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Abstract Environmental cleaning is essential to patient and health worker safety, yet it is a substantially neglected area in terms of knowledge, practice, and capacity-building, especially in resource-limited settings. Public health advocacy, research and investment are urgently needed to develop and implement cost-effective interventions to improve environmental cleanliness and, thus, overall healthcare quality and safety. We outline here the CLEAN Group Consensus exercise yielding twelve urgent research questions, grouped into four thematic areas: standards, system strengthening, behaviour change, and innovation.

Abstract Background Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs). Methods Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted. Results The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs. Conclusions Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Abstract Background Hand hygiene is a crucial measure for the prevention of healthcare-associated infections (HAIs). The Hand Hygiene Excellence Award (HHEA) is an international programme acknowledging healthcare facilities for their leadership in implementing hand hygiene improvement programmes, including the World Health Organisation’s Multimodal Improvement Strategy. This study aimed at summarising the results of the HHEA campaign between 2010 and 2021 and investigating the relationship between different hand hygiene parameters based on data from participating healthcare facilities. Methods A retrospective analysis was performed on datasets from HHEA forms, including data on hand hygiene compliance, alcohol-based handrub (ABHR) consumption, and Hand Hygiene Self-Assessment Framework (HHSAF) scores. Descriptive statistics were reported for each variable. The correlation between variables was inspected through Kendall’s test, while possible non-linear relationships between hand hygiene compliance, ABHR consumption and HHSAF scores were sought through the Locally Estimated Scatterplot Smoothing or logistic regression models. A tree-structured partitioning model was developed to further confirm the obtained findings. Results Ninety-seven healthcare facilities from 28 countries in three world regions (Asia-Pacific, Europe, Latin America) were awarded the HHEA and thus included in the analysis. HHSAF scores indicated an advanced hand hygiene promotion level (median 445 points, IQR 395–480). System change (100 [95–100] points) and institutional safety climate (85 [70–95] points) showed the highest and lowest score, respectively. In most cases, hand hygiene compliance was above 70%, with heterogeneity between countries. ABHR consumption above 20 millilitres per patient-day (ml/PD) was widely reported, with overall increasing trends. HHSAF scores were positively correlated with hand hygiene compliance (τ = 0.211, p = 0.007). We observed a positive correlation between compliance rates and ABHR consumption (τ = 0.193, p

Abstract Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose threats to global health. Effective hand hygiene is essential for preventing HAIs and the spread of AMR in healthcare. We aimed to highlight the recent progress and future directions in hand hygiene and alcohol-based handrub (ABHR) use in the healthcare setting. In September 2023, 42 experts in infection prevention and control (IPC) convened at the 3rd International Conference on Prevention and Infection Control (ICPIC) ABHR Taskforce in Geneva, Switzerland. The purpose of this meeting was to provide a synthesis of recent evidence and formulate a research agenda on four critical areas for the implementation of effective hand hygiene practices: (1) ABHR formulations and hand rubbing techniques, (2) low-resource settings and local production of ABHR, (3) hand hygiene monitoring and technological innovations, and (4) hand hygiene standards and guidelines.

Abstract The 5th edition of the Global Ministerial Summit on Patient Safety was held in Montreux, Switzerland, in February 2023, delayed by three years due to the COVID-19 pandemic. The overarching theme of the summit was “Less Harm, Better Care – from Resolution to Implementation”, focusing on the challenges of implementation of infection prevention and control (IPC) strategies as well as antimicrobial stewardship programs (ASP) around the world. IPC strategies and ASP are of increasing importance due to the substantial burden of healthcare-associated infections and antimicrobial resistance threatening patient safety. Here, we summarize countries’ and regional experiences and activities related to the implementation of IPC strategies and ASP shared at the meeting. Full implementation of effective programs remains a major challenge in all settings due to limited support by political and healthcare leaders, and human and financial constraints. In addition, the COVID-19 pandemic challenged already well-established programs. By enforcing sustained implementation by dedicated, cross-disciplinary healthcare personnel with a broad skill set, a reduction in healthcare-associated infections and multidrug-resistant pathogens can be achieved, leading ultimately to improved patient safety.

Abstract The World Health Organization’s (WHO) World Hand Hygiene Day continues to “bring people together and accelerate hand hygiene action at the point of care in health care to contribute to a reduction in health care-associated infections and the achievement of safer, quality health care for all”.

Abstract Background Few studies have investigated how the effectiveness of hand washing in removing hand contaminants is influenced by the performance and duration of each step involved. We conducted an observational study by recruiting participants from a university campus, with the aim to comprehensively evaluate how performance, duration and demographic factors influence hand washing effectiveness. Methods A total of 744 videos were collected from 664 participants in July-October 2022 and independently evaluated by two infection control experts through labelling videos for correct and incorrect performance of each step. The individual hand washing effectiveness was determined by quantifying the percentage of residual fluorescent gel on the dorsum and palm areas of each participant’s hands. A logistic regression analysis was conducted to identify factors that were significantly associated with better hand washing effectiveness. An exposure-response relationship was constructed to identify optimal durations for each step. Approximately 2300 hand images were processed using advanced normalization algorithms and overlaid to visualize the areas with more fluorescence residuals after hand washing. Results Step 3 (rub between fingers) was the most frequently omitted step and step 4 (rub the dorsum of fingers) was the most frequently incorrectly performed step. After adjustment for covariates, sex, performance of step 4 and step 7 (rub wrists), rubbing hands during rinsing, and rinsing time were significantly associated with hand washing effectiveness. The optimal overall hand washing time was 31 s from step 1 to step 7, and 28 s from step 1 to step 6, with each step ideally lasting 4–5 s, except step 3. The palms of both hands had less fluorescence residuals than the dorsums. The areas where residuals most likely appeared were wrists, followed by finger tips, finger webs and thumbs. Conclusions Performance and duration of some hand washing steps, sex and rinsing time were associated with hand washing effectiveness. The optimal duration might be applied to all seven steps to achieve the best decontamination results. Further studies are needed to refine hand hygiene standards and enhance compliance.

Abstract Background “Train-the-Trainers in hand hygiene” (TTT) is a standardized training to train infection prevention and control (IPC) practitioners with the aim to promote hand hygiene in health care according to the World Health Organization (WHO) multimodal improvement strategy. Little is known in the literature about the sustained impact of hand hygiene and IPC trainings adapted locally. The aim of this study is to describe the impact of three TTT courses conducted annually in Japan on the adoption of the WHO multimodal improvement strategy by local IPC practitioners who became a “trainer” after their first TTT participation as a “trainee”. Methods Three TTT courses were conducted annually from 2020 to 2022 in Japan. A team “TTT-Japan” composed of more than 20 IPC practitioners who completed their first TTT participation adapted the original TTT program to reflect the local healthcare context in Japan, and subsequently convened the 2nd and 3rd TTTs. Pre- and post-course evaluations and post-course satisfaction surveys of the course participants were conducted to assess improvement in knowledge on hand hygiene and perception towards the course, respectively. Attitude and practice surveys of the TTT-Japan trainers were conducted to assess their perception and experience in hand hygiene promotion. The Hand Hygiene Self-Assessment Framework (HHSAF), a validated tool created by WHO to monitor the capacity of hand hygiene promotion at facility level, was applied at TTT-Japan trainers’ facilities to compare results before and after trainers’ engagement. We applied inductive thematic analysis for qualitative analyses of open-ended survey questions of the trainers’ attitude and practice surveys, and the Wilcoxon Sign Rank test for quantitive comparisons of pre- and post-data for the surveys and HHSAF. Results 158 Japanese healthcare workers participated in three TTT courses, the majority of whom (131, 82.9%) were nurses. Twenty-seven local trainers were involved in 2nd and 3rd TTTs. The scores of pre- and post-course evaluations significantly improved after the course (P

Abstract Binding antibody levels against SARS-CoV-2 have shown to be correlates of protection against infection with pre-Omicron lineages. This has been challenged by the emergence of immune-evasive variants, notably the Omicron sublineages, in an evolving immune landscape with high levels of cumulative incidence and vaccination coverage. This in turn limits the use of widely available commercial high-throughput methods to quantify binding antibodies as a tool to monitor protection at the population-level. Here we show that anti-Spike RBD antibody levels, as quantified by the immunoassay used in this study, are an indirect correlate of protection against Omicron BA.1/BA.2 for individuals previously infected by SARS-CoV-2. Leveraging repeated serological measurements between April 2020 and December 2021 on 1083 participants of a population-based cohort in Geneva, Switzerland, and using antibody kinetic modeling, we found up to a three-fold reduction in the hazard of having a documented positive SARS-CoV-2 infection during the Omicron BA.1/BA.2 wave for anti-S antibody levels above 800 IU/mL (HR 0.30, 95% CI 0.22-0.41). However, we did not detect a reduction in hazard among uninfected participants. These results provide reassuring insights into the continued interpretation of SARS-CoV-2 binding antibody measurements as an independent marker of protection at both the individual and population levels.

Background: Children and adolescents are highly vulnerable to the impact of sustained stressors during developmentally sensitive times. We investigated how demographic characteristics intersect with socioeconomic dimensions to shape the social patterning of quality of life and mental health in children and adolescents, two years into the COVID-19 pandemic. Methods: We used data from the prospective SEROCoV-KIDS cohort study of children and adolescents living in Geneva (Switzerland, 2022). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy by nesting participants within 48 social strata defined by intersecting sex, age, immigrant background, parental education and financial hardship in Bayesian multilevel logistic models for poor health-related quality of life (HRQoL, measured with PedsQL) and mental health difficulties (measured with the Strengths and Difficulties Questionnaire). Results: Among participants aged 2–17 years, 240/2096 (11.5%, 95%CI 10.1–12.9) had poor HRQoL and 105/2135 (4.9%, 95%CI 4.0–5.9) had mental health difficulties. The predicted proportion of poor HRQoL ranged from 3.4% for 6–11 years old Swiss girls with highly educated parents and no financial hardship to 34.6% for 12–17 years old non-Swiss girls with highly educated parents and financial hardship. Intersectional strata involving adolescents and financial hardship showed substantially worse HRQoL than their counterparts. Between-stratum variations in the predicted frequency of mental health difficulties were limited (range 4.4%–6.5%). Conclusions: We found considerable differences in adverse outcomes across social strata. Our results suggest that, post-pandemic, interventions to address social inequities in HRQoL should focus on specific intersectional strata involving adolescents and families experiencing financial hardship, while those aiming to improve mental health should target all children and adolescents.

