The Open Microbiology Journal




ISSN: 1874-2858 ― Volume 13, 2019
RESEARCH ARTICLE

Hand Washing Before and After Applying Different Hand Hygiene Techniques in Places of Public Concern in Tripoli-Libya



Mohamed R. Alsagher*, Sally A. Soudah, Asma E. Khsheba, Sara M. Fadel, Masara A. Dadiesh, Maram A. Houme, Aya S. Eshagroni, Fadia F. Alosta, Soad M. Almsalaty
Faculty of Pharmacy, Department of Microbiology & Immunology, University of Tripoli, Tripoli, Libya

Abstract

Background:

Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens. There is substantial evidence that incidence of hospital acquired infections is reduced by applying hand antisepsis. Regarding hand hygiene and public concern, hand washing has revealed that 85% of the observed adults wash their hands after using public toilets.

Objective:

To compare the efficacy of hand rubbing with an alcohol based solution versus conventional hand washing with antiseptic and non-antiseptic soaps in reducing bacterial counts using different hand hygiene techniques.

Methods:

Ninety-three volunteers took part in this study; 57 from Tripoli Medical Center (TMC); 16 from school; 11 from bank; and 9 from office. All volunteers performed six hand hygiene techniques, immediately before and after a volunteer practice activity: hand washing with non-antiseptic soap for 10 and 30 second (s); hand washing with antiseptic soap for 10, 30 or 60 s; and alcohol-based hand rub. A total of 864 specimens were taken: 432 before and 432 after volunteer's hand hygiene. The fingertips of the dominant hand for each volunteer were pressed on to agar for culture before and after each hand hygiene technique. Plates were incubated at 37oC, and colony-forming units were counted after 48 hours and pathogenic bacteria were identified.

Results:

Results showed that 617 specimens (71.41%) were positive for bacterial growth. 301 (48.78%) were from TMC, 118 (19.12%) were from office; 107 (14.34%) were from school and 91 (14.75%) were from bank.

Conclusion:

Both antiseptic and non–antiseptic soaps did not work properly in reducing bacterial counts of worker’s hands at all places of study, but significantly improved by an application of alcohol based gel.

Keywords: Hand hygiene, Hand washing, Hospital acquired infections, Microbial contamination, Alcohol based gel.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 12
First Page: 364
Last Page: 375
Publisher Id: TOMICROJ-12-364
DOI: 10.2174/1874285801812010364

Article History:

Received Date: 13/8/2018
Revision Received Date: 15/11/2018
Acceptance Date: 17/11/2018
Electronic publication date: 30/11/2018
Collection year: 2018

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© 2018 Alsagher et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Faculty of Pharmacy, Department of Microbiology & Immunology, University of Tripoli, P.O. Box 13645, Tripoli, Libya, Tel: +218 91 329 3623 Fax: +218 21 462 7798;; E-mail: alsagher2002@yahoo.co.uk




1. INTRODUCTION

Hand washing is the first line of defence and is one of the oldest methods of preventing the spread of disease. Public health officials pay attention to the Health Care Workers (HCWs) in hospitals and in places related to human activity by urging people to wash and/or hygiene their hands more frequently to fight occurring of infectious diseases. In terms of definition, hand washing is a process of hand cleaning using water and/or soap for the purpose of physically or mechanically removing dirt and organic material. By contrast hand hygiene is a general term referring to any action of hand cleansing for the purpose of reducing or inhibiting the growth of microorganisms through the application of an antiseptic hand rub or through antiseptic hand washing [1Guzewich J, Ross MP. Evaluation of risk related to microbiological contamination of ready-to-eat foods by food preparation workers and the effectiveness of interventions to minimize those risks 1999.].

One of the most important steps in avoiding getting sick and preventing spread of microbes to others is by keeping hands clean. Neglecting washing hands with soap and clean running water will lead to spread many types of diseases. Centres for Disease Control and Prevention (CDC) [2Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999; 5(5): 607-25.[http://dx.doi.org/10.3201/eid0505.990502] [PMID: 10511517] ], revealed that almost 50% of all foodborne illness outbreaks occur due to failing to wash or insufficiently washing hands. A review from 1975 to 1998 showed that unwashed hands of infected food workers are responsible for transmitting pathogens on food and resulting in 93% of the foodborne disease outbreaks [2Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999; 5(5): 607-25.[http://dx.doi.org/10.3201/eid0505.990502] [PMID: 10511517] , 3Borchgrevink CP, JaeMin Cha, SeungHyun K. Hand washing practice in a college town environment. J Environ Health 2013; 75(6): 18-24.[PMID: 23621052] ]. Additionally, diarrheal disease risks can be reduced by more than 40% when hands washed with soap and that hand washing interventions could save one million lives annually [4Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A. Hygiene: New hopes, new horizons. Lancet Infect Dis 2011; 11(4): 312-21.[http://dx.doi.org/10.1016/S1473-3099(10)70224-3] [PMID: 21453872] ].

