of infection control especially since there was no significant change of nursing and other paramedical staff working in NICU? Though various other factors can be invoked for the increased necrotizing enterocolitis, few points could be pondered upon. Firstly, handwashing required a high compliance rate - but with adequate supervision this philosophy was ingrained in us and we would cover all areas likely to be missed in a routine/casual handwash. On the other hand, alcoholic rubs being easier there was a likelihood of breach of protocols - easier the procedure , easier the breach also because of the casualness. This could have occurred with inadequate initial handwash/skipping of same by paramedical staff in the absence of any prying eyes and instead resorting to direct alcoholic handrubs. For handrubs to be effective there has to be again an adequate coverage of skin including areas which are included in an adequate handwash protocol as well as an adequate contact time. One has to desist from rushing to touch the patient immediately after pouring alcoholic solution onto the hands. Such breaches are more likely with new staff with inadeqaute training in the technique of handwash.An adequately carried out initial handwash would definitely reduce the microbial load carried on the hands and should make the subsequent alcoholic rubs more efficacious (3). The question of adequate effectiveness time of sole usage of handrubs prior to resorting again to a handwash is something which needs to be studied further(1,4). Perhaps with a grossly septic baby, it would be more prudent to combine both a wash and alcoholic rub together. Alcoholic solutions are not entirely innocous - fumes definitely hurt the eyes and cause nasal irritation and with prexisting eczema/fissures the tactile sensation is not exactly pleasant after a rub. Of course, individual sensibilities vary. However, the contribution to indoor pollution of relatively closed environments of an intensive care setup needs consideration - especially the mucocutaneous surfaces of premature neonates. Even with an alcoholic handrub protocol for an absolute prevention of crossinfection, each baby/patient should have his/her unique dispenser of the solution. We took care of this by placing a disposable antibiotic container or IV bottle container with a fresh IV set with its valve alongside each baby. The protocol for each baby was to rub the handrub solution from the dispenser prior to examination as well as after the end prior to moving onto the next baby so as not to carry any flora on the outer surfaces of the dispenser. The dermatitis of soap contact can be reduced by use of soft soaps as well as use of emollinents. Either coconut oil or a solution of 1:1 glycerine and liquid paraffin were applied while exiting from the intensive care setup. The prexit application only procol meant no carriage of any flora via these solutions. Any rentry meant following of the protocol allover again - initial handwash and the rub. To conclude, handwash cannot be entirely eliminated. Barring the compliance factor which can be taken care of by adequate education programmes, adequate training in the principles of nosocomial transmission in between examinations, proper display and example of techniques of handwashing and handrub, a mixed protocol should be preferable to handwashing only protocols (suffer from complexity and low compliance and higher eczema) or exclusive alcoholic rub protocols (if easier to carry out,easier to breach too and possible cost factors, need for separate dispensers and inadequate evidence for superiority over handwash). With either protocols once the philosophy is understood, no caretaker would like to deliberately endanger the life placed in his/her care.Adequate supervision of sobordinate staff is as important for infection control as routine microbiological cultures (2). 1. Girou E, Loyeau S, Legrand P, Oppein F, Brun-Boisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002; 325: 362[Abstract/Free Full Text]. (17 August.) 2. Juhani Ojajarvi, Arti Thakerar, and Collin GoodbournAlcohol handrubs v soap. BMJ 2003; 326: 50a [Full text] 3. Cooper BS, Medley GF, Scott GM. Preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects.J Hosp Infect 1999 Oct;43(2):131-47 4.Paulson DS, Fendler EJ, Dolan MJ, Williams RA. A close look at alcohol gel as antimicrobial sanitizing agent. Am J Infect Control 1999; 27: 332-338 Competing interests:   None declared
Hand rubs having antiviral properties 10 May 2005
Rajendra P Deolankar, Assistant Director National Institute of Virology, 20 A, Dr. Ambedkar Road, Pune 411 001, INDIA Send response to journal: Re: Hand rubs having antiviral properties	Effective hand hygiene for high levels of viral contamination with a nonenveloped virus was best achieved by physical removal with a nonantimicrobial soap or tap water alone [1]. The importance of hand hygiene came in to focus after the outbreak of SARS [2]. Hygienic hand antiseptic usually make claims on their label about activity against viruses [3].  It is usually inconvenient for health care workers (or anyone else) to get to a sink to use soap and water. Hands could get contaminated anywhere say during the epidemics of Acute Haemorrhagic Conjunctivitis. Hence, waterless hand wipes or alcohol based hand rubs are indispensable.  The constituents in the popular commercial herbal hand rubs in India are Neem, Azadirachta indica, (germicidal action), Lemon, Citrus acida, (freshness), Hrivera, Coleus vettiveroides, (softening action), Dhanyaka, Coriandrum sativum, (antimicrobial & astringent properties) and rectified spirit. Spirit combined with peracetic acid is more virucidal than spirit alone [4]. Monopercitric acid (MPCA) is more virucidal than peracetic acid [5]. Glycyrrhizin (GL) was found to inhibit SARS-coronavirus (SARS-CoV) replication in vitro [6]. An ointment containing propolis is more effective than acyclovir [7]. Could such ingredients provide better hand disinfectant?  Herbal derived New Chemical Entities have been produced in several labs. It is felt that hand sanitizer costing less and having antiviral effects could not only fetch a good market but would be an asset in reducing morbidity and mortality due to viral diseases.  References:   1.      Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control. 2005 Mar;33(2):67-77.[Medline] 2.      Shapiro SE, McCauley LA. SARS update: Winter, 2003 to 2004. AAOHN J. 2004 May;52(5):199-203. [Medline] 3.      Sattar SA, Springthorpe VS, Tetro J, Vashon R, Keswick B. Hygienic hand antiseptics: should they not have activity and label claims against viruses? Am J Infect Control. 2002 Oct;30(6):355-72.[Medline] 4.      Wutzler P, Sauerbrei A. Virucidal efficacy of a combination of 0.2% peracetic acid and 80% (v/v) ethanol (PAA-ethanol) as a potential hand disinfectant. J Hosp Infect. 2000 Dec;46(4):304-8. [Medline] 5.      Wutzler P, Sauerbrei A. Virucidal activity of the new disinfectant monopercitric acid. Lett Appl Microbiol. 2004;39(2):194-8.[Medline] 6.      Hoever G, Baltina L, Michaelis M, Kondratenko R, Baltina L, Tolstikov GA, Doerr HW, Cinatl J Jr. Antiviral activity of glycyrrhizic acid derivatives against SARS-coronavirus. J Med Chem. 2005 Feb 24;48(4):1256-9.[Medline] 7.      Vynograd N, Vynograd I, Sosnowski Z. A comparative multi-centre study of the efficacy of propolis, acyclovir and placebo in the treatment of genital herpes (HSV). Phytomedicine. 2000 Mar;7(1):1-6. [Medline]     Competing interests: None declared