Abstract Healthcare environmental hygiene (HEH) has become recognized as being increasingly important for patient safety and the prevention of healthcare-associated infections. At the 2022 Healthcare Cleaning Forum at Interclean in Amsterdam, the academic lectures focused on a series of main areas of interest. These areas are indicative of some of the main trends and avenues for research in the coming years. Both industry and academia need to take steps to continue the momentum of HEH as we transition out of the acute phase of the Covid-19 pandemic. There is a need for new ways to facilitate collaboration between the academic and private sectors. The Clean Hospitals® network was presented in the context of the need for both cross-disciplinarity and evidence-based interventions in HEH. Governmental bodies have also become more involved in the field, and both the German DIN 13603 standard and the UK NHS Cleaning Standards were analyzed and compared. The challenge of environmental pathogens was explored through the example of how P. aeruginosa persists in the healthcare environment. New innovations in HEH were presented, from digitalization to tracking, and automated disinfection to antimicrobial surfaces. The need for sustainability in HEH was also explored, focusing on the burden of waste, the need for a circular economy, and trends towards increasingly local provision of goods and services. The continued focus on and expansion of these areas of HEH will result in safer patient care and contribute to better health systems.

Abstract Background Infection prevention and control (IPC) measures in Japan are facilitated by a financial incentive process at the national level, where facilities are categorized into three groups (Tier 1, Tier 2, or no financial incentive). However, its impact on IPC at the facility level using a validated tool has not been measured. Methods A nationwide cross-sectional study was conducted from August 2019 to January 2020 to evaluate the situation of IPC programs in Japan, using the global IPC Assessment Framework (IPCAF) developed by the World Health Organization. Combined with the information on the national financial incentive system, the demographics of facilities and each IPCAF item were descriptively analyzed. IPCAF scores were analyzed according to the facility level of care and the national financial incentive system for IPC facility status, using Dunn-Bonferroni and Mann–Whitney U tests. Results Fifty-nine facilities in Japan responded to the IPCAF survey: 34 private facilities (57.6%) and 25 public facilities (42.4%). Of these, 11 (18.6%), 29 (49.2%), and 19 (32.3%) were primary, secondary, and tertiary care facilities, respectively. According to the national financial incentive system for IPC, 45 (76.3%), 11 (18.6%), and three (5.1%) facilities were categorized as Tier 1, Tier 2, and no financial incentive system, respectively. Based on the IPCAF total score, more than half of the facilities were categorized as “Advanced” (n = 31, 55.3%), followed by “Intermediate” (n = 21, 37.5%). The IPCAF total score increased as the facility level of care increased, while no statistically significant difference was identified between the secondary and tertiary care facilities (p = 0.79). There was a significant difference between Tier 1 and Tier 2 for all core components and total scores. Core components 5 (multimodal strategies for implementation of IPC interventions) and 6 (monitoring/audit of IPC and feedback) were characteristically low in Japan with a median score of 65.0 (interquartile range 40.0–85.0) and 67.5 (interquartile range 52.5–87.5), respectively. Conclusions The national financial incentive system was associated with IPC programs at facility level in Japan. The current financial incentive system does not emphasize the multimodal strategy or cover monitoring/audit, and an additional systematic approach may be required to further promote IPC for more practical healthcare-associated infection prevention.

Abstract Background Traditionally, hand hygiene (HH) interventions do not identify the observed healthcare workers (HWCs) and therefore, reflect HH compliance only at population level. Intensive care units (ICUs) in seven European hospitals participating in the “Prevention of Hospital Infections by Intervention and Training” (PROHIBIT) study provided individual HH compliance levels. We analysed these to understand the determinants and dynamics of individual change in relation to the overall intervention effect. Methods We included HCWs who contributed at least two observation sessions before and after intervention. Improving, non-changing, and worsening HCWs were defined with a threshold of 20% compliance change. We used multivariable linear regression and spearman’s rank correlation to estimate determinants for the individual response to the intervention and correlation to overall change. Swarm graphs visualized ICU-specific patterns. Results In total 280 HCWs contributed 17,748 HH opportunities during 2677 observation sessions. Overall, pooled HH compliance increased from 43.1 to 58.7%. The proportion of improving HCWs ranged from 33 to 95% among ICUs. The median HH increase per improving HCW ranged from 16 to 34 percentage points. ICU wide improvement correlated significantly with both the proportion of improving HCWs (ρ = 0.82 [95% CI 0.18–0.97], and their median HH increase (ρ = 0.79 [0.08–0.97]). Multilevel regression demonstrated that individual improvement was significantly associated with nurse profession, lower activity index, higher nurse-to-patient ratio, and lower baseline compliance. Conclusions Both the proportion of improving HCWs and their median individual improvement differed substantially among ICUs but correlated with the ICUs’ overall HH improvement. With comparable overall means the range in individual HH varied considerably between some hospitals, implying different transmission risks. Greater insight into improvement dynamics might help to design more effective HH interventions in the future.

Abstract Background Hand hygiene is universally recognized as a cornerstone measure for the prevention of healthcare-associated infections. Although the WHO “My five Moments for hand hygiene” poster has been used for more than a decade to delineate hand hygiene indications and promote action, adherence levels among healthcare workers are still notoriously low and disquieting. To compensate for the lack of effective hand hygiene communication, we aimed to evaluate emojis as possible surrogates for the non-verbal aspects of hand hygiene behaviour. Methods Following a thorough review of the Unicode version 12.0, the most applicable emojis to the terms used in the WHO 5 Moments poster were extracted. We developed a self-administered questionnaire to assess the view of infection prevention and control (IPC) practitioners regarding the use of emojis to show the WHO 5 Moments. Completed questionnaires were collected and analysed to determine the suitability of the existing emojis to illustrate a unified emoji poster. Data were analysed using R (version 3.6.3). Results A total of 95 IPC practitioners completed the questionnaire from May to October 2019 from different countries. Of these, 69 (74%) were female, and the mean age of the participants was 44.6 ± 10.87 years. We found appropriate emojis for six of the words used in the poster, including for touching (72%), for patient (63%), for clean (53%), for procedure (56%), for body fluid (58%), and for exposure risk (71%). The existing emojis proposed for the words “hygiene”, “aseptic”, and “surrounding” seemed to be less satisfactory. Conclusions In summary, the findings of this study indicate that the existing emojis may not be able to substitute the words used in the WHO 5 Moments poster. Emojis might be helpful to address hand hygiene indications in healthcare that may eventually play a role in promoting this measure. However, emojis should be further studied to choose the most appropriate ones and avoid ambiguity and misinterpretation. More emojis to convey health related messages are needed. We recommend further research in this area to evaluate the effect of using emojis in healthcare-related behaviours.

Abstract Background The approval of ethanol by the Biocidal Products Regulation has been under evaluation since 2007. This follows concern over alcohol uptake from ethanol-based hand rubs (EBHR). If ethanol is classified as carcinogenic, mutagenic, or reprotoxic by the European Chemicals Agency (ECHA), then this would affect infection prevention and control practices. Aim A review was performed to prove that ethanol is toxicological uncritical and indispensable for hand antisepsis because of its unique activity against non-enveloped viruses and thus the resulting lack of alternatives. Therefore, the following main points are analyzed: The effectiveness of ethanol in hand hygiene, the evidence of ethanol at blood/tissue levels through hand hygiene in healthcare, and the evidence of toxicity of different blood/tissue ethanol levels and the non-comparability with alcoholic consumption and industrial exposure. Results EBHR are essential for preventing infections caused by non-enveloped viruses, especially in healthcare, nursing homes, food industry and other areas. Propanols are effective against enveloped viruses as opposed to non-enveloped viruses but there are no other alternatives for virucidal hand antisepsis. Long-term ingestion of ethanol in the form of alcoholic beverages can cause tumours. However, lifetime exposure to ethanol from occupational exposure

Abstract Introduction Healthcare workers often experience skin dryness and irritation from performing hand hygiene frequently. Low acceptability and tolerability of a formulation are barriers to hand hygiene compliance, though little research has been conducted on what specific types of formulation have higher acceptability than others. Objective To compare the acceptability and tolerability of an ethanol-based handrub gel with superfatting agents to the isopropanol-based formulations (a rub and a gel formulation) currently used by healthcare workers at the University of Geneva Hospitals, Geneva, Switzerland. Methods Forty-two participants were randomized to two sequences, testing the isopropanol-based formulation that they are using currently (Hopirub® or Hopigel®), and the ethanol-based formulation containing superfatting agents (Saniswiss Sanitizer Hands H1). Participants tested each of the formulations over 7–10 day work shifts, after which skin condition was assessed and feedback was collected. Results H1 scored significantly better than the control formulations for skin dryness (P = 0.0209), and participants felt less discomfort in their hands when using that formulation (P = 0.0448). H1 caused less skin dryness than Hopirub®/Hopigel® (P = 0.0210). Though overall preference was quite polarized, 21 participants preferred H1 intervention formulation and 17 preferred the Hopirub®/Hopigel® formulation that they normally used in their care activities. Conclusion We observed a difference in acceptability and strongly polarized preferences among the participants' reactions to the formulations tested. These results indicate that giving healthcare workers a choice between different high-quality products is important to ensure maximum acceptability.

Abstract Introduction Little is known about the bloodstream infection (BSI) risk associated with short-term peripheral venous catheters (PVCs) and no large study investigated the insertion site-related risk for PVC-BSI. Methods We performed a cohort study at the University of Geneva Hospitals using the prospective hospital-wide BSI surveillance database. We analyzed the association between insertion site and risk of PVC-BSI on the upper extremity using univariable and multivariable marginal Cox models. Results Between 2016 and 2020, utilization of 403′206 peripheral venous catheters were prospectively recorded in a 2000-bed hospital consortium with ten sites. Twenty-seven percent of PVC (n = 109′686) were inserted in the hand. After adjustment for confounding factors, hand insertion was associated with a decreased PVC-BSI risk (adjusted hazard ratio [HR] 0.42, 95% CI 0.18–0.98, p = 0.046) compared to more proximal insertion sites. In a sensitivity analysis for PVCs with ≥ 3 days of dwell time, we confirmed a decreased PVC-BSI risk after hand insertion (HR 0.37, 95% CI 0.15–0.93, p = 0.035). Conclusion Hand insertion should be considered for reducing PVC infections, especially for catheters with an expected dwell time of more than 2 days.

