It is a well-known fact that healthcare associated infections (HAIs) are a global problem that affect between around 7 and 10% of patients, depending on the country. 1 The novel coronavirus pandemic (COVID-19) is exacerbating this already dire situation and is currently causing a significant increase in the rate of HAIs around the world. 2 , 3 The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus is mainly transmitted through droplets, close contact with infected individuals and contaminated surfaces. 4 This makes healthcare workers (HCWs) a highly susceptible population both for contracting as well as for spreading the virus. The infection prevention and control (IPC) measures to limit or prevent HAIs caused by the SARS-CoV-2 are crucial to combatting this pandemic. Hand hygiene is widely recognized as the most effective and economically viable measure in IPC. 5 Even before COVID-19, HAIs were a pandemic in and of themselves. Annually, they are responsible for the death of millions of people per year-more than tuberculosis, malaria, and AIDS combined. In Europe, over 4 million patients are affected by approximately 4.5 million episodes of HAIs every year, leading to 16 million extra days of hospital stay, 37,0 0 0 attributable deaths and the contributing factor to an additional 110,0 0 0 deaths, resulting in € 7 billion of additional healthcare costs. 1 In the USA, it is estimated that around 1.7 million patients are affected by HAIs each year, and that they account for 99,0 0 0 deaths, costing hospitals between US$35.7 to US$45 billion. 1 Although the direct costs due to these types of infections are already very significant, the indirect costs to health systems and economies are both extremely high and almost impossible to measure.
As seen in the last two major outbreaks of the coronavirus family (severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS)), coronavirus epidemics can have a severe effect on both countries' individual economies and the global economy as a whole. The COVID-19 pandemic is currently estimated to have cost 1-2% of global gross domestic product (GDP). 2 This number is of course still evolving and will vary greatly across regions and countries. Recently, it has been estimated that COVID-19 could cost the global economy up to US$1.1 trillion in lost income. 6 Infectious disease outbreaks challenge healthcare systems in many different aspects, impacting everything from resource allocation and staffing, education, politics and governance, to the systems' culture and economics. The current pandemic has highlighted the need for every country to be better prepared to deal with the effects that an infectious disease outbreak could have on healthcare systems and society as a whole.
Preventing nosocomial spread of COVID-19 is a top priority for healthcare systems around the world. Though all HCWs are exposed at various levels, nurses are evidently at the front lines with the most patient contact. They are the ones responsible for daily patient care, while simultaneously being responsible for protecting patients against HAIs. If their IPC practices, especially their hand hygiene, are suboptimal, nurses become a source of transmission of infections between patients and to themselves. Contaminated hands are one of the main vectors of spreading SARS-CoV-2. 7 It is crucial that nurses adhere to proper hand hygiene in order to reduce HAIs, save money and ultimately, save lives. To achieve acceptable levels of hand hygiene compliance, nursing teams need to be adequately staffed, well trained, and have access to good quality alcohol-based handrub. 8 Adequate hand hygiene would ensure prevention of nosocomial spread not only from patient to patient through contaminated HCW hands, but also from patients to HCWs.
Globally, an increasing number of HCWs are also contracting nosocomial COVID-19 as a consequence of providing patient care. As of early March 2020, more than 3300 HCWs in China 9 and 10% of all physicians and nurses in Lombardy, Italy were infected with the virus. 3 This emergency is worldwide of course, but the breadth and scope of COVID-19 infection in HCWs will only become apparent as the pandemic progresses.
Following its designation of 2020 as the Year of the Nurse and the Midwife, the World Health Organization (WHO) identified that there is a shortage of 9 million nurses and midwives around the world. 10 The emergence of the COVID-19 pandemic has only further highlighted the global need for HCWs. Adequate staffing is not the only challenge to the HCW population; IPC measures are crucial for keeping HCWs healthy and operational in hospitals. In addition to being a population that is not easily replaceable once taken out of the workforce, an increased strain on the staffing levels of HCWs also has a negative effect on patient outcomes.
Hand hygiene with alcohol-based handrub is globally recommended as one of the most effective and low-cost procedures against SARS-CoV-2 cross-transmission. 5 It is well known that improving hand hygiene compliance among HCWs reduces HAIs in hospital settings. 11 , 12 The economic implications of successful hand hygiene improvement have long been established. It has been demonstrated that these programs cost less than 1% of the HAI-related costs, making them relatively cheap and unequivocally worth investing in. 13 In another study, the net benefit of a hospital-wide hand hygiene program was reported as $5,289,364 USD, again proving the program's cost-effectiveness com pared to the costs generated by HAIs. 14 According to the aforementioned study, every US$1 spent on the program could result in a $23.70 USD return on investment-the highest return of any IPC measure. 14 Good hand hygiene programs are also dependent on systemic components of the healthcare facility, including access to supplies, how nurses are allocated, organized and trained, and the work culture. Constant exposure to patients with COVID-19, a lack of supplies such as adequate personal protective equipment in many hospitals, fatigue and stressful work environments put nurses at a higher risk of acquiring or transmitting the virus. 15 , 16 Infected HCWs reduce the workforce of well-trained HCWs that are able to provide sufficient care for their patients, which in turn reduces the hospitals' ability to deal with an outbreak. 17 Since emergency situations are associated with increased HCW anxiety, some individuals may be less willing to work in such contexts, which can in turn create or exacerbate any already existing staffing shortages. 18 If societies want to make economically sound, lasting investments they must invest not only in the materials needed, but also in the people doing the actual work. According to the existing evidence, investing in health sectors such as education and job creation will improve health outcomes, global health security, and inclusive economic growth. 10 Ensuring adequate HCW staffing, training and support lead to a decreasing rate of HAIs, and is considered a core component of effective IPC programs by the WHO. 1 Clean and safe care starts with investing in our nurses, and the message to policy makers should be clear: "increase nurse staffing levels to prevent infections and improve quality of care. Create the means to empower nurses and midwives." Doing any less wouldn't make human or economic sense.
None declared.