Thinking Wet, Lather, Scrub, Rinse, and Dry are the five simple and effective steps of hand washing like a “do-it-yourself” vaccine. Removing microbes, avoiding getting sick, and preventing the spread of microbes to others can be successfully achieved by applying regular hand washing, particularly before and after certain activities [5Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: A meta-analysis. Am J Public Health 2008; 98(8): 1372-81.[http://dx.doi.org/10.2105/AJPH.2007.124610] [PMID: 18556606] ]. In this respect, the development in the guidance for effective hand washing and use of hand sanitizer was almost based on data from a number of studies [4Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A. Hygiene: New hopes, new horizons. Lancet Infect Dis 2011; 11(4): 312-21.[http://dx.doi.org/10.1016/S1473-3099(10)70224-3] [PMID: 21453872] , 6Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev 2008; 1(1): CD004265.[PMID: 18254044] , 7Palit A, Batabyal P, Kanungo S, Sur D. In-house contamination of potable water in urban slum of Kolkata, India: A possible transmission route of diarrhea. Water Sci Technol 2012; 66(2): 299-303.[http://dx.doi.org/10.2166/wst.2012.177] [PMID: 22699333] ].

Since a decade ago approximately in 2002 when CDC published its “Guideline for hand hygiene in Health-Care Settings, and the question that still excite is: Does all that hand washing and gelling work?

Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens.

Although cross infection via the hands of health care personnel is responsible for an estimated 20% to 40% of nosocomial infections, still the patient’s endogenous flora considered as a major source of nosocomial pathogens. Noncompliance with hand hygiene, however, remains a major problem in hospitals, and compliance with hand washing in hospital environments is generally less than 50% [8Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: A multimodal intervention and impact on nosocomial infection. Pediatrics 2004; 114(5): e565-71.[http://dx.doi.org/10.1542/peds.2004-1107] [PMID: 15492360] ].

The intensity of environmental contamination is strongly correlated with the frequency of positive personnel hand culture [11World Health Organization (WHO). WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary 2006.]. For example, 0% to 25% environmental contamination represents 0% hand contamination, 8% when environmental contamination was 26% to 50%, and when environmental contamination was greater than 50% the hand contamination was 36%.

There is a substantial evidence that incidence of Hospital Acquired Infections (HAIs) is reduced by applying hand antisepsis [9 Health Canada: Infection Control Guidelines: Hand washing, Cleaning, Disinfection and Sterilization in Health Care. Ottawa, Canada; Health Canada, Laboratory Centre for Disease Control Bureau of Infectious Diseases, Nosocomial and Occupational Infections. Dec. 1998.-24Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003; 31(2): 109-16.[http://dx.doi.org/10.1067/mic.2003.15] [PMID: 12665745] ]. Therefore, patient’s safety is fundamentally ensured by the action of hand hygiene as a process of care in a timely and effective manner. However, unacceptably low compliance with hand hygiene is to be taken as universal in health care [25Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: A multimodal intervention and impact on nosocomial infection. Pediatrics 2004; 114(5): e565-71.[http://dx.doi.org/10.1542/peds.2004-1107] [PMID: 15492360] ]. This contributes to low number of transmission microbes capable of causing HAIs. However, reduction in HAIs can be successful achieved by betteradherence to hand hygiene guidelines and policies [26Won SP, Chou HC, Hsieh WS, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004; 25(9): 742-6.[http://dx.doi.org/10.1086/502470] [PMID: 15484798] -32Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. J Hosp Infect 2004; 58(1): 42-9.[http://dx.doi.org/10.1016/j.jhin.2004.04.021] [PMID: 15350713] ].