Abstract Background Healthcare-associated infections (HAI) are one of the gravest threats to patient safety worldwide. The importance of the hospital environment has recently been revalued in infection prevention and control. Though the literature is evolving rapidly, many institutions still do not consider healthcare environmental hygiene (HEH) very important for patient safety. The evidence for interventions in the healthcare environment on patient colonization and HAI with multidrug-resistant microorganisms (MDROs) or other epidemiologically relevant pathogens was reviewed. Methods We performed a systematic review according to the PRISMA guidelines using the PubMed and Web of Science databases. All original studies were eligible if published before December 31, 2019, and if the effect of an HEH intervention on HAI or patient colonization was measured. Studies were not eligible if they were conducted in vitro, did not include patient colonization or HAI as an outcome, were bundled with hand hygiene interventions, included a complete structural rebuild of the healthcare facility or were implemented during an outbreak. The primary outcome was the comparison of the intervention on patient colonization or HAI compared to baseline or control. Interventions were categorized by mechanical, chemical, human factors, or bundles. Study quality was assessed using a specifically-designed tool that considered study design, sample size, control, confounders, and issues with reporting. The effect of HEH interventions on environmental bioburden was studied as a secondary outcome. Findings After deduplication, 952 records were scrutinized, of which 44 were included for full text assessment. A total of 26 articles were included in the review and analyzed. Most studies demonstrated a reduction of patient colonization or HAI, and all that analyzed bioburden demonstrated a reduction following the HEH intervention. Studies tested mechanical interventions (n = 8), chemical interventions (n = 7), human factors interventions (n = 3), and bundled interventions (n = 8). The majority of studies (21/26, 81%) analyzed either S. aureus, C. difficile, and/or vancomycin-resistant enterococci. Most studies (23/26, 88%) reported a decrease of MDRO-colonization or HAI for at least one of the tested organisms, while 58% reported a significant decrease of MDRO-colonization or HAI for all tested microorganisms. Forty-two percent were of good quality according to the scoring system. The majority (21/26, 81%) of study interventions were recommended for application by the authors. Studies were often not powered adequately to measure statistically significant reductions. Interpretation Improving HEH helps keep patients safe. Most studies demonstrated that interventions in the hospital environment were related with lower HAI and/or patient colonization. Most of the studies were not of high quality; additional adequately-powered, high-quality studies are needed. Systematic registration number: CRD42020204909

Abstract Background The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review. Aim To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time. Methods Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively. Findings Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (− 0.70; 95%CI: − 1.13 to − 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias. Conclusions There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20–30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

Abstract Background We developed SmartRub® powered by iQati®, an electronic device composed of a wristband and an alcohol-based handrub pocket-sized dispenser that measures and provides feedback on the duration of hand friction and the volume poured during each hand hygiene action. We aimed to assess the accuracy of SmartRub®. Methods The specificity, sensitivity, positive and negative predictive values (PPV and NPV) of SmartRub® were assessed in a 3-phased experiment: (1) laboratory-controlled conditions with volunteers; (2) pre-planned clinical path with volunteers and (3) real clinical conditions with healthcare workers. The accuracy of SmartRub® was evaluated by quantifying its ability to correctly capture true hand hygiene actions and to not record other actions performed while wearing the device. Results In the laboratory, 7 volunteers performed 816 actions. Overall sensitivity was 94.1% (95% CI 91.4–96.2%) with a PPV of 99.0% (95% CI 97.3–99.6%) and specificity was 99.0% (95% CI 97.5–99.7%) with a NPV of 94.4% (95% CI 91.9–96.1%). During the pre-planned clinical path phase, 13 volunteers performed 98 planned paths and a total of 967 actions were performed. Overall sensitivity was 94.6% (95% CI 92.2–96.5%) with a PPV of 84.3% (95% CI 81.6–86.7%) and specificity was 82.4% (95% CI 78.7–85.7%) with a NPV of 93.9% (95% CI 91.3–95.7%). During the real clinical conditions phase, 17 healthcare workers were observed for a total of 15 h and 3 min while they performed 485 actions. Sensitivity was 96.8% (95% CI 93.8–98.6%) with a PPV of 98.3% (95% CI 95.6–99.3%) and specificity was 98.3% (95% CI 95.7–99.5%) with a NPV of 96.8% (95% CI 93.9–98.4%). Conclusions Smartrub® is a highly reliable device for capturing hand hygiene actions under a range of conditions, from the laboratory to clinical care activities.

Abstract Background With the current COVID-19 pandemic, many healthcare facilities have been lacking a steady supply of filtering facepiece respirators. To better address this challenge, the decontamination and reuse of these respirators is a strategy that has been studied by an increasing number of institutions during the COVID-19 pandemic. Methods We conducted a systematic literature review in PubMed, PubMed Central, Embase, and Google Scholar. Studies were eligible when (electronically or in print) up to 17 June 2020, and published in English, French, German, or Spanish. The primary outcome was reduction of test viruses or test bacteria by log3 for disinfection and log6 for sterilization. Secondary outcome was physical integrity (fit/filtration/degradation) of the respirators after reprocessing. Materials from the grey literature, including an unpublished study were added to the findings. Findings Of 938 retrieved studies, 35 studies were included in the analysis with 70 individual tests conducted. 17 methods of decontamination were found, included the use of liquids (detergent, benzalkonium chloride, hypochlorite, or ethanol), gases (hydrogen peroxide, ozone, peracetic acid or ethylene oxide), heat (either moist with or without pressure or dry heat), or ultra violet radiation (UVA and UVGI); either alone or in combination. Ethylene oxide, gaseous hydrogen peroxide (with or without peracetic acid), peracetic acid dry fogging system, microwave-generated moist heat, and steam seem to be the most promising methods on decontamination efficacy, physical integrity and filtration capacity. Interpretation A number of methods can be used for N95/FFP2 mask reprocessing in case of shortage, helping to keep healthcare workers and patients safe. However, the selection of disinfection or sterilization methods must take into account local availability and turnover capacity as well as the manufacturer; meaning that some methods work better on specific models from specific manufacturers. Systematic registration number CRD42020193309.

Objectives To estimate the prevalence of children and adolescents reporting persistent symptoms after SARS-CoV-2 infection.Design A random sample of children and adolescents participated with their family members to a serological survey including a blood drawing for detecting antibodies targeting the SARS-CoV-2 nucleocapsid (N) protein and a questionnaire on COVID-19-related symptoms experienced since the beginning of the pandemic.Setting The study took place in the canton of Geneva, Switzerland, between June and July 2021.Participant 660 children aged between 2 and 17 years old.Primary and secondary outcome The primary outcome was the persistence of symptoms beyond 4 weeks comparing seropositive and seronegative participants. The type of declared symptoms were also studied as well as associated risk factors.Results Among seropositive children, the sex-adjusted and age-adjusted prevalence of symptoms lasting longer than 2 weeks was 18.3%, compared with 11.1% among seronegatives (adjusted prevalence difference (ΔaPrev)=7.2%, 95% CI: 1.5% to 13.0%). Among adolescents aged 12–17 years, we estimated the prevalence of experiencing symptoms lasting over 4 weeks to be 4.4% (ΔaPrev,95% CI: −3.8% to 13.6%), whereas no seropositive child aged 2–11 reported symptoms of this duration. The most frequently declared symptoms were fatigue, headache and loss of smell.Conclusions We estimated the prevalence of experiencing persistent symptoms lasting over 4 weeks to be around 4% among adolescents, which represents a large absolute number, and should raise awareness and concern. We did not observe meaningful differences of persistent symptoms between seropositive and seronegative younger children, suggesting that they may be less affected than their older counterparts.

Many job sectors classified as ‘essential’ have continued operating with limited restrictions during the COVID-19 pandemic, potentially placing workers at higher risk of infection. Here, the authors show that seropositivity rates in workers vary widely across and between job sectors in Geneva, Switzerland.

Abstract Background With the current SARS-CoV-2 pandemic, many healthcare facilities are lacking a steady supply of masks worldwide. This emergency situation warrants the taking of extraordinary measures to minimize the negative health impact from an insufficient supply of masks. The decontamination, and reuse of healthcare workers’ N95/FFP2 masks is a promising solution which needs to overcome several pitfalls to become a reality. Aim The overall aim of this article is to provide the reader with a quick overview of the various methods for decontamination and the potential issues to be taken into account when deciding to reuse masks. Ultraviolet germicidal irradiation (UVGI), hydrogen peroxide, steam, ozone, ethylene oxide, dry heat and moist heat have all been methods studied in the context of the pandemic. The article first focuses on the logistical implementation of a decontamination system in its entirety, and then aims to summarize and analyze the different available methods for decontamination. Methods In order to have a clear understanding of the research that has already been done, we conducted a systematic literature review for the questions: what are the tested methods for decontaminating N95/FFP2 masks, and what impact do those methods have on the microbiological contamination and physical integrity of the masks? We used the results of a systematic review on the methods of microbiological decontamination of masks to make sure we covered all of the recommended methods for mask reuse. To this systematic review we added articles and studies relevant to the subject, but that were outside the limits of the systematic review. These include a number of studies that performed important fit and function tests on the masks but took their microbiological outcomes from the existing literature and were thus excluded from the systematic review, but useful for this paper. We also used additional unpublished studies and internal communication from the University of Geneva Hospitals and partner institutions. Results This paper analyzes the acceptable methods for respirator decontamination and reuse, and scores them according to a number of variables that we have defined as being crucial (including cost, risk, complexity, time, etc.) to help healthcare facilities decide which method of decontamination is right for them. Conclusion We provide a resource for healthcare institutions looking at making informed decisions about respirator decontamination. This informed decision making will help to improve infection prevention and control measures, and protect healthcare workers during this crucial time. The overall take home message is that institutions should not reuse respirators unless they have to. In the case of an emergency situation, there are some safe ways to decontaminate them.

Abstract Objectives To compile current published reports on nosocomial outbreaks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), evaluate the role of healthcare workers (HCWs) in transmission, and evaluate outbreak management practices. Methods Narrative literature review. Short conclusion The coronavirus disease 2019 (COVID-19) pandemic has placed a large burden on hospitals and healthcare providers worldwide, which increases the risk of nosocomial transmission and outbreaks to “non-COVID” patients or residents, who represent the highest-risk population in terms of mortality, as well as HCWs. To date, there are several reports on nosocomial outbreaks of SARS-CoV-2, and although the attack rate is variable, it can be as high as 60%, with high mortality. There is currently little evidence on transmission dynamics, particularly using genomic sequencing, and the role of HCWs in initiating or amplifying nosocomial outbreaks is not elucidated. There has been a paradigm shift in management practices of viral respiratory outbreaks, that includes widespread testing of patients (or residents) and HCWs, including asymptomatic individuals. These expanded testing criteria appear to be crucial in identifying and controlling outbreaks.

Abstract Background Social media may provide a tool, when coupled with a patient-included™ conference, to enhance the engagement among the general public. We describe authors and potential readers of Twitter content surrounding a patient-included™ scientific congress, the International Consortium for Prevention and Infection Control (ICPIC) 2019. Methods Retrospective observational analysis of Twitter users posting with the #ICPIC2019 hashtag during the conference. Tweet authors, overall followers, and active followers were categorized according to their Twitter biographies using unsupervised learning. Diversity of professional backgrounds of Tweet authors and their followers was explored. Network analysis explored connectedness between the reach of authors. Results In total, 1264 participants attended ICPIC 2019, of which 28 were patients. From September 7 to 16, 2019, we were able to categorize 235′620 (41%) followers linked to 474 (76%) authors. Among authors and followers, respectively 34% and 14% were healthcare workers, 11% and 15% were from industry representatives, 8% and 7% were academic researchers. On average, 23% (range 9–39%) followers belonged to the same categories as authors. Among all followers categorized, only 582/235 620 (0.25%) interacted with original messages, including healthcare workers (37%), global and public health (12%), academic research (11%) and those from industry (11%). Though the similarity between Tweet authors and followers was supported by network analysis, we also observed that non-healthcare workers (including patients) appeared to have more diverse followers. Conclusions We observed the participation of numerous Tweet authors and followers from diverse professional backgrounds potentially supporting the benefit of including patients in conferences to reach a more general, non-specialized public.

