The Efficacy of Commercial Surface Sanitizers against Norovirus on Formica Surfaces with and without Inclusion of a Wiping Step.

Commonly used surface sanitizers often lack activity against human noroviruses (hNoVs). The impact of inactivation versus removal when these products are applied via wiping is poorly characterized. The purpose of this work was to assess the anti-hNoV efficacy of various surface sanitizer chemistries, as applied to a laminate material commonly used for restaurant tabletops, using standard surface assays (ASTM E1053-11) and a newly developed wiping protocol. Four commercially available products with different active ingredient(s) (i.e., ethanol [EtOH], acid + anionic surfactant [AAS], quaternary ammonium compound [QAC], and sodium hypochlorite [NaOCl]) and a water control were evaluated against hNoV GII.4 Sydney, hNoV GI.6, and the cultivable surrogate Tulane virus (TuV). Virus concentration was evaluated using RNase-reverse transcriptase (RT)-quantitative PCR (qPCR) (hNoV) and infectivity assay (TuV). Only the EtOH-based product significantly reduced virus concentration (>3.5 log10 reduction [LR]) by surface assay, with all other products producing ≤0.5 LR. The inclusion of a wiping step enhanced the efficacy of all products, producing complete virus elimination for the EtOH-based product and 1.6 to 3.8 LR for the other chemistries. For hNoVs, no detectable residual virus could be recovered from paper towels used to wipe the EtOH-based product, while high concentrations of virus could be recovered from the used paper towel and the wiped coupon (1.5 to 2.5 log10 lower genome equivalent copies [GEC] compared to control) for the QAC- and AAS-based products and for water. These results illustrate the variability in anti-hNoV activity of representative surface sanitizers and highlights the value of wiping, the efficacy of which appears to be driven by a combination of virus inactivation and removal. IMPORTANCE Human noroviruses (hNoVs) are the leading cause of acute gastroenteritis and food-borne disease worldwide. Noroviruses are difficult to inactivate, being recalcitrant to sanitizers and disinfectants commonly used by the retail food sector. This comparative study demonstrates the variability in anti-hNoV activity of representative surface sanitizers, even those allowed to make label claims based on the cultivable surrogate, feline calicivirus (FCV). It also highlights the importance of wiping in the process of sanitization, which significantly improves product efficacy through the action of physical removal of surface microbes. There is a need for more and better product formulations with demonstrated efficacy against hNoVs, which will likely necessitate the use of alternative cultivable surrogates, such as Tulane virus (TuV). These findings help food safety professionals make informed decisions on sanitizing product selection and application methods in order to reduce the risk of hNoV contamination and transmission in their facilities.

Efficacy of an alcohol-based surface disinfectant formulation against human norovirus.

AIM: To evaluate the anti-noroviral efficacy of PURELL® surface sanitizer and disinfectant spray (PSS, an alcohol-based formulation) using human norovirus GII.4 Sydney [hNoV, by RT-qPCR and human intestinal enteroid (HIE) infectivity assay] and its cultivable surrogate, Tulane virus (TuV, infectivity assay), compared to sodium hypochlorite (NaOCl) solutions. METHODS AND RESULTS: PSS efficacy was evaluated in suspension and on surfaces [stainless steel (SS)] using ASTM methods. Results were expressed as log10 reduction (LR) of genome equivalent copy number (GEC, for hNoV, assayed by RT-qPCR) and plaque forming units (PFU, for TuV, per infectivity assay). In suspension, PSS achieved a 2.9 ± 0.04 LR hNoV GEC irrespective of contact time (30 or 60 s) and soil load (2.5% or 5%). Under all treatment conditions, infectious TuV could not be recovered following exposure to PSS, corresponding to the assay limit of detection (3.1-5.2 log10 PFU). Infectious hNoV could not be detected in the HIE model after exposure to PSS. On SS and 2.5% soil, PSS produced a 3.1 ± 0.1 LR hNoV GEC, comparable to 500 ppm NaOCl for 60 s. With 5.0% soil, PSS produced a 2.5 ± 0.2 LR hNoV GEC, which was similar to 1000-5000 ppm NaOCl for 60 s. CONCLUSIONS: PSS showed high anti-hNoV efficacy by RT-qPCR and in in vitro (TuV) and ex vivo (HIE) infectivity assays and performed similar to 1000-5000 ppm NaOCl for a 60-s contact time on SS with added soil. SIGNIFICANCE AND IMPACT OF STUDY: hNoV remains a significant cause of morbidity globally, partly due to its resistance to numerous surface disinfectants. RT-qPCR results from this study indicate PSS efficacy against hNoV is comparable to NaOCl efficacy. Infectivity assays leveraging TuV and the HIE model for hNoV support and confirm loss of virus infectivity. Collectively, these results indicate the product's ability to inactivate hNoV quickly, which could be beneficial in settings having elevated risk for hNoV transmission.

