# Presentation: 841241

## 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

## Slide 4

## EFFECTIVENESS OF HAND HYGIENE IN THE HOSPITAL

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

## Primary Child Care Arrangements for Children 

**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
- Hepatitis
- Pathogens
- Hepatitis A
- Norovirus
- Rotavirus
*E. coli* O157:H7
*Shigella*
*Cryptosporidium*

- Respiratory
- Otitis media
- Sinusitis
- Pharyngitis
- Pneumonia
- Pathogens
*H. influenzae* type B
*S. pneumoniae*

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

**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)

## Slide 11

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

| Author, Year | DCC | Intervention | Reduction in Diarrhea |
| --- | --- | --- | --- |
| Kotch J, 1994 | 24 | HH, environmental cleaning, improved diapering, ed | Reduction 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

## Slide 17