As a result of the coronavirus disease pandemic, commercial hand hygiene products have become scarce and World Health Organization (WHO) alcohol-based hand rub formulations containing ethanol or isopropanol are being produced for hospitals worldwide. Neither WHO formulation meets European Norm 12791, the basis for approval as a surgical hand preparation, nor satisfies European Norm 1500, the basis for approval as a hygienic hand rub. We evaluated the efficacy of modified formulations with alcohol concentrations in mass instead of volume percentage and glycerol concentrations of 0.5% instead of 1.45%. Both modified formulations met standard requirements for a 3-minute surgical hand preparation, the usual duration of surgical hand treatment in most hospitals in Europe. Contrary to the originally proposed WHO hand rub formulations, both modified formulations are appropriate for surgical hand preparation after 3 minutes when alcohol concentrations of 80% wt/wt ethanol or 75% wt/wt isopropanol along with reduced glycerol concentration (0.5%) are used.

Abstract Currently available evidence supports that the predominant route of human-to-human transmission of the SARS-CoV-2 is through respiratory droplets and/or contact routes. The report by the World Health Organization (WHO) Joint Mission on Coronavirus Disease 2019 (COVID-19) in China supports person-to-person droplet and fomite transmission during close unprotected contact with the vast majority of the investigated infection clusters occurring within families, with a household secondary attack rate varying between 3 and 10%, a finding that is not consistent with airborne transmission. The reproduction number (R0) for the SARS-CoV-2 is estimated to be between 2.2–2.7, compatible with other respiratory viruses associated with a droplet/contact mode of transmission and very different than an airborne virus like measles with a R0 widely cited to be between 12 and 18. Based on the scientific evidence accumulated to date, our view is that SARS-CoV-2 is not spread by the airborne route to any significant extent and the use of particulate respirators offers no advantage over medical masks as a component of personal protective equipment for the routine care of patients with COVID-19 in the health care setting. Moreover, prolonged use of particulate respirators may result in unintended harms. In conjunction with appropriate hand hygiene, personal protective equipment (PPE) used by health care workers caring for patients with COVID-19 must be used with attention to detail and precision of execution to prevent lapses in adherence and active failures in the donning and doffing of the PPE.

Abstract Background Hand hygiene can only be efficient if the whole hand surface is treated with sufficient alcohol-based handrub (ABHR); therefore, the volume of handrub applied is a critical factor in patient safety. The proper amount of ABHR should be provided by handrub dispensers. The aim of this study was to investigate the dispensing performance of wall-mounted ABHR dispensers commonly employed in hospital settings. Method In a multicenter study, we tested 46 dispensers (22 in laboratory and 24 in clinical environments), measuring dispensed ABHR volume during continuous use and after a period of non-use. The influence of the pumping mechanism, liquid level, ABHR formats, handrub composition, temperature, and atmospheric pressure was investigated. Results A total of 7 out of the 22 investigated dispensers (32%) lost a significant amount of handrub; greater than 30% of the nominal volume after 8 h of non-use, thus frequently dispensing suboptimal volume, as measured in laboratory settings. Key influencing factors were found to be handrub format (gel or liquid), handrub level in the container and type of dispenser. When gel ABHR was used, after 4 h of non-use of the dispensers, the volume of the dispensed amount of ABHR insignificantly changed (97% of the original amount), while it technically decreased to zero in the case of liquid ABHR (1% of the original amount). The liquid level had a medium effect on the dispensed volume in each investigated case; the magnitude of this effect varied widely depending on the dispensing mechanism. When dispensers were in continuous use, they dispensed a cumulated 3 mL of ABHR from two consecutive pushes, while when they were not in use for 1 h, up to 4 consecutive pushes were necessary to provide a total of 3 mL ABHR. Design and production quality were also identified as important contributing factors with respect to the volume dispensed. Data collected in clinical settings confirmed these findings, for multiple types of dispensers. Conclusion All ABHR dispensers should be regularly audited to control the reference volume distributed, with particular attention paid to regular mechanical pump units filled with liquid handrub.

Abstract Background Hung Vuong Hospital (HVH) is a 900-bed maternity hospital in Ho-Chi-Minh-City, Vietnam. Due to low compliance, a quasi-experimental, observational study was conducted with the aim to improve hand hygiene. Methods A multimodal promotion strategy was established in 2010 and further developed towards ongoing, repetitive and inventive campaigns including patient participation. Hand hygiene compliance was monitored by direct observation and healthcare-associated infections (HAIs) by applying standard definitions. Results Between 2010 and 2018, a total of 43,711 hand hygiene opportunities were observed. Compliance improved from 21.5% (95%CI: 20.2–22.8%) in 2010 to 75.1% (73.9–76.2%) in 2018 (incidence rate ratio, IRR , 1.10; 95%CI, 1.10–1.11). This was achieved through increasing recourse to alcohol-based hand rubbing. A total of 554,720 women were admitted to HVH during the study period for 353,919 deliveries (198,679 vaginal; 155,240 by C-section) and 257,127 surgical procedures. The HAI-incidence decreased significantly from 1.10 episodes per 1000 patient-days in 2010 to 0.45 per 1000 patient-days in 2018 (IRR 0.85; 95%CI, 0.79–0.90). Significant improvement was observed also for surgical site infections after gynaecological surgery (IRR 0.95; 95%CI, 0.92–0.99) and endometritis after abortion (IRR 0.80; 95%CI, 0.68–0.93). Conclusions A multimodal strategy aiming at behaviour change significantly improved and sustained hand hygiene, which contributed to the reduction of healthcare-associated infections.

Abstract Background Healthcare-associated infections (HAIs) challenge modern medicine. Considering their high prevalence in Iran, we aimed to provide knowledge on the subject, and to teach about the importance of infection prevention and control (IPC) to a broad audience of pre-graduate healthcare professionals, focusing on education as the cornerstone of IPC. Main body We invited Iranian medical students to present ideas on “how to reduce HAIs.” Projects were eligible if being original and addressing the call. Accepted projects were quality assessed using a scoring system. Forty-nine projects were submitted, of which 37 met the inclusion criteria. They had a mean score of 69.4 ± 18.3 out of the maximum possible score of 115. Four reviewers assessed the 37 projects for clinical applicability, impact on patient safety, and innovation, and selected the best 12 to compete at the 2nd International Congress on Prevention Strategies for Healthcare-associated Infections, Mashhad, Iran, 2018. The competition took place in three rounds. The selected teams presented their projects in the first round and debated one by one in a knockout manner, while the jury reviewed their scientific content and presentation skills. In the second round, the top 5 projects competed for reaching the final stage, in which the teams presented their ideas in front of a panel of international IPC experts to determine the first three ranks. At the end of the contest, the participants gained valuable criticisms on how to improve their ideas. Moreover, by its motivating atmosphere, the contest created an excellent opportunity to promote IPC in medical schools. Conclusions Using innovation contests in pre-graduates is an innovative education strategy. It sensitizes medical students to the challenges of IPC and antimicrobial resistance and drives them to think about solutions. By presenting and defending their innovations, they deepen their understanding on the topic and generate knowledge transfer in both ways, from students to teachers and vice versa.

Abstract Background The burden of healthcare-associated infection (HAI) is 2 to 18 times higher in developing countries. However, few data are available regarding infection prevention and control (IPC) process indicators in these countries. We evaluated hand hygiene (HH) facilities and compliance amongst healthcare workers (HCW) in a 600-bed healthcare facility in Northcentral Nigeria providing tertiary care service for a catchment population of about 20 million. Methods An in-house facility assessment tool and the World Health Organization (WHO) direct observation method were used to assess the HH facilities and compliance, respectively. Factors associated with good compliance were determined by multivariate analysis. Results The facility survey was carried out in all 46 clinical units of the hospital. 72% of the units had no poster or written policy on HH; 87% did not have alcohol-based hand rubs; 98% had at least one handwash sink; 28% had flowing tap water all day while 72% utilized cup and bucket; and 58% had no hand drying facilities. A total of 406 HH opportunities were observed among 175 HCWs. The overall compliance was 31%, ranging from 18% among ward attendants to 82% among medical students. Based on WHO “5 moments” for HH, average compliance was 21% before patient contact, 23% before aseptic procedure, 63% after body fluid exposure risk, 41% after patient contact and 40% after contact with patients’ surrounding. Being a medical student was independently associated with high HH compliance, adjusted odds ratio: 13.87 (1.70–112.88). Conclusions Availability of HH facilities and HCW compliance in a large tertiary hospital in Nigeria is poor. Our findings confirm that HCWs seem more sensitized to their risk of exposure to potential pathogens than to the prevention of HAI cross-transmission. Inadequate HH facilities probably contributed to the poor compliance. Specific measures such as improved facilities, training and monitoring are needed to improve HH compliance.

Abstract Emojis are frequently used picture characters known as possible surrogates for non-verbal aspects of behavior. Considering the ability of emojis to enhance and facilitate communication, there has been a growing interest in studying their effects in scientific and health-related topics over the past few years. Infection prevention and control (IPC) is a field of medicine that is directly associated with specific behaviors. These include hand hygiene, which is the cornerstone of the prevention of healthcare-associated infections, and essential in stemming the spread of antimicrobial resistance. This paper aims to provide an overview of how emojis have been used in the medical and public health literature and proposes their possible use in IPC and hand hygiene to put forth a vision for the future research.

Abstract Background Harmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a “Train-the-Trainers” (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries. Methods We developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training. Results Between June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p

Abstract In honor of Florence Nightingale’s 200th birthday, the World Health Organization (WHO) has declared 2020 the “Year of the Nurse and Midwife”. On May 5th of this year, for the annual celebration of the SAVE LIVES: Clean Your Hands campaign, WHO will focus on the essential role that nurses and midwives play in contributing to saving millions of lives per year. It is necessary to recognize the work and the immense responsibility that nurses and midwives carry since achieving Universal Health Coverage is highly reliant on them.

Abstract The World Health Organization (WHO) has declared 2020 the “Year of the Nurse and Midwife”. On May 5th of this year, for the annual celebration of the SAVE LIVES: Clean Your Hands campaign, the WHO will focus on the critical role of nurses and midwives in promoting public health. The brain drain of healthcare workers (HCWs) leads to unequal distribution of nurses and midwives around the world, which affects the quality of care provided to patients. This phenomenon should be addressed as a global problem as it highlights staff shortages in the health system.

Abstract Background Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion. Methods This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires. Results Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement. Conclusion Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.