Hand hygiene intervention to optimize helminth infection control: Design and baseline results of Mikono Safi-An ongoing school-based cluster-randomised controlled trial in NW Tanzania.

INTRODUCTION: Soil transmitted helminths (STH) can affect over 50% of children in some parts of Tanzania. Control measures involve annual deworming campaigns in schools, but re-infection is rapid. This paper presents the design and baseline survey results of an ongoing school-based cluster-randomised controlled trial in Kagera region, NW Tanzania. The trial aims to determine whether the effect of routine deworming on the prevalence of Ascaris lumbricoides and Trichuris trichiura infections among school aged children can be sustained when combined with a behaviour change intervention promoting handwashing with water and soap. METHODS: As part of the trial, a total of 16 schools were randomised to receive the intervention (N = 8) or as controls (N = 8). Randomisation was stratified per district and restricted to ensure pre-trial STH prevalence was balanced between study arms. The combination intervention to be tested comprises class-room based teacher-led health education, improvement of handwash stations, coloured nudges to facilitate handwashing and parental engagement sessions. The impact evaluation involves two cross-sectional surveys conducted at baseline and endline. The objectives of the baseline survey were: (i) to confirm whether the deworming campaign was successful, and identify and treat students still infected about 2 weeks after deworming, (ii) to document any baseline differences in STH prevalence between trial arms, and (iii) to assess handwashing behaviours, and access to water and sanitation at school and home. We randomly sampled 35 students per class in Grades 1-6 (an average of 200 children per school), stratified to ensure equal representation between genders. Assenting students were interviewed using a structured questionnaire and asked to provide a stool specimen. RESULTS: Results of the baseline survey conducted about 2 weeks after deworming shows balanced demographic and STH prevalence data across trial arms. We observed a low prevalence of ascariasis (< 5%) as expected; however, the prevalence of trichuriasis was still about 35% in both arms. CONCLUSION: The randomisation procedure was successful in achieving a balanced distribution of demographic characteristics and helminth infections between trial arms. The intervention is being rolled out. The current deworming treatment regimen may need to be revised with regards to the treatment of trichuriasis.

The evaluation of a multimodal hand hygiene improvement strategy in Cambodian hospitals.

INTRODUCTION: Hand hygiene is the most effective method of preventing healthcare-associated infections. Healthcare-associated infections are considered serious in developing countries, and there are few reports on the hand-hygiene status of these countries. Thus, we evaluated hand-hygiene status in eight hospitals in Cambodia to understand and identify factors hindering effective infection control. METHODOLOGY: Eight infection-management instructors working in one of the eight Cambodian government hospitals in a large city were interviewed with the WHO Hand Hygiene Self-Assessment Framework. RESULTS: The mean Hand Hygiene Self-Assessment Framework score across the eight hospitals was 177.81 ± 56.73. The overall level of compliance with the multimodal hand hygiene improvement strategy across these eight hospitals was basic-two hospitals scored inadequate and six hospitals scored basic. The scores for the 5 factors of the Hand Hygiene Self-Assessment Framework were as follows: 45.63 ± 15.45 for system change, 33.13 ± 16.89 for education and training, 27.81 ± 21.65 for evaluation and feedback, 58.13 ± 5.30 for reminders in the workplace, and 13.13 ± 11.00 for institutional safety climate for hand hygiene CONCLUSIONS: The promotion of hand hygiene compliance requires the establishment of a basic infrastructure, reinforcement of the hand hygiene education system, and provision of diverse educational materials, as well as the fostering of a professional workforce for education. Hospitals should also bolster their management systems for hand hygiene compliance.

Multimodal strategy for hand hygiene in field hospitals of COVID-19.

OBJECTIVE: Reflect and propose adaptations to the Multimodal Hand Hygiene Strategy for field hospitals, in the context of the COVID-19 pandemic. METHOD: Reflective study, carried out in April 2020, based on the recommendations of the World Health Organization and the guide for the implementation of the five components of the Multimodal Strategy: system change related to infrastructure; training/education; evaluation and feedback; reminders in the workplace; and institutional security climate. RESULTS: The Multimodal Strategy, proposed for hospitals in general, can be adapted for field hospitals in order to reduce the transmission of the SARS-CoV-2 virus. Investments to adapt the infrastructure and education of workers require foresight and speed and are of special relevance to promote hand hygiene in this care context. FINAL CONSIDERATIONS: Adjusting the Multimodal Strategy, especially for the reduced time in the execution of each component, is necessary for field hospitals with a view to preventing COVID-19.

