The 2009 H1N1 Influenza A Pandemic and Hand Hygiene Practices in a Hospital in the South of Brazil

To the Editor—Brazil was severely affected by the 2009 H1N1 influenza A pandemic. The pandemic was most felt in the southern states (8.6 cases per 100,000 inhabitants), a temperate zone region bordering Argentina, Uruguay, and Paraguay. Hospital de Clinicas de Porto Alegre is a 790-bed, university-affiliated tertiary care hospital located in the southernmost state of Brazil. By late July, the hospital had organized its strategy to respond to the pandemic: suspected patients were seen in a distinct unit, a unique ward and intensive care unit (ICU) were used for inpatient care, and staff training about virus transmission and the benefits of hand hygiene in preventing dissemination was reinforced. From June through September (winter season) 2009, a total of 548 inpatients were evaluated for 2009 H1N1 influenza A infection. Among 154 patients tested for the presence of the H1N1 virus with real-time polymerase chain reaction assay, 75 (48.7%) had positive results. Adherence to hand hygiene has been monitored by means of direct observation in our ICU since 2006. The ICU staff are aware that observation occurs but cannot detect it or predict when it will occur. From July 2006 through March 2010, the hand-washing technique of physicians, nurses, and technicians was observed daily for 20-30-minute intervals during 5 morning, 5 afternoon, and 3 night shifts, during all 5 weekdays. Weekends were excluded from the observation schedule. In addition, the consumption of alcohol-based hand rub was measured in milliliters per 100 patient-days. The 1-sample Student rtest was used to compare the mean rates of adherence to hand-washing. One-way analysis of variance with the 2-sided Tukey test for multiple comparisons was performed to compare mean differences in adherence between groups of professionals. Time-series segmented regression analysis was used to determine significant changes in level (immediate) and trend (slope) of adherence to handwashing, before (July 2006 through May 2009) and during and after (June 2009 through March 2010) the 2009 H1N1 influenza A season in Brazil. " From July 2006 through March 2010, 21,438 opportunities for hand hygiene were observed. The overall mean adherence rate was 57.1% (range, 46.2%-69.7%). The mean rate of adherence to hand hygiene was 76.6% (range, 59.5-96.6%) for nurses, compared with 54.1% (range, 43.7%-69.6%) for technicians (P< .001) and 44.2% (range, 23.0%-70.6%) for physicians (P< .001). Segmented regression analysis revealed no difference in the observed rate of adherence before the 2009 H1N1 influenza A pandemic, compared with during and after the pandemic (slope change from 0.07 to 0.24; P = .44). The use of alcoholbased hand rub from wall dispensers showed no significant difference in immediate consumption in the ICU (level change from 0.83 to 0.28; P = .17) but a significant decrease thereafter (slope change from 0.33 to -0.38; P = .05). The use of hand rub from wall dispensers throughout the entire hospital showed a transient significant increase in consumption (level change from 0.59 to 0.64; P< .001) and a slope decrease thereafter (trend change from 0.59 to —0.36; P = .02) (Figure 1). The mean rate of adherence to hand hygiene before patient contact was 44.5% (range, 23.0%-66.7%) and after patient contact was 74.9% (range, 61.8%-87.5%) (P< .001). The segmented regression model revealed no change in the rate of adherence before and after patient contact in relation to the 2009 H1N1 influenza A pandemic. Despite the increase in consumption of alcohol-based hand rub during the peak period of the pandemic, this behavior was not sustained through the subsequent months. The numerous media reports related to 2009 H1N1 influenza A had an effect in terms of dissemination of hand-washing practices. As reported by the Brazilian Ministry of Health, 89% of people surveyed were informed about the pandemic by television. However, the media most influenced changes in social behavior, and importantly, these changes, as manifested in the hand hygiene practices of healthcare workers, were transient, as we have shown. A change in social behavior does not necessarily lead to a long-term change in hand hygiene practices in hospitals. Inherent community and home hand-washing practices are a predictor of in-hospital hand-washing behavior," which means that, in hospitals, hand hygiene will be performed as one learns at home: one cleans one's hands after they become visibly soiled—in other words, an action to protect oneself. This was the message people received from television: "protect yourself," not "protect your patient. " This is why we would not expect a significant change in healthcare worker behavior in hospitals. Direct observation at our hospital revealed no change in hand-washing practices in relation to the World Health Organization (WHO) 5 moments. The mean rate of adherence before patient contact (ie, to protect the patient) was significantly lower than the rate of adherence after patient contact (ie, to protect the healthcare worker), and this scenario did not change after the beginning of the pandemic.