Recently, new approaches have been introduced despite improvements in understanding of the epidemiology of hand hygiene compliance [33El Shafie SS, Alishaq M, Leni Garcia M. Investigation of an outbreak of multidrug-resistant acinetobacter baumannii in trauma intensive care unit. J Hosp Infect 2004; 56(2): 101-5.[http://dx.doi.org/10.1016/j.jhin.2003.09.024] [PMID: 15019220] , 34Sartor C, Jacomo V, Duvivier C, Tissot-Dupont H, Sambuc R, Drancourt M. Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap. Infect Control Hosp Epidemiol 2000; 21(3): 196-9.[http://dx.doi.org/10.1086/501743] [PMID: 10738989] ]. A group of international professionals from the Centers for Disease Control and Prevention, the Healthcare Infection Control Practices Advisory Committee, the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology have developed guidelines for hand hygiene in healthcare settings [35Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005; 165(3): 302-7.[http://dx.doi.org/10.1001/archinte.165.3.302] [PMID: 15710793] ] and anticipated that these guidelines should improve the standards and practice in healthcare settings. Unfortunately, it has been always documented in several literature studied that the importance of hand hygiene is not sufficiently recognized HCWs [36Passaro DJ, Waring L, Armstrong R, et al. Postoperative Serratia marcescens wound infections traced to an out-of-hospital source. J Infect Dis 1997; 175(4): 992-5.[http://dx.doi.org/10.1086/514008] [PMID: 9086167] -38] and compliance with recommended practices is unacceptably low [33El Shafie SS, Alishaq M, Leni Garcia M. Investigation of an outbreak of multidrug-resistant acinetobacter baumannii in trauma intensive care unit. J Hosp Infect 2004; 56(2): 101-5.[http://dx.doi.org/10.1016/j.jhin.2003.09.024] [PMID: 15019220] -46Graham M. Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990; 18(2): 77-81.[http://dx.doi.org/10.1016/0196-6553(90)90085-7] [PMID: 2337258] ]. Moreover, as the average level of compliance with hand hygiene recommendations is low, also the time spent is usually insufficient. An observational studies showed that the duration time of hand washing or hygienic hand wash spent by HCWs varies from few seconds to more than a minute, and the average is between 4.7 and 24 seconds [35Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005; 165(3): 302-7.[http://dx.doi.org/10.1001/archinte.165.3.302] [PMID: 15710793] ]. Despite this short period of washing time, HCWs often fail to cover all surfaces of their hands and fingers [47Taylor LJ. An evaluation of handwashing techniques-1. Nurs Times 1978; 74(2): 54-5.[PMID: 622326] ] and to use an effective technique of hand hygiene, even under observation [48van den Broek PJ, Verbakel-Salomons EMA, Bernards AT. Quantity versus quality of hand hygiene. J Hosp Infect 2001; 49(4): 297-8.[http://dx.doi.org/10.1053/jhin.2001.1103] [PMID: 11740882] ].

Investigations related to outbreaks have suggested an existing correlation between infections and understaffing or overcrowding which consistently linked with reduced compliance with hand hygiene practices [49Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17(3): 150-8.[http://dx.doi.org/10.2307/30142373] [PMID: 8708352] -51Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. J Hosp Infect 1999; 43(2): 109-13.[http://dx.doi.org/10.1053/jhin.1999.0246] [PMID: 10549310] ]. Other investigation showed that transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) considered as a risk factor in an Intensive Care Unit (ICU) [52Grundmann H, Hori S, Winter B, Tami A, Austin DJ. Risk factors for the transmission of methicillin-resistant Staphylococcus aureus in an adult intensive care unit: Fitting a model to the data. J Infect Dis 2002; 185(4): 481-8.[http://dx.doi.org/10.1086/338568] [PMID: 11865400] ].

Larson and colleagues [53Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 2000; 26(1): 14-22.[http://dx.doi.org/10.1080/08964280009595749] [PMID: 10971880] ] documented that the prevalence of nosocomial infections decreased as HCWs’ compliance with recommended hand hygiene measures improved. Top hospital management and medical and nursing leaders provided active support for a culture change, highlighting and enforcing the expectation for hand hygiene compliance for all HCWs.

Regarding hand hygiene and toilets as an example of a place of public concern related to human activity, an investigation study revealed that 85% of the observed adults wash their hands after using public toilets [54Survey of hand washing behaviour (trended) 2010.]. This habit of washing hands increased from 77% to 83% in years 2005 to 2007 respectively [55].

A study focusing on gender as a contribution factor in hand washing practices showed that, women usually wash their hands more frequently than men. The percentage of hand washing for women is 83%, whereas only 74% was recorded for men, as it had been observed in a study carried out by American Society for Microbiology in 2003 [56]. Women showed to be consistently wash their hands more than men during a multiyear study across public attractions. 90%, 88%, and 93% were the average observed hand washing percentages for women in the years 2005, 2007, and 2010 respectively. The equivalent percentages for men were 75% in 2005, 66% in 2007, and 77% in 2010 [54].

Regardless of simplicity of hand washing, it is seriously important in schools, where lots of things such as desks, books, pencils, food and even germs are shared. However without adapting a proper hand cleaning regime, students and their families and friends will get quickly infected by germs. A study involved 120 secondary school students [56] revealed that 58% of female students washed their hands after using toilets and only 28% of them used soap. In contrast 48% of male students do so with only 8% of them used soap [57].

In a university campus public toilets a study focusing on the effect of introducing hand washing sign to encourage hand washing found that 61% of women washed their hand regardless to the presence of sign, this washing rate climbed to 97% in the presence of sign, while the hand washing rate for men was 37% without sign and this rate fall to 35% when a sign is displayed [58]. In other study carried out in British highland washing service station toilets, showed that 65% of women and 32% of men washed their hands, but after displaying electronic screen sign the hand washing rate increased to as much as 71% for women and 35% for men [59].