Healthcare facilities in low- and middle-income countries affected by COVID-19: Time to upgrade basic infection control and prevention practices.

COVID-19 as a pandemic has spanned across all continents. With the increasing numbers in cases worldwide, even the countries with the best of healthcare facilities are reeling under the burden of the disease. Therefore, in countries with limited access to resources and poor healthcare infrastructure, the low and middle-income countries (LMICs), limiting spread becomes even more challenging. Low- and middle-income countries (LMICs) are severely hit by any outbreak and pandemics and face the lack of infrastructure and problem of overcrowding. Health facilities are compromised and almost exhausted at the time of emergency. There is disruption of normal supply chain, and consumables are not in sufficient quantity. In the current situation, rationalized use of available supplies is important. This paper presents the perspective on the basis of current literature on gaps in various infection prevention and control (IPC) strategies that are being followed currently in LMICs and suggestions for bridging these gaps.

A review of studies on the COVID-19 epidemic crisis disease with a preventive approach.

BACKGROUND: COVID-19 is a highly contagious acute respiratory syndrome and has been declared a pandemic in more than 209 countries worldwide. At the time of writing, no preventive vaccine has been developed and tested in the community. This study was conducted to review studies aimed at preventing the spread of the coronavirus worldwide. METHODS: This study was a review of the evidence-based literature and was conducted by searching databases, including Google Scholar, PubMed, and ScienceDirect, until April 2020. The search was performed based on keywords including "coronavirus", "COVID-19", and "prevention". The list of references in the final studies has also been re-reviewed to find articles that might not have been obtained through the search. The guidelines published by trustworthy organizations such as the World Health Organization and Center for Disease Control have been used in this study. CONCLUSION: So far, no vaccine or definitive treatment for COVID-19 has been invented, and the disease has become a pandemic. Therefore, observation of hand hygiene, disinfection of high-touch surfaces, observation of social distance, and lack of presence in public places are recommended as preventive measures. Moreover, to control the situation and to reduce the incidence of the virus, some of the measures taken by the decision-making bodies and the guidelines of the deterrent institutions to strengthen telecommuting of employees and reduce the presence of people in the community and prevent unnecessary activities, are very important.

Hand hygiene in surgery in Benin: opportunities and challenges.

BACKGROUND: Hand Hygiene (HH) has been described as the cornerstone and starting point in all infection control. Compliance to HH is a fundamental quality indicator. The aim of this study was to investigate the HH compliance among Health-care Workers (HCWs) in Benin surgical care units. METHODS: A multicenter prospective observational study was conducted for two months. The World Health Organization (WHO) Hand Hygiene Observation Tool was used in obstetric and gastrointestinal surgery through six public hospitals in Benin. HH compliance was calculated by dividing the number of times HH was performed by the total number of opportunities. HH technique and duration were also observed. RESULTS: A total of 1315 HH opportunities were identified during observation period. Overall, the compliance rate was 33.3% (438/1315), without significant difference between professional categories (nurses =34.2%; auxiliaries =32.7%; and physicians =32.4%; p = 0.705). However, compliance rates differed (p < 0.001) between obstetric (49.4%) and gastrointestinal surgery (24.3%). Generally, HCWs were more compliant after body fluid exposure (54.5%) and after touching patient (37.5%), but less before patient contact (25.9%) and after touching patient surroundings (29.1%). HCWs were more likely to use soap and water (72.1%) compared to the alcohol based hand rub solution (27.9%). For all of the WHO five moments, hand washing was the most preferred action. For instance, hand rub only was observed 3.9% after body fluid exposure and 16.3% before aseptic action compared to hand washing at 50.6 and 16.7% respectively. Duration of HH performance was not correctly adhered to 94% of alcohol hand rub cases (mean duration 9 ± 6 s instead of 20 to 30 s) and 99.5% of hand washing cases (10 ± 7 s instead of the recommended 40 to 60 s). Of the 432 HCWs observed, 77.3% followed HH prerequisites (i.e. no artificial fingernails, no jewellery). We also noted a lack of permanent hand hygiene infrastructures such as sink, soap, towels and clean water. CONCLUSION: Compliance in surgery was found to be low in Benin hospitals. They missed two opportunities out of three to apply HH and when HH was applied, technique and duration were not appropriate. HH practices should be a priority to improve patient safety in Benin.

Implementation of the WHO hand hygiene strategy in Faranah regional hospital, Guinea.

BACKGROUND: Healthcare-associated infections are the most frequent adverse events in healthcare worldwide, with limited available evidence suggesting highest burden in resource-limited settings. Recent Ebola epidemics emphasize the disastrous impact that spread of infectious agents within healthcare facilities can have, accentuating the need for improvement of infection control practices. Hand hygiene (HH) measures are considered to be the most effective tool to prevent healthcare-associated infections. However, HH knowledge and compliance are low, especially in vulnerable settings such as Guinea. The aim of PASQUALE (Partnership to Improve Patient Safety and Quality of Care) was to assess knowledge and compliance with HH and improve HH by incorporating the WHO HH Strategy within the Faranah Regional Hospital (FRH), Guinea. METHODS: In a participatory approach, a team of FRH staff and leadership was invited to identify priorities of the hospital prior to the start of PASQUALE. The local hygiene committee was empowered to increase its activities and take ownership of the HH improvement strategy. A baseline assessment of knowledge, perception and compliance was performed months before the intervention. The main intervention consisted of local alcohol-based-hand-rub (ABHR) production, with final product efficacy testing, in conjunction with a training adapted to the needs identified in the baseline assessment. A follow-up assessment was conducted directly after the training. Effectiveness of the intervention was assessed via uncontrolled before-and-after comparison. RESULTS: Baseline knowledge score (13.0/25) showed a significant increase to 19.0/25 in follow-up. Baseline-Compliance was 23.7% and increased significantly to 71.5% in follow-up. Compliance rose significantly across all professional groups except for midwifes and in all indications for HH, with the largest in the indication "Before aseptic tasks". The increase in compliance was associated with the intervention and remained significant after adjusting for confounders. The local pharmacy successfully supplies the entire hospital. The local supply resulted in a ten-fold increase of monthly hospital disinfectant consumption. CONCLUSION: The WHO HH strategy is an adaptable and effective method to improve HH knowledge and compliance in a resource-limited setting. Local production is a feasible method for providing self-sufficient supply of ABHR to regional hospitals like the FRH. Participatory approaches like hygiene committee ownership builds confidence of sustainability.

The great nursing brain drain and its effects on patient safety.

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.

"Nurses and midwives: clean care is in your hands": the 5th May 2020 World Health Organization SAVE LIVES: Clean Your Hands campaign.

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.

A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group.

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread globally since being identified as a public health emergency of major international concern and has now been declared a pandemic by the World Health Organization (WHO). In December 2019, an outbreak of atypical pneumonia, known as COVID-19, was identified in Wuhan, China. The newly identified zoonotic coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is characterized by rapid human-to-human transmission. Many cancer patients frequently visit the hospital for treatment and disease surveillance. They may be immunocompromised due to the underlying malignancy or anticancer therapy and are at higher risk of developing infections. Several factors increase the risk of infection, and cancer patients commonly have multiple risk factors. Cancer patients appear to have an estimated twofold increased risk of contracting SARS-CoV-2 than the general population. With the WHO declaring the novel coronavirus outbreak a pandemic, there is an urgent need to address the impact of such a pandemic on cancer patients. This include changes to resource allocation, clinical care, and the consent process during a pandemic. Currently and due to limited data, there are no international guidelines to address the management of cancer patients in any infectious pandemic. In this review, the potential challenges associated with managing cancer patients during the COVID-19 infection pandemic will be addressed, with suggestions of some practical approaches. IMPLICATIONS FOR PRACTICE: The main management strategies for treating cancer patients during the COVID-19 epidemic include clear communication and education about hand hygiene, infection control measures, high-risk exposure, and the signs and symptoms of COVID-19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case-by-case basis. Minimizing outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure. More research is needed to better understand SARS-CoV-2 virology and epidemiology.

A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control.

BACKGROUND: The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively. AIM: The aim of this systematic review was to verify the causes and problems contributing to transmission and to identify control measures during outbreaks in LTCFs. METHODS: Four electronic databases were searched for articles published from 2007 to 2018. Articles written in English reporting outbreaks in LTCFs were included. The quality of the studies was assessed using the risk-of-bias assessment tool for nonrandomized studies. FINDINGS: A total of 37 studies were included in the qualitative synthesis. The most commonly reported single pathogen was influenza virus, followed by group A streptococcus (GAS). Of the studies that identified the cause, about half of them noted outbreaks transmitted via person-to-person. Suboptimal infection control practice including inadequate decontamination and poor hand hygiene was the most frequently raised issue propagating transmission. Especially, lapses in specific care procedures were linked with outbreaks of GAS and hepatitis B and C viruses. About 60% of the included studies reported affected cases among staff, but only a few studies implemented work restriction during outbreaks. CONCLUSIONS: This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs.

A quasi-randomized controlled before-after study using performance feedback and goal setting as elements of hand hygiene promotion.

BACKGROUND: Hand hygiene (HH) plays an important role in infection prevention but is often suboptimal. AIM: To test the potential of goal setting and performance feedback in improving HH. METHODS: A prospective controlled intervention study was conducted at a German hospital. The study involved four phases: habituation to novel count dispensers and observers (T0), baseline (T1), intervention (T2) and postintervention (T3). Four non-intensive-care units were assigned to one of four conditions: goal setting, performance feedback, both goal setting and performance feedback, or none (control). During all phases, dispenser usage was electronically recorded 24/7. In addition, randomly sampled direct observation was conducted by trained external observers during each phase. The main outcome measure was the daily average of electronically counted hand hygiene events (HHEs) per patient room. FINDINGS: In the feedback condition, a marginally significant increase in HHEs was found from T1 to T2 (MT1 = 7.3, MT2 = 10.3, MT3 = 8.2). In the goal-setting condition, HHEs increased only descriptively from T1 to T2 (MT1 = 6.8, MT2 = 8.7, MT3 = 7.8). In the combined condition, HHEs increased significantly from T1 to T2, and were still significantly elevated at T3 (MT1 = 7.9, MT2 = 17.0, MT3= 12.9). Over all wards and study phases, count dispenser usage frequency was highly correlated with HH compliance (ρ = 0.766, P<0.001). CONCLUSION: This study suggests that combining goal setting and feedback is a useful approach for improving HH.

Infrastructure for hand hygiene in a teaching hospital. / Infraestrutura para higienização das mãos em um hospital universitário.

OBJECTIVE: To evaluate the hospital infrastructure and the knowledge of the coordinators about the unit structure for hand hygiene. METHODS: Descriptive cross-sectional design study carried out in a teaching hospital in the South of Brazil, in the period between December 2016 and January 2017. Eighteen inpatient care units were evaluated, and 16 coordinators were interviewed. We used the questionnaire of the World Health Organization multimodal strategy on the structure of the units for hand hygiene. It was used descriptive statistics. RESULTS: All the units had alcohol-based sanitizers, and 93.8% of the dispensers were substituted when they got empty. The difficulties observed were the lack of illustrating posters, the location of sinks and dispensers of alcohol-based hand sanitizers in some nursing infirmarys, and the fact that there were few dispensers at hand reach near the patient's bed. CONCLUSIONS: We concluded that there were protocols for hand hygiene, and professionals were instructed about it. There were gaps in the inpatient units, such as the presence of inadequate sinks and taps.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach During 3 Years in 6 Hospitals in 3 Mexican Cities.

OBJECTIVES: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene (HH) approach in Mexico, and analyze predictors of poor HH compliance. METHODS: From June 2002 to April 2006, we conducted a prospective, observational, before-and-after study in 8 intensive care units (ICUs) from 6 hospitals in 3 cities of Mexico. The approach included administrative support, availability of supplies, education and training, reminders in the workplace, process surveillance, and performance feedback. RESULTS: A total of 13,201 observations for HH opportunities were done in each ICU, during randomly selected 30-minute periods. Overall, HH compliance increased from 45% to 79% (95% confidence interval [CI], 69.1-86.5; P = 0.01). Univariate and multivariate analyses showed that several variables were significantly associated with poor HH compliance: males versus females (61% versus 66%; 95% CI, 0.91-0.96; P = 0.0001), physicians versus nurses (62% versus 67%; 95% CI, 0.91-0.97; P = 0.0001), and adult versus neonatal ICUs (67% versus 54%; 95% CI, 0.79-0.84; P = 0.0001), among others. CONCLUSIONS: Hand hygiene programs should focus on variables found to be predictors of poor HH compliance.

Infraestrutura para higienização das mãos em um hospital universitário / Infraestructura para higienización de manos en un hospital universitario / Infrastructure for hand hygiene in a teaching hospital

Resumo OBJETIVO Avaliar a infraestrutura hospitalar e o conhecimento dos coordenadores sobre a estrutura da unidade para à higienização das mãos. MÉTODO Estudo transversal descritivo realizado em um hospital universitário no Sul do Brasil, entre dezembro de 2016 e janeiro de 2017. Foram avaliadas 18 unidades de internação e entrevistados 16 coordenadores. Utilizou-se o questionário sobre estrutura da unidade para a higienização das mãos da estratégia multimodal da Organização Mundial de Saúde. Utilizou-se a estatística descritiva. RESULTADOS Todas as unidades possuíam preparações alcóolicas, e 93,8% dos dispensadores eram substituídos quando vazios. Observaram-se falta de cartazes ilustrativos, dispensadores de álcool gel, pias em algumas enfermarias, e pouca disponibilidade de dispensadores ao alcance das mãos próximos ao leito/maca do paciente. CONCLUSÕES Constatou-se que os profissionais recebiam instruções para a higienização das mãos e a existência de protocolos. Lacunas foram observadas na infraestrutura das unidades, como a presença de pias e torneiras não adequadas.

Resumen OBJETIVO Evaluar la infraestructura hospitalaria y el conocimiento de los coordinadores sobre la estructura de la unidad para la higienización de las manos. MÉTODO Estudio transversal descriptivo realizado en un hospital universitario en el Sur de Brasil, entre diciembre de 2016 y enero de 2017. Se evaluaron 18 unidades de internación y 16 coordinadores han sido entrevistados. Se utilizó la encuesta sobre la estructuración de las unidades hospitalarias para la higienización de las manos de la estrategia multimodal de la Organización Mundial de la Salud y se utilizó la estadística descriptiva. RESULTADOS Todas las unidades poseían preparados alcohólicos y el 93,8% de los dispensadores eran reemplazados cuando quedaban vacíos. Se observaron falta de carteles ilustrativos, de dispensadores de alcohol gel, de lavabos en algunas enfermerías, y de poca disponibilidad de dispensadores al alcance de las manos cerca del lecho/ maca del paciente. CONCLUSIONES Se constató que los profesionales recibían instrucciones para la higienización de las manos y que había protocolos para esta práctica. Se observaron algunas fallas en la infraestructura de las unidades, además de la inadecuación de algunos lavabos y grifos.

Resumo OBJECTIVE To evaluate the hospital infrastructure and the knowledge of the coordinators about the unit structure for hand hygiene. Methods Descriptive cross-sectional design study carried out in a teaching hospital in the South of Brazil, in the period between December 2016 and January 2017. Eighteen inpatient care units were evaluated, and 16 coordinators were interviewed. We used the questionnaire of the World Health Organization multimodal strategy on the structure of the units for hand hygiene. It was used descriptive statistics. Results All the units had alcohol-based sanitizers, and 93.8% of the dispensers were substituted when they got empty. The difficulties observed were the lack of illustrating posters, the location of sinks and dispensers of alcohol-based hand sanitizers in some nursing infirmarys, and the fact that there were few dispensers at hand reach near the patient's bed. Conclusions We concluded that there were protocols for hand hygiene, and professionals were instructed about it. There were gaps in the inpatient units, such as the presence of inadequate sinks and taps.

Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.

BACKGROUND: The National Hand Hygiene Initiative (NHHI) is a standardised culture-change programme based on the WHO My 5 Moments for Hand Hygiene approach to improve hand hygiene compliance among Australian health-care workers and reduce the risk of health-care-associated infections. We analysed its effectiveness. METHODS: In this longitudinal study, we assessed outcomes of the NHHI for the 8 years after implementation (between Jan 1, 2009, and June 30, 2017), including hospital participation, hand hygiene compliance (measured as the proportion of observed Moments) three times per year, educational engagement, cost, and association with the incidence of health-care-associated Staphylococcus aureus bacteraemia (HA-SAB). FINDINGS: Between 2009 and 2017, increases were observed in national health-care facility participation (105 hospitals [103 public and two private] in 2009 vs 937 hospitals [598 public and 339 private] in 2017) and overall hand hygiene compliance (36 213 [63·6%] of 56 978 Moments [95% CI 63·2-63·9] in 2009 vs 494 673 [84·3%] of 586 559 Moments [84·2-84·4] in 2017; p<0·0001). Compliance also increased for each Moment type and for each health-care worker occupational group, including for medical staff (4377 [50·5%] of 8669 Moments [95% CI 49·4-51·5] in 2009 vs 53 620 [71·7%] of 74 788 Moments [71·4-72·0]; p<0·0001). 1 989 713 NHHI online learning credential programmes were completed. The 2016 NHHI budget was equivalent to AUD$0·06 per inpatient admission nationally. Among Australia's major public hospitals (n=132), improved hand hygiene compliance was associated with declines in the incidence of HA-SAB (incidence rate ratio 0·85; 95% CI 0·79-0·93; p≤0·0001): for every 10% increase in hand hygiene compliance, the incidence of HA-SAB decreased by 15%. INTERPRETATION: The NHHI has been associated with significant sustained improvement in hand hygiene compliance and a decline in the incidence of HA-SAB. Key features include sustained central coordination of a standardised approach and incorporation into hospital accreditation standards. The NHHI could be emulated in other national culture-change programmes. FUNDING: Australian Commission on Safety and Quality in Health Care.

Identifying heterogeneity in the Hawthorne effect on hand hygiene observation: a cohort study of overtly and covertly observed results.

BACKGROUND: Observation and feedback are core strategies of hand hygiene (HH) improvement. Direct overt observation is currently the gold standard method. Observation bias, also known as the Hawthorne effect, is a major disadvantage of this method. Our aim was to examine the variation of the Hawthorne effect on HH observation in different healthcare groups and settings. METHODS: A prospective cohort study was performed in a tertiary teaching hospital during a 15-month period. Up to 38 overt observers (82% nurses) and 93 covert observers (81% medical students) participated in HH observation. The HH events observed overtly were matched for occupation, department, observation time, and location with those observed covertly. The data of matched pairs were then analysed to detect possible Hawthorne effects on different variables. RESULTS: A total of 31,522 HH opportunities were observed (4581 overtly, 26,941 covertly). There were 3047 matched pairs after 1:1 matching of overt and covert observations. The overall HH compliance was higher with overt observation than with covert observation (78% vs. 55%, p < 0.001). The Hawthorne effect was nearly three times larger in nurses (30 percentage points) than in physicians (11 percentage points) and was significantly greater in outpatient clinics (41 percentage points) than in intensive care units (11 percentage points). The magnitude of the Hawthorne effect varied among healthcare worker occupations and observation locations (p values both < 0.001) but not among departments, observation times, or HH indications. CONCLUSIONS: Heterogeneity in the Hawthorne effect may influence the interpretation of overt observations and prevent the correct identification of target populations with poor HH compliance. Therefore, directly observed HH compliance may not be an adequate performance indicator for infection control.