Washing our hands of the problem

The JHI has a long history of publishing on hand hygiene, with a review article as early as 1983 highlighting that hands are the most common vehicle of transmission in the hospital setting [1], whilst recent innovations from the past decade were highlighted by Kathryn French [2]. Last year in our hand hygiene special issue Vermeil et al. summarised the history of hand hygiene in a fascinating article ranging from the ancient Babylonians to Semmelweis, Pasteur and Lister before addressing the revolution of alcohol based hand rub (ABHR) and the impact of the World Health Organisation (WHO) SAVE LIVES: Clean Your Hands campaign [3]. This year the focus of the WHO campaign is “Nurses and Midwives: CLEAN CARE is in YOUR HANDS” in honour of the 200^th anniversary of Florence Nightingale's birth.

Whilst randomised controlled trials comparing hand washing with placebo, such as the 1960's trial by Mortimer et al. in an Ohio hospital nursery are clearly now unethical [4], there remain areas in which the optimum practice is yet to be identified. For example, the method of hand drying; paper towels, hot air dryers or jet air dryers (JAD's). JAD's are becoming ubiquitous, including within the public areas of hospitals, and whilst one study found lower rates of bacterial contamination on hands following the use of JAD's compared with paper towels, Best et al. found higher rates of environmental contamination, which may have implications for JAD use within hospitals [5,6]. There is clearly scope for further work in this area.

The role of sinks and hospital drainage as a source of infection is increasingly recognised, especially in the context of multidrug-resistant Gram-negative bacteria (MDRGNB) [[7], [8], [9], [10]]. Perhaps we should just remove the sinks altogether? This was investigated in a Spanish intensive care unit troubled by MDRGNB as well as a neonatal intensive care unit [11,12] and as an option it appears increasingly feasible given that handwashing activities only encompassed 4% of activities at sinks in one series [13].

Following global recognition of the harms of single-use plastic, the environmental impact of personal protective equipment (PPE) in hospitals has come under increasing scrutiny with many hospitals seeking to reduce unnecessary glove use. Repeated replacement of gloves to undertake hand hygiene is one such instance where it could be argued that plastic is being wasted. Gloved hand disinfection (for a single patient encounter) has been shown to increase compliance with hand hygiene [14]. Where glove use is appropriate, careful removal and disposal of gloves is important as environmental contamination is known to occur with doffing of PPE and gloves [[15], [16], [17]].

Given the strength of evidence of the benefit of hand hygiene, combined with national and international guidance, it is remarkable that compliance is not higher [18]. The first barrier is in accurately measuring compliance, which can be a challenge due to the Hawthorne effect — whereby awareness of observation may affect a subject's behaviour. One way to circumvent this is to use ABHR consumption as a proxy measure for hand hygiene events, although this is also not without its limitations [19,20].

Once compliance has been accurately measured, work can then be undertaken to improve it, the optimal approach to this remains elusive [[21], [22], [23], [24], [25], [26], [27], [28]]. The importance of customizing messaging and interventions: “One size does not fit all” was highlighted in this special edition last year [29] and has been embraced by Salmon et al. in the context of the effect of messaging on different healthcare professions [30]. The benefit of taking into account cultural differences was demonstrated by Brink et al. who report on the success of introducing a multi-modal hand hygiene framework leveraging the Ubuntu philosophy of “I am who I am because of who we all are” [31]. Greenough et al. present a follow-up to a previously published letter on the use of verbal reminders to increase compliance with hand hygiene amongst hospital visitors [32,33]. This recognition of the role that visitors and family members play in the spread of nosocomial infections, particularly if they also have a caring role, as is common in low and middle income countries (LMIC's), has been considered and the impact of an educational intervention assessed [34]. Along with education, reducing barriers to hand hygiene would be expected to increase compliance rates, borne out by a study demonstrating that a 15s duration of hand rubbing with ABHR was non-inferior to the currently recommended 30s and that compliance was higher with the shorter duration [35].

This issue also has a section on the evolving epidemic of COVID-19/SARS-CoV-2. Whilst the 2020 WHO hand hygiene campaign laudably marks the 200^th anniversary of Florence Nightingale's birth, we suspect that history will associate hand hygiene promotion in 2020 more with control of COVID-19. Hand hygiene has now taken on increased significance in the public mind, being a key measure recommended by the health bodies ECDC, WHO and PHE for preventing the spread of SARS-CoV-2. Already the JHI has published experience from China that wearing N95 respirators and enhanced hand hygiene protects healthcare workers from COVID-19 [36]. This is one of a number of articles on COVID-19 that are currently in press. The JHI has signed up to the Wellcome initiative to make all COVID-19 related papers freely available, and we have also widened the opportunity to publish brief descriptions of experiences with COVID-19 as Practice Points. The JHI aims to make articles related to COVID-19 freely available as rapidly as possible after submission to assist the international community in planning their responses with access to all available evidence. As such, we welcome further high-quality submissions on this topic.

Conflict of interest statement

None.

Ethical statement

N/A.

Funding sources

Chris Lynch is funded by the Healthcare Infection Society (HIS) as a Graham Ayliffe Training Fellow, GATF/2019/001. The HIS had no input into the content of this article.