2. METHODS

2.1. Setting and Study Design

This study was a prospective microbiological evaluation. The study was performed on volunteers from four different places of public concern in city of Tripoli, Libya namely; TMC Teaching Hospital, Zawiat El-Dehmani School, El-Wahda Bank, and Sook El-Juomah Education Bureau. Three units in TMC were studied: the surgical unit, the medicine unit, and the dermatology unit. All volunteers were screened for hand contamination within 24 hours twice per week. Colonized volunteers were placed under contact precautions. Each volunteer performed six hand hygiene techniques in random order: hand hygiene with non-antiseptic soap for 10 and 30 second (s); hand washing with antiseptic soap for 10, 30 or 60 s; and hand rubbing with alcohol-based hand antiseptic. The six hand hygiene techniques were typically performed over four week by each volunteer.

The non-antiseptic soap, the antiseptic soap and the alcohol-based antiseptic used in this study are listed in Table 1. Before each monitoring period, a selective agar media were used (Nutrient agar NA; MacConkey agar MCA; Blood agar BA & Mannitol salt agar MSA), each volunteer in this study was invited to informed consent. The information included; age, sex, job category, health condition of the hands and use of antibiotics in the past month were collected from each volunteer.

Table 1
Types of disinfectants used in this study.


2.2. Microbiological Techniques

After a procedure, three fingertips on the dominant hand of the volunteer were pressed on the surface of agar plate for approximately 15 second. In order to obtain identical conditions for each specimen, the agar was applied on to the fingers by the help of the students to obtain identical pressure. The hand hygiene technique was then performed, and a second imprint of the fingertips was obtained one minute later. Plates were incubated at 37oC under aerobic conditions, and Colony-Forming Units (CFUs) were counted after 48 hours. The maximum count was 300 CFUS; beyond this figure, it was considered too many to count (TMTC). Potential pathogenic bacteria from transient were identified using standard microbiological techniques (Gram staining biochemical tests) and Phoenix reading using Phoenix machine (BD Phoenix ID/ASTBD Diagnostic, Dickinson and Company, Sparks, MD 21152-0999) at Diseases Control Centre in Tripoli-Libya.

3. RESULTS

A total of 93 volunteers took part in the study Table 2; 18 from TMC surgery unit (5 physicians, 7 nurses, 3 patients, and 3 health workers HCWs); 19 from TMC medicine unit (8 physicians, 5 HCWs, 4 patients, and 2 nurses); 20 from TMC dermatology unit (4 physicians, 13 nurses, and 3 patients) 16 from school (7 teachers, 5 students, 2 officers, 1 security man, and 1 kitchen worker); 11 from bank (6 accountants, 3 security men, 1 cleaner, and 1 kitchen worker); and 9 from office (7 employees, 1 cleaner, and 1 kitchen worker). There were 53 women and 21 men, with average age of 13-50 years. All volunteers performed six hand hygiene techniques.

Table 2
Number and characterization of volunteers involved in the study.


In an investigation carried out by gram staining technique on different places of the study, the number and distribution of identified bacteria (as gram positive or gram negative) revealed that a total of 874 specimens were collected: 437 before and 437 after hand hygiene. 627 (71.74%) were cultured-positive (i.e. growth) and 247 (28.26%) were cultured-negative (no growth). 507 (80.86%) of positive-culture specimens were gram positive bacteria, and 120 (19.14%) were gram negative bacteria. 305 (48.64%) out of gram positive-culture specimens were from TMC [106 (34.75%) from medicine unit (83.02% gram positive 16.98% gram negative bacteria); 101 (33.11%) from surgery unit (75.25% gram positive & 24.75% gram negative bacteria); 94 (30.82%) from dermatology unit (85.11% gram positive & 14.89% gram negative bacteria); 2 (0.66%) from washing water (100% gram negative bacteria], 118 (18.82%) were from office (81.36% gram positive & 18.64% gram negative bacteria); 107 (17.07%) were from school (79.44% gram positive & 20.56% gram negative bacteria); 91 (14.51%) were from bank (83.52% gram positive & 16.48% gram negative bacteria) and 6 (0.96%) were from environmental air (100% gram positive bacteria).

A total of 44 potential pathogenic bacterial strains were isolated and identified. These bacterial strains are listed in Table 3. 21 bacterial strains were isolated from TMC; 6 from surgical unit; 4 were Methicillin Resistant Strains MSR; (2 Staphylococcus aureus and 2 Staphylococcus capitis), the other two namely Escherichia coli and Enterococcus spp. were isolated from water used for washing, while 7 bacteria were isolated from medicine unit, 3 of them were MRS (Staphylococcus aureus, Staphylococcus haemolyticus, Staphylococcus capitis), the others were Pasteurella aerogene, