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1.
mSphere ; 6(2)2021 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-33658274

RESUMO

Hand sanitizers have been developed as a convenient means to decontaminate an individual's hands of bacterial pathogens in situations in which soap and water are not available. Yet to our knowledge, no study has compared the antibacterial efficacy of a large collection of hand sanitizers. Using zone of growth inhibition and kill curve assays, we assessed the performance of 46 commercially available hand sanitizers that were obtained from national chain big-box stores, gasoline stations, pharmacies, and boutiques for antibacterial activity toward prototypical Gram-positive (Staphylococcus aureus) and Gram-negative (Escherichia coli) bacterial pathogens. Results revealed substantial variability in the efficacy of many sanitizers evaluated. Formulations following World Health Organization-recommended ingredients (80% ethanol or 75% isopropyl alcohol) or those including benzalkonium chloride as the active principal ingredient displayed excellent antibacterial activity, whereas others exhibited modest or poor activity in the assays performed. Results also revealed that E. coli was generally more susceptible to most sanitizers in comparison to S. aureus and that there was significant strain-to-strain variability in hand sanitizer antimicrobial efficacy regardless of the organism evaluated. Further, tests of a subset of hand sanitizers toward severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) revealed no direct correlation between antibacterial and antiviral performance, with all ethyl alcohol formulations performing equally well and displaying improved activity in comparison to benzalkonium chloride-containing sanitizer. Taken together, these results indicate that there is likely to be substantial variability in the antimicrobial performance of commercially available hand sanitizers, particularly toward bacterial pathogens, and a need to evaluate the efficacy of sanitizers under development.IMPORTANCE In response to the coronavirus disease 2019 (COVID-19) pandemic, hand hygiene has taken on a prominent role in efforts to mitigate SARS-CoV-2 transmission and infection, which has led to a radical increase in the number and types of hand sanitizers manufactured to meet public demand. To our knowledge, no studies have evaluated or compared the antimicrobial performance of hand sanitizers that are being produced under COVID-19 emergency authorization. Tests of 46 commercially available hand sanitizers purchased from national chain brick-and-mortar stores revealed considerable variability in their antibacterial performance toward two bacterial pathogens of immediate health care concern, S. aureus and E. coli Expanded testing of a subset of hand sanitizers revealed no direct correlation between antibacterial performance of individual sanitizers and their activity toward SARS-CoV-2. These results indicate that as the pandemic subsides, there will be a need to validate the antimicrobial efficacy of sanitizers being produced.


Assuntos
/prevenção & controle , Escherichia coli/efeitos dos fármacos , Higienizadores de Mão/farmacologia , Staphylococcus aureus/efeitos dos fármacos , Animais , Linhagem Celular , Chlorocebus aethiops , Infecções por Escherichia coli/prevenção & controle , Infecções por Escherichia coli/transmissão , Desinfecção das Mãos/métodos , Humanos , Testes de Sensibilidade Microbiana , Infecções Estafilocócicas/prevenção & controle , Infecções Estafilocócicas/transmissão , Células Vero
2.
Emerg Infect Dis ; 27(4): 1229-1231, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33755002

RESUMO

Severe acute respiratory syndrome coronavirus 2 can persist on surfaces, suggesting possible surface-mediated transmission of this pathogen. We found that fomites might be a substantial source of transmission risk, particularly in schools and child daycares. Combining surface cleaning and decontamination with mask wearing can help mitigate this risk.


Assuntos
Transmissão de Doença Infecciosa/prevenção & controle , Fômites/virologia , Controle de Infecções , /isolamento & purificação , Idoso , Número Básico de Reprodução , /prevenção & controle , /virologia , Criança , Creches/normas , Descontaminação/métodos , Contaminação de Equipamentos/prevenção & controle , Desinfecção das Mãos/métodos , Humanos , Controle de Infecções/instrumentação , Controle de Infecções/métodos , Máscaras , Casas de Saúde/normas , Instituições Acadêmicas/normas , Estados Unidos/epidemiologia
3.
J Hosp Infect ; 111: 35-39, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33577834

RESUMO

BACKGROUND: The coronavirus disease 2019 pandemic has resulted in high levels of exposure of medical workers to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Hand decontamination is one of the actions recommended to reduce the risk of infection. AIM: Two disinfectants - BIAKOS antimicrobial skin and wound cleanser (AWC) and AWC2 (Sanara MedTech, Fort Worth, TX, USA) - were tested to determine whether they can inactivate SARS-CoV-2 upon contact or as a coating applied before contact with the virus. METHODS: The ability of AWC and AWC2 to inactivate SARS-CoV-2 was tested in liquid and dried form on plastic surfaces and porcine skin. FINDINGS: AWC and AWC2 were effective in reducing the infectious titre of SARS-CoV-2 in liquid form during application and in dried form 4 h after application. Virus on skin was reduced up to 2 log10-fold and 3.5 log10-fold after treatment with AWC and AWC2, respectively. CONCLUSION: Application of AWC and AWC2 to skin reduces the level of SARS-CoV-2 and the risk of infection.


Assuntos
Antivirais/administração & dosagem , Desinfecção das Mãos/métodos , Higienizadores de Mão/administração & dosagem , Viabilidade Microbiana/efeitos dos fármacos , Pele/virologia , Administração Tópica , Humanos , Pandemias
4.
Cochrane Database Syst Rev ; 12: CD004265, 2021 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-33539552

RESUMO

BACKGROUND: Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing. OBJECTIVES: To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness. AUTHORS' CONCLUSIONS: Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.


Assuntos
Diarreia/prevenção & controle , Desinfecção das Mãos/métodos , Adulto , Viés , Criança , Creches/estatística & dados numéricos , Infecções Comunitárias Adquiridas/prevenção & controle , Infecção Hospitalar/prevenção & controle , Países Desenvolvidos/estatística & dados numéricos , Países em Desenvolvimento/estatística & dados numéricos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Instituições Acadêmicas/estatística & dados numéricos , Sabões
5.
Mo Med ; 118(1): 81-84, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33551491

RESUMO

The public health community has used contact tracing to address pandemics since the eighteenth century. With the emergence of COVID-19, these classical skills are the primary defense for communities to limit morbidity and mortality during the pandemic. Here we describe the methods, strengths, and challenges of contact tracing.


Assuntos
/prevenção & controle , Busca de Comunicante/métodos , Pandemias/prevenção & controle , Conscientização , /epidemiologia , Busca de Comunicante/estatística & dados numéricos , Surtos de Doenças/prevenção & controle , Desinfecção das Mãos/métodos , Humanos , Missouri/epidemiologia , Isolamento de Pacientes/métodos , Saúde Pública/métodos , Saúde Pública/normas , Quarentena/métodos , /isolamento & purificação
6.
BMC Infect Dis ; 21(1): 75, 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33446137

RESUMO

BACKGROUND: The elderly population in Hong Kong is rapidly growing, and the need for residential care homes (RCHs) is increasing. The risk of being infected with micro-organisms increases among the frail and the vulnerable elderly population as their immunity system begins to deteriorate. Furthermore, the residents in RCHs are at high risk of healthcare-associated infections (HAIs) due to the confined living environments and individual co-morbidities. In relation to this, infection control practice (ICP) is considered a crucial and effective approach in preventing HAIs. This study aimed to observe the daily ICP of healthcare workers in RCH settings. METHODS: An observational study was conducted to observe daily ICP among healthcare workers in private and subsidized RCHs. Each RCH was separated into different units based on the location (common area and bedroom area) and nature of residents for successive days. The ICP episodes were observed until 200 opportunities in each unit. The ICP episodes were recorded by an electronic tool called "eRub," which is an ICP checklist based on international guidelines. RESULTS: The most frequent observed ICP episodes were hand hygiene (n = 1053), the use of gloves (n = 1053) and respiratory protection (n = 1053). The overall compliance of hand hygiene was poor, with only 15% of participants performing this during the "five moments for hand hygiene." Furthermore, the observations showed that 77.9% improperly performed the use of gloves, and 31.8% failed to wear a mask during the care provision for the elderly. However, the results showed that most healthcare workers can wear the mask in a proper way when they should. Generally, the personal care workers were the worst in terms of hand hygiene and use of gloves compared with the other types of healthcare workers. CONCLUSIONS: Despite the fact that the practice of hand hygiene, the use of gloves, and respiratory protection were the important elements of ICP, overall compliance to these elements was still poor. Personal care workers had the most frequent contact with the residents, but they had the worst compliance rate. Hence, continued monitoring and training among healthcare workers is needed, particularly personal care workers, in this healthcare service setting.


Assuntos
Infecção Hospitalar/prevenção & controle , Fidelidade a Diretrizes/estatística & dados numéricos , Instalações de Saúde , Pessoal de Saúde , Instituição de Longa Permanência para Idosos , Controle de Infecções/métodos , Casas de Saúde , Infecção Hospitalar/epidemiologia , Luvas Protetoras , Desinfecção das Mãos/métodos , Hong Kong/epidemiologia , Humanos , Máscaras , Guias de Prática Clínica como Assunto , Dispositivos de Proteção Respiratória
7.
Contact Dermatitis ; 84(1): 1-14, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33063847

RESUMO

BACKGROUND: The use of alcoholic-based hand rubs (ABHRs) is an important tool for hand hygiene, especially in times of the COVID-19 pandemic. Possible irritant effects of ABHR may prevent their use by persons at risk of infection. METHODS: This systematic review is based on a PubMed search of articles published between January 2000 and September 2019 in English and German, and a manual search, related to the irritation potential of alcohol-based disinfectants restricted to n-propanol (1-propanol) and its structural isomer isopropanol (isopropyl alcohol, 2-propanol). RESULTS: The majority of the included studies show a low irritation potential of n-propanol alone. However, recent studies provide evidence for significant barrier damage effects of repeated exposure to 60% n-propanol in healthy, as well as atopic skin in vivo. The synergistic response of combined irritants, (ie, a combination of n-propanol or isopropanol with detergents such as sodium lauryl sulfate) is greater, compared with a quantitatively identical application of the same irritant alone. CONCLUSION: While recent studies indicate a higher risk of skin irritation for n-propanol and isopropanol than reported in the past, this risk still seems to be lower than that for frequent handwashing with detergents, as recommended by some to prevent COVID-19 infections.


Assuntos
1-Propanol/efeitos adversos , 2-Propanol/efeitos adversos , Dermatite Irritante/etiologia , Anti-Infecciosos Locais/efeitos adversos , Desinfecção das Mãos/métodos , Humanos
8.
Ned Tijdschr Geneeskd ; 1642020 11 05.
Artigo em Holandês | MEDLINE | ID: mdl-33331733

RESUMO

Because of COVID-19 outbreak people wash more often their hands and use more often and longer disposable gloves. The natural skin barrier function is damaged by washing hand or using disinfectants, because of this allergic and irritative hand eczema develops. Allergic hand eczema can be caused by materials which people work with, and by ingredients of creme and soap, but also by wearing gloves. To prevent hand eczema, good protection of the hands is essential. It is very important to have knowledge about different gloves to inform (health) worker about wearing gloves in the proper way.


Assuntos
Eczema , Luvas Protetoras , Desinfecção das Mãos/métodos , Higienizadores de Mão/efeitos adversos , Prevenção Primária/métodos , Sabões/efeitos adversos , /epidemiologia , Eczema/etiologia , Eczema/prevenção & controle , Luvas Protetoras/efeitos adversos , Luvas Protetoras/classificação , Mãos , Humanos , Inquéritos e Questionários
9.
Eur Rev Med Pharmacol Sci ; 24(21): 11432-11439, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33215466

RESUMO

OBJECTIVE: Soap has been used by humankind since ancient times and was probably already known to the Sumerians. It is a fatty acid salt obtained from the reaction of a strong base with a fatty substance of animal (tallow) or plant origin (oil). This reaction is called saponification. Syndets, on the other hand, are much more recent and have been in use for about a century. In the case of liquid syndets, they are mainly alkyl sulphates and their derivatives alkyl ether sulphates while isethionates and sarcosinates are more commonly found in solid syndets. Synthetic soaps and detergents are surfactants and, as such, they have detergent properties. The way soap works accounts for its antimicrobial properties. Thanks to its amphiphilic structure, it is able to interact with the lipid membranes of microorganisms (viruses, bacteria, etc.) and inactivate them. In this coronavirus pandemic period, health authorities worldwide recommend hand washing with soap and water. We therefore wanted to provide a summary of the chemical characteristics and applications of soaps, on the one hand, and synthetic detergents, on the other. Soap is not the only product used for hand hygiene and, given the current situation, alternatives are complex and varied.


Assuntos
Anti-Infecciosos/farmacologia , Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus/prevenção & controle , Detergentes/farmacologia , Desinfecção das Mãos/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Sabões/farmacologia , Anti-Infecciosos/química , Anti-Infecciosos/normas , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/normas , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Detergentes/química , Detergentes/normas , Desinfecção das Mãos/normas , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Sabões/química , Sabões/normas
10.
Saudi Med J ; 41(11): 1263-1269, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33130849

RESUMO

OBJECTIVES: To assess the role of the Coronavirus Disease 2019 (COVID-19)  pandemic in improving personal hygiene in Saudi Arabia. Methods: We administered a questionnaire distributed online between 19 and 28 May 2020 to determine alterations in personal hygiene practices during this pandemic compared to the pre-pandemic phase. Results: We included 211 respondents from the Kingdom of Saudi Arabia (KSA) in this study.  Improvement at different levels was detected in all examined personal hygiene items compared to the pre-pandemic stage. The percentages of respondents who always washed their hands after coming back home (34.1%), used soap to wash their hands (58.8%), used a hand sanitizer outside (5.2%), wore a face masks while outside (1.4%) and washed their hands before preparing and/or eating food (74.9%) was increased before the pandemic to 89.6%, 90%, 63.5%, 59.2% and 89.1% during the pandemic, respectively. The percentage of respondents who never shake hands with people they know increased from 0% before the pandemic to 62.6% during the pandemic. The mean duration of washing hands with soap significantly increased from 13.31 seconds before the pandemic to 28.01 seconds during the pandemic (p less than 0.0001). CONCLUSION: The COVID-19 pandemic resulted in a noticeable improvement in the personal hygiene habits in Saudi Arabia mainly those related to COVID-19 prevention.


Assuntos
Infecções por Coronavirus/prevenção & controle , Desinfecção das Mãos/métodos , Higiene/normas , Controle de Infecções/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Adulto , Controle de Doenças Transmissíveis/métodos , Infecções por Coronavirus/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Papel (figurativo) , Arábia Saudita , Inquéritos e Questionários
12.
ACS Chem Neurosci ; 11(20): 3188-3190, 2020 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-33006886

RESUMO

SARS-CoV-2 is a positive stranded-RNA human viral pathogen that attacks the central nervous system (CNS), causing interminable diseases. Although alcohol-based hand sanitizers (ABHS) control the widespread transmission of such pathogens through dermal contact, excessive exposure to alcohol mists and vapors causes CNS disorders, apart from skin infections and negative impacts on the useful microbiome. Herein, we propose bentonite paste, which interacts strongly with different +RNA viruses such as SARS-CoV-2/poliovirus, for dermal sanitization. Repeated hand cleansing with bentonite paste not only provides complete protection against any viruses but also improves the skin condition. The proposed method is useful for contact isolation and as a strict infection control tool in hospital settings and in public.