Both Handwashing and an Alcohol-Based Hand Sanitizer Intervention Reduce Soil and Microbial Contamination on Farmworker Hands during Harvest, but Produce Type Matters.

Hand hygiene interventions are critical for reducing farmworker hand contamination and preventing the spread of produce-associated illness. Hand hygiene effectiveness may be produce-commodity specific, which could influence implementation strategies. This study's goal was to determine if produce commodity influences the ability of handwashing with soap and water or two-step alcohol-based hand sanitizer (ABHS) interventions to reduce soil and bacteria on farmworker hands. Farmworkers (n = 326) harvested produce (cantaloupe, jalapeño, and tomato) for 30 to 90 minutes before engaging in handwashing, two-step ABHS (jalapeño and cantaloupe), or no hand hygiene. Hands were rinsed to measure amounts of soil (absorbance at 600 nm) and indicator bacteria (coliforms, Enterococcus sp., generic Escherichia coli, and Bacteroidales universal [AllBac] and human-specific [BFD] 16S rRNA gene markers). Without hand hygiene, bacterial concentrations (0.88 to 5.1 log10 CFU/hand) on hands significantly differed by the produce commodity harvested. Moderate significant correlations (ρ = -0.41 to 0.56) between soil load and bacterial concentrations were observed. There were significant produce-commodity-specific differences in the ability of handwashing and two-step ABHS interventions to reduce soil (P < 0.0001), coliforms (P = 0.002), and Enterococcus sp. (P = 0.003), but not the Bacteroidales markers AllBac (P = 0.4) or BFD (P = 0.3). Contamination on hands of farmworkers who harvested cantaloupe was more difficult to remove. Overall, we found that a two-step ABHS intervention was similar to handwashing with soap and water at reducing bacteria on farmworker hands. In summary, produce commodity type should be considered when developing hand hygiene interventions on farms.IMPORTANCE This study demonstrated that the type of produce commodity handled influences the ability of handwashing with soap and water or a two-step alcohol-based hand sanitizer (ABHS) intervention to reduce soil and bacterial hand contamination. Handwashing with soap and water, as recommended by the FDA's Produce Safety Rule, when tested in three agricultural environments, does not always reduce bacterial loads. Consistent with past results, we found that the two-step ABHS method performed similarly to handwashing with soap and water but also does not always reduce bacterial loads in these contexts. Given the ease of use of the two-step ABHS method, which may increase compliance, the two-step ABHS method should be further evaluated and possibly considered for implementation in the agricultural environment. Taken together, these results provide important information on hand hygiene effectiveness in three agricultural contexts.

The relative influences of product volume, delivery format and alcohol concentration on dry-time and efficacy of alcohol-based hand rubs.

BACKGROUND: Alcohol-based hand rubs (ABHR) range in alcohol concentration from 60-95% and are available in a variety of delivery formats, such as rinses, gels, and foams. Recent studies suggest that some ABHR foams dry too slowly, thereby encouraging the use of inadequate volumes. This study investigates the influence of product volume, delivery format, and alcohol concentration on dry-time and antimicrobial efficacy of ABHR foams, gels and rinses. METHODS: ABHR dry-times were measured using volunteers to determine the influences of product volume, delivery format, and alcohol concentration. ABHR efficacies were evaluated according to the European Standard for Hygienic Hand Disinfection (EN 1500) using 3-mL application volumes rubbed for 30 s, and additionally, using volumes of the products determined to rub dry in 30 s. RESULTS: Volumes of six ABHR determined to rub dry in 30 s ranged from 1.7 mL to 2.1 mL, and the rate of drying varied significantly between products. ABHR dry-times increased linearly with application volume and decreased linearly with increasing alcohol concentration, but were not significantly influenced by product format. An ABHR foam (70% EtOH), rinse (80% EtOH), and gel (90% EtOH) each met EN 1500 efficacy requirements when tested at a volume of 3 mL, but failed when tested at volumes that dried in 30 s. CONCLUSIONS: Application volume is the primary driver of ABHR dry-time and efficacy, whereas delivery format does not significantly influence either. Although products with greater alcohol concentration dry more quickly, volumes required to meet EN 1500 can take longer than 30 s to dry, even when alcohol concentration is as high as 90%. Future studies are needed to better understand application volumes actually used by healthcare workers in practice, and to understand the clinical efficacy of ABHR at such volumes.

The effect of a prospective intervention program with automated monitoring of hand hygiene performance in long-term and acute-care units at a Veterans Affairs medical center.

OBJECTIVE: To measure the impact of an automated hand hygiene monitoring system (AHHMS) and an intervention program of complementary strategies on hand hygiene (HH) performance in both acute-care and long-term care (LTC) units. DESIGN: Prospective, nonrandomized, before-and-after intervention study. SETTING: Single Veterans Affairs Medical Center (VAMC), with 2 acute-care units and 6 LTC units. METHODS: An AHHMS that provides group HH performance rates was implemented on 8 units at a VAMC from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included multiple evidence-based components designed to improve HH compliance. Unit HH performance rates were expressed as the number of dispenses (events) divided by the number of patient room entries and exits (opportunities) × 100. Statistical analysis was performed with a Poisson general additive mixed model. RESULTS: During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI, 16.5-21.0) for all 8 units. During the intervention period, the median HH rate increased to 21.6 (95% CI, 19.1-24.4; P < .0001), and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 (95% CI, 22.2-28.4; P < .0001). The median HH rate increased from 17.5 to 20.0 (P < .0001) in LTC units and from 22.9 to 27.2 (P < .0001) in acute-care units. CONCLUSIONS: The intervention was associated with increased HH performance rates for all units. The performance of acute-care units was consistently higher than LTC units, which have more visitors and more mobile veterans.

Laboratory evidence of norwalk virus contamination on the hands of infected individuals.

Human norovirus (NoV) outbreak investigations suggest that the hands of infected individuals play an important role in NoV transmission. However, there is no experimental evidence documenting the likelihood and degree of NoV contamination on hands. As part of a clinical trial designed to evaluate the efficacy of high-pressure processing for Norwalk virus (NV) inactivation in oysters, 159 hand rinse samples were collected from 6 infected and 6 uninfected subjects. NV was concentrated from the samples by polyethylene glycol precipitation, followed by RNA extraction using an automated guanidinium isothiocyanate-silica method. NV RNA was detected and quantified using multiple NV-specific reverse transcription-quantitative PCR (RT-qPCR) assays. A total of 25.4% (18/71) of the hand rinse samples collected from 6 infected volunteers were presumptively positive for NV, with an average of 3.86 log10 genomic equivalent copies (GEC) per hand. Dot blot hybridization of PCR products obtained using a different primer set, and DNA sequencing of selected amplicons, provided further confirmation of the presence of NV in the hand rinses. NV contamination was also detected in two hand rinse samples obtained from one uninfected subject. These findings provide definitive evidence of NV contamination on the hands of infected subjects observed under controlled clinical research conditions. Such data support the need for better hand hygiene strategies to prevent NoV transmission.

Sample sizes for estimating the sensitivity of a monitoring system that generates repeated binary outcomes with autocorrelation.

Sample size formulas are provided to determine how many events and how many patient care units are needed to estimate the sensitivity of a monitoring system. The monitoring systems we consider generate time series binary data that are autocorrelated and clustered by patient care units. Our application of interest is an automated hand hygiene monitoring system that assesses whether healthcare workers perform hand hygiene when they should. We apply an autoregressive order 1 mixed effects logistic regression model to determine sample sizes that allow the sensitivity of the monitoring system to be estimated at a specified confidence level and margin of error. This model overcomes a major limitation of simpler approaches that fail to provide confidence intervals with the specified levels of confidence when the sensitivity of the monitoring system is above 90%.

Hand hygiene product use by food employees in casual dining and quick-service restaurants.

Hand hygiene product usage characteristics by food employees when hand sanitizers are made available are not well understood. To investigate hand hygiene product usage in casual dining and quick-service restaurants, we placed automated monitoring soap and sanitizer dispensers side-by-side at handwash sinks used by food employees in seven restaurants. Dispenses were monitored, and multiple dispenses that occurred within 60 s of each other were considered a single hand hygiene event. This resulted in 186,998 events during the study (149,779 soap only, 21 985 sanitizer only, and 15,234 regimen [defined as soap followed by sanitizer at the same sink within 60 s]) over 15,447 days of use. Soap was the most frequently used hand hygiene method by food employees in both restaurant types. Regimen use, despite being the preferred hand hygiene method by both restaurant chains, was the least used hand hygiene method. When pooled over restaurant types, the median daily usage for soap was statistically significantly highest of all methods at 23.5 dispenses per sink per day (p < 0.0001), the sanitizer median daily usage was 4.27 dispenses per sink per day, and regimen use was statistically significantly lowest of all methods at 4.02 dispenses per sink per day (p < 0.0001). When hand hygiene event types were pooled, casual dining restaurants had similar median hand hygiene event rates (11.4 dispenses per sink per day) compared to quick-service restaurants (11.9 dispenses per sink per day; p = 0.890). The number of events by sink location varied, with sinks located at a warewash station having the highest number of events (19.3 dispenses per sink per day; p < 0.0001), while sinks located by a ready-to-eat food preparation area had the lowest number of events (6.8 dispenses per sink per day; p < 0.0001). These data provide robust baseline benchmarks for future hand hygiene intervention studies in these settings.

The impact of automated hand hygiene monitoring with and without complementary improvement strategies on performance rates.

OBJECTIVE: To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates. DESIGN: Prospective, before-and-after, controlled observational study. SETTING: The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals. METHODS: HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1­2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives. RESULTS: Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001). CONCLUSIONS: AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.

A multi-centre study of the effects of direct observation of hand hygiene practices on alcohol-based handrub consumption.

Introduction: The World Health Organization recommends monitoring alcohol-based handrub (ABHR) consumption and direct observation of hand hygiene practices to ensure compliance. In Japan monitoring of ABHR consumption is widely performed. However, direct observation is not common, particularly in small facilities and non-acute-care facilities. Hence, the current study aimed to evaluate the longitudinal effects of direct observation of hand hygiene practices and monitoring of ABHR consumption with provision of feedback to healthcare personnel on ABHR consumption and hand hygiene compliance. Methods: We conducted a 4-year prospective intervention study. Monitoring of ABHR consumption and direct observation of hand hygiene practices with monthly feedback to healthcare personnel was implemented in 17 facilities. These consisted of 11 acute-care facilities of varying sizes and six non-acute-care facilities. A generalized linear mixed model analysis was performed to assess factors associated with ABHR consumption. Results: All facilities implemented ABHR consumption monitoring within one month of starting the study. However, the mean time required to implement direct observation of hand hygiene practices was 24.7 (±19.1) months. The ABHR consumption increased significantly (P<0.0001) in all medical facilities after implementing the direct observation. Multivariable regression analysis showed the hospital ward type, duration of ABHR consumption monitoring, and duration of direct observation of hand hygiene practices were independently associated with ABHR consumption. Conclusions: Direct observation of hand hygiene practices with feedback should be implemented more widely in combination with ABHR consumption monitoring to help increase hand hygiene compliance.

Comparative Assessment of the Efficacy of Commercial Hand Sanitizers Against Human Norovirus Evaluated by an in vivo Fingerpad Method.

Human noroviruses (hNoV) are the leading cause of acute non-bacterial gastroenteritis worldwide and contaminated hands play a significant role in the spread of disease. Some hand sanitizers claim to interrupt hNoV transmission, but their antiviral efficacy on human hands is poorly characterized. The purpose of this work was to characterize the efficacy of representative commercial hand sanitizers against hNoV using an in vivo fingerpad method (ASTM E1838-17). Eight products [seven ethanol-based and one benzalkonium chloride (BAK)-based], and a benchmark 60% ethanol solution, were each evaluated on 10 human volunteers using the epidemic GII.4 hNoV strain. Virus titers before and after treatment were evaluated by RT-qPCR preceded by RNase treatment; product efficacy was characterized by log10 reduction (LR) in hNoV genome equivalent copies after treatment. The benchmark treatment produced a 1.7 ± 0.5 LR, compared with Product A (containing 85% ethanol) which produced a 3.3 ± 0.3 LR and was the most efficacious (p < 0.05). Product B (containing 70% ethanol), while less efficacious than Product A (p < 0.05), performed better than the benchmark with a LR of 2.4 ± 0.4. Five of the other ethanol-based products (labeled ethanol concentration ranges of 62-80%) showed similar efficacy to the 60% ethanol benchmark with LR ranging from 1.3 to 2.0 (p > 0.05). Product H (0.1% BAK) was less effective than the benchmark with a LR of 0.3 ± 0.2 (p < 0.05). None of the products screened were able to completely eliminate hNoV (maximum assay resolution 5.0 LR). Product performance was variable and appears driven by overall formulation. There remains a need for more hand sanitizer formulations having greater activity against hNoV, a virus that is comparatively recalcitrant relative to other pathogens of concern in community, healthcare, and food preparation environments.

Presence of unsafe chemical impurities, accelerated evaporation of alcohol, and lack of key labeling requirements are risks and concerns for some alcohol-based hand sanitizers and dispenser practices during the COVID-19 pandemic.

Alcohol-based hand sanitizers (ABHS) have been an important hand hygiene tool during the COVID-19 pandemic. Recently, ABHS from non-traditional drug manufacturers have entered the market, triggered by a lack of ABHS availability. Some of these ABHS contain high levels of chemical impurities that may be harmful with frequent exposure. Additionally, the use of refillable dispensers designed to accept ABHS from bulk containers allows for mixing and evaporation that may compromise ABHS integrity. To understand the risks associated with low quality ABHS and bulk refilling practices, we collected 77 ABHS samples sourced from community settings (restaurants, grocery stores, etc.) and 40 samples from a single school district. All samples were obtained from bulk refillable dispensers that were in use. Samples were analyzed for alcohol content, chemical impurities, aesthetic qualities, and presence of drug labeling information. Additionally, we performed laboratory-based experiments to determine the impact of dispenser design on alcohol evaporation rates. Over 70% of samples for which photos were available showed lack of essential labeling information, including missing "Drug Facts Labels". For ABHS samples acquired from community settings, nearly 14% of samples had visible impurities, and over 30% of samples had concentrations of acetal and acetaldehyde in excess of FDA interim limits. Subpotent ethanol concentrations were observed in 9.09% and 82.05% of samples from community settings and the school district, respectively, with the school district sample results being associated with dispenser misuse. Laboratory-based experiments show dispenser design significantly impacts the rate of ethanol evaporation of ABHS products, especially if stored in open refillable dispensers without an internal reservoir. This study demonstrates risks associated with use of inferior ABHS and bulk refilling practices. Regulatory agencies should issue guidance on best practices in community settings to ensure the integrity of ABHS as an essential public health tool to prevent the spread of COVID-19 and other transmissible diseases.

Quest for a realistic in vivo test method for antimicrobial hand-rub agents: introduction of a low-volume hand contamination procedure.

A novel method has been developed for the evaluation of alcohol-based hand rubs (ABHR) that employs a hand contamination procedure that more closely simulates the in-use conditions of ABHR. Hands of human subjects were contaminated with 0.2 ml of a concentrated suspension of Serratia marcescens (ATCC 14756) to achieve baseline contamination between 8 and 9 log10 CFU/hand while allowing product to be applied to dry hands with minimal soil load. Evaluation of 1.5 ml of an ABHR gel containing 62% ethanol produced log10 reductions of 2.66 ± 0.96, 2.40 ± 0.50, 2.41 ± 0.61, and 2.33 ± 0.49 (means ± standard deviations) after 1, 3, 7, and 10 successive contamination/product application cycles. In a study comparing this low-volume contamination (LVC) method to ASTM E1174, product dry times were more realistic and log10 reductions achieved by the ABHR were significantly greater when LVC was employed (P < 0.05). These results indicate that a novel low-volume hand contamination procedure, which more closely represents ABHR use conditions, provides more realistic estimates of in-use ABHR efficacies. Based on the LVC method, log10 reductions produced by ABHR were strongly dependent on the test product application volume (P < 0.0001) but were not influenced by the alcohol concentration when it was within the range of 62 to 85% (P = 0.378).

Bacterial hand contamination and transfer after use of contaminated bulk-soap-refillable dispensers.

Bulk-soap-refillable dispensers are prone to extrinsic bacterial contamination, and recent studies demonstrated that approximately one in four dispensers in public restrooms are contaminated. The purpose of this study was to quantify bacterial hand contamination and transfer after use of contaminated soap under controlled laboratory and in-use conditions in a community setting. Under laboratory conditions using liquid soap experimentally contaminated with 7.51 log(10) CFU/ml of Serratia marcescens, an average of 5.28 log(10) CFU remained on each hand after washing, and 2.23 log(10) CFU was transferred to an agar surface. In an elementary-school-based field study, Gram-negative bacteria on the hands of students and staff increased by 1.42 log(10) CFU per hand (26-fold) after washing with soap from contaminated bulk-soap-refillable dispensers. In contrast, washing with soap from dispensers with sealed refills significantly reduced bacteria on hands by 0.30 log(10) CFU per hand (2-fold). Additionally, the mean number of Gram-negative bacteria transferred to surfaces after washing with soap from dispensers with sealed-soap refills (0.06 log(10) CFU) was significantly lower than the mean number after washing with contaminated bulk-soap-refillable dispensers (0.74 log(10) CFU; P < 0.01). Finally, significantly higher levels of Gram-negative bacteria were recovered from students (2.82 log(10) CFU per hand) than were recovered from staff (2.22 log(10) CFU per hand) after washing with contaminated bulk soap (P < 0.01). These results demonstrate that washing with contaminated soap from bulk-soap-refillable dispensers can increase the number of opportunistic pathogens on the hands and may play a role in the transmission of bacteria in public settings.

The impact of COVID-19 pandemic on hand hygiene performance in hospitals.

BACKGROUND: Achieving high levels of hand hygiene compliance of health care personnel has been an ongoing challenge. The objective of this study was to examine the impact of the COVID-19 pandemic on hand hygiene performance (HHP) rates in acute care hospitals. METHODS: HHP rates were estimated using an automated hand hygiene monitoring system installed in 74 adult inpatient units in 7 hospitals and 10 pediatric inpatient units in 2 children's hospitals. A segmented regression model was used to estimate the trajectory of HHP rates in the 10 weeks leading up to a COVID-19-related milestone event (eg, school closures) and for 10 weeks after. RESULTS: Three effects emerged, all of which were significant at P < .01. Average HHP rates increased from 46% to 56% in the months preceding pandemic-related school closures. This was followed by a 6% upward shift at the time school closures occurred. HHP rates remained over 60% for 4 weeks before declining to 54% at the end of the study period. CONCLUSIONS: Data from an automated hand hygiene monitoring system indicated that HHP shifted in multiple directions during the early stages of the pandemic. We discuss possible reasons why HHP first increased as the pandemic began and then decreased as it progressed.

Infection Risk Reduction Program on Pathogens in High School and Collegiate Athletic Training Rooms.

BACKGROUND: Athletic training rooms have a high prevalence of bacteria, including multidrug-resistant organisms, increasing the risk for both local and systematic infections in athletes. There are limited data outlining formal protocols or standardized programs to reduce bacterial and viral burden in training rooms as a means of decreasing infection rate at the collegiate and high school levels. HYPOTHESIS: Adaptation of a hygiene protocol would lead to a reduction in bacterial and viral pathogen counts in athletic training rooms. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Two high school and 2 collegiate athletic training rooms were studied over the course of the 2017-2018 academic year. A 3-phase protocol, including introduction of disinfectant products followed by student-athlete and athletic trainer education, was implemented at the 4 schools. Multiple surfaces in the athletic training rooms were swabbed at 4 time points throughout the investigation. Bacterial and viral burden from swabs were analyzed for overall bacterial aerobic plate count (APC), bacterial adenosine triphosphate activity, influenza viral load, and multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). RESULTS: Overall bacterial load, as measured by APC, was reduced by 94.7% (95% CI, 72.6-99.0; P = 0.003) over the course of the investigation after protocol implementation. MRSA and VRE were found on 24% of surfaces prior to intervention and were reduced to 0% by the end of the study. Influenza was initially detected on 25% of surfaces, with no detection after intervention. No cases of athletic training room-acquired infections were reported during the study period. CONCLUSION: A uniform infection control protocol was effective in reducing bacterial and viral burden, including multidrug-resistant organisms, when implemented in the athletic training rooms of 2 high schools and 2 colleges. CLINICAL RELEVANCE: A standardized infection control protocol can be utilized in athletic training rooms to reduce bacterial and viral burden.

Nursing preference for alcohol-based hand rub volume.

BACKGROUND: The effectiveness of alcohol-based hand rub (ABHR) is correlated with drying time, which depends on the volume applied. Evidence suggests that there is considerable variation in the amount of ABHR used by healthcare providers. OBJECTIVE: We sought to identify the volume of ABHR preferred for use by nurses. METHODS: A prospective observation study was performed in 8 units at a tertiary-care hospital. Nurses were provided pocket-sized ABHR bottles with caps to record each bottle opening. Nurses were instructed to use the volume of ABHR they felt was best. The average ABHR volume used per hand hygiene event was calculated using cap data and changes in bottle mass. RESULTS: In total, 53 nurses participated and 140 nurse shifts were analyzed. The average ABHR dose was 1.09 mL. This value was greater for non-ICU nurses (1.18 mL) than ICU nurses (0.96 mL), but this difference was not significant. We detected no significant association between hand surface area and preferred average dose volume. The ABHR dose volume was 0.006 mL less per use as the number of applications per shift increased (P = .007). CONCLUSIONS: The average dose of ABHR used was similar to the dose provided by the hospital's automated dispensers, which deliver 1.1 mL per dose. The volume of ABHR dose was inversely correlated with the number of applications of ABHR per shift and was not correlated with hand size. Further research to understand differences and drivers of ABHR volume preferences and whether automated ABHR dosing may create a risk for people with larger hands is warranted.

Challenges encountered and lessons learned during a trial of an electronic hand hygiene monitoring system.

BACKGROUND: Automated hand hygiene monitoring systems (AHHMS) are being developed to supplement direct observations of hand hygiene (HH). We compared compliance rates generated by direct observations and by a badge-based AHHMS. METHODS: Observations of HH compliance were conducted in a surgical intensive care unit (SICU) and a general medical ward (GMW) during a 7-month baseline period and a 13-week intervention period, when compliance was also estimated using an AHHMS. Compliance rates were analyzed using time-series analysis. RESULTS: During the entire pre- and postintervention period, univariate analysis of observations revealed significant improvement in overall HH compliance in the SICU (P = .001) and the GMW (P = .03), beginning before implementation of the AHHMS. Initiation of the AHHMS was associated with a transient drop in entry and exit compliance on both units. During the intervention period, observations suggested that compliance on entry and exit continued to increase in the SICU, but not in the GMW. Time series analysis of AHHMS data revealed that entry and exit compliance did not change significantly in the SICU but decreased significantly in the GMW (P = .001). The average accuracy of the AHHMS was 60%. CONCLUSIONS: Based on observations, HH compliance increased during the baseline period. Observations and the AHHMS yielded different trends in compliance. The AHHMS's accuracy of HH events and health care personnel location were suboptimal.