A doctor wearing a protective suit takes a swab from a man to test for coronavirus disease (COVID-19), at a neighbourhood in Ahmedabad, April 7, 2020. (Reuters Photo: Amit Dave)
One of the most widely cited advice amid the coronavirus outbreak has been to wash hands with soap for at least 20 seconds frequently during the day. The same goes for healthcare workers as well, but this is just one of the precautions they need to take to make sure that they don’t get infected with COVID-19 themselves while caring for patients.
Ideally, those medical workers dealing with COVID-19 patients should be equipped with personal protective equipment (PPE), which includes masks, eye protection gear and gloves. Despite this, healthcare workers need to be extremely careful in their workplace, which includes following proper protocol on donning and doffing off the PPE and complying to hand hygiene requirements.
Recently, researchers from different institutions across the UK have pointed out a “neglected aspect of hand hygiene”, or the recontamination of hands of healthcare workers when they touch contaminated surfaces or objects in the workplace with or without gloves. “Infection prevention is key during this pandemic, and reducing hand recontamination is important to ensuring patient and health worker safety at all times,” researchers have said.
How important is hand hygiene in infection prevention?
In its guidelines on hand hygiene in healthcare, the World Health Organization (WHO) notes that by their very nature, infections are caused by many different factors related to systems and processes of care provision as well as by human behaviour conditioned by education, political and economic constraints on systems and countries. Therefore, hand hygiene is the primary measure to reduce infections.
According to the WHO, the risk of acquiring health-care-associated infection (HCAI) depends on factors related to the infectious agent (for example virulence, capacity to survive in the environment, antimicrobial resistance and the host). It further points out that while the risk of acquiring HCAI is “universal”, the global burden remains unknown because of difficulty in gathering diagnostic data. “Therefore, HCAI remains a hidden, cross-cutting concern that no institution or country can claim to have solved as yet.”
Medical workers treat a patient in the intensive care unit (ICU) of a hospital during the coronavirus disease (COVID-19) outbreak in Payerne, Switzerland, April 6, 2020. (Laurent Gillieron/Pool via Reuters)
Further, preventing HCAI in developing countries is more difficult since “basic infection control measures are virtually non-existent” due to factors such as understaffing, poor hygiene and sanitation, lack or shortage of basic equipment and inadequate structures and overcrowding among other factors.
Significantly, during infectious disease outbreaks, healthcare workers can get infected themselves during patient care. For instance, during the Marburg viral hemorrhagic fever in Angola, transmission within the health care settings played a major role in exacerbating the outbreak.
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According to WHO, the transmission of health-care-associated pathogens from one patient to another via healthcare workers can happen in five sequential steps. First is that the pathogen is present on the patient’s skin, or has been shed on to an inanimate object in his/her vicinity, second step involves the transfer of the pathogen to the hands of the healthcare worker, third requirement is that the pathogen should be able to survive on the hands of the healthcare worker for at least several minutes, fourth requirement is that the hand hygiene followed by the healthcare worker is inadequate or was entirely omitted and lastly, the healthcare worker’s contaminated hands should come into direct contact with another patient or an inanimate object that will come into direct contact with the patient.
Steps through which pathogens can transmit from one patient to another via healthcare workers. Click image to enlarge. (Source: National Center for Biotechnology Information)
How can healthcare workers avoid recontamination of hands?
One of the reasons that recontamination of hands may happen in medical facilities is because there is no clear distinction between surfaces that are clean and those that are not. Recontamination of hands may also be an indication that the medical staff is adequately trained or they do not clearly understand the WHO hand hygiene guidelines.
“An understanding of surfaces that are safe to touch depend upon assumptions about appropriate cleaning of surfaces, cleaning frequencies, established methods and sufficient trained cleaning staff. In spite of incredible efforts from all staff including cleaners, standards are not always optimal in the UK as in many other countries,” the researchers noted.
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They also said surface contamination played a plausible role in transmission during the SARS and MERS outbreaks. Significantly, the researchers have said that behaviour change plays an important role in avoiding recontamination. This can be done through training and monitoring of healthcare workers and issuing clear guidelines with regards to understanding which surfaces are clean “with directions on what health workers can and cannot touch within the patient zone”. Further social norms can be set, which encourage following hand hygiene protocol and avoiding recontamination and building a “user-friendly” environment that makes practicing hand hygiene easier and reducing the opportunities for recontamination.
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