Assuntos
Bentonita/farmacologia , Infecções por Coronavirus/prevenção & controle , Desinfecção das Mãos/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Betacoronavirus , Argila , Humanos
13.
Health Educ Res ; 35(5): 353-361, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32951026

RESUMO

Proper training on the preventive measures against COVID-19 among health-care workers is crucial for mitigating the spread of viral infection. The present study evaluated the efficacy of a brief web-based module on the practice of hand hygiene and respiratory etiquette among respective health-care workers. A comparative study was conducted with a total of 500 participants. A self-reported questionnaire was used for both pre- and post-intervention evaluation. The post-intervention assessment was conducted 1-2 weeks following the intervention. The difference in the practice of hand hygiene and respiratory etiquettes during work hours was recorded. We found that the intervention resulted in an evident difference in the use of alcohol-based hand sanitizer by the participating doctors before examining the patient. Interns showed a much higher propensity to wash their hands for at least 20 s, relative to other health-care workers. The difference between pre- and post-intervention handwashing for >5 times/day was 6.5% in females and 4.5% in males. In short, the study was able to demonstrate that a web-based health education module is an effective tool for the education and promotion of preventative measures in hospital setups, which may ultimately aid in halting the spread of COVID-19 among health-care workers.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Educação em Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Adulto , Feminino , Desinfecção das Mãos/métodos , Higiene das Mãos , Pessoal de Saúde , Humanos , Internet , Masculino , Autorrelato , Inquéritos e Questionários , Adulto Jovem
19.
S Afr Med J ; 110(4): 291-295, 2020 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-32657740

RESUMO

BACKGROUND: South Africa (SA) and other countries worldwide are experiencing extreme drought conditions. Since the start of the drought in SA, many ways of saving water have been proposed and innovative water-saving mechanisms have become part of the lives of communities. We investigated water use during surgical scrubbing procedures and possible interventions to reduce water consumption. OBJECTIVES: To compare water use during surgical hand preparation before and after the implementation of specific water-saving interventions. METHODS: This was a non-randomised controlled study, following a before-and-after design, of orthopaedic theatre personnel scrubbing for surgical cases at Tygerberg Hospital, Cape Town. A control (CON) group (n=32) was established to observe standard practice for baseline measurements including total amount of water used, wash time and water flow rate during surgical hand preparation. After this, three interventions were randomly assigned to a single theatre each, where the same variables were measured. Intervention AS entailed using an alcohol scrub (n=18), intervention SN (n=12) had a dedicated assistant to open and close taps during scrubbing, and intervention SW (n=12) made use of adjusted tap levers to allow the surgeon to open and close taps more easily. Analysis of variance was used to detect global differences between groups, and Tukey's post hoc test was performed to detect differences between groups. RESULTS: Significant differences in water use (p<0.001), wash time (p<0.001) and water flow rate (p<0.001) were observed between the four groups. On average, the AS group used the least water per scrub (mean (standard deviation) 0.82 (1.43) L), which was significantly less than the CON (5.56 (1.79) L; p<0.001) and SN (2.29 (0.37) L; p=0.002) groups. The amount of time spent per scrub was significantly less in the AS group than all the other groups (p<0.05 for all comparisons), with no significant differences observed between the CON, SN and SW groups independently. The SW group had the lowest mean water flow rate (0.73 (0.22) L/min), which was significantly lower than the CON group (2.19 (0.84) L/min; p<0.001). The flow rate of the SN group (1.36 (0.66) L/min) was also significantly lower than that of the CON group (p=0.005). CONCLUSIONS: Water use during surgical hand preparation can easily be reduced by implementing easy and effective interventions. The practicality of interventions may differ between institutions, and their acceptance by surgical staff is important to ensure compliance. However, ensuring that alternative scrubbing options are available to surgical staff would equate to substantial savings over time.


Assuntos
Conservação dos Recursos Hídricos/métodos , Secas , Desinfecção das Mãos/métodos , Higienizadores de Mão , Pessoal de Saúde , Estudos Controlados Antes e Depois , Humanos , Ortopedia , África do Sul , Fatores de Tempo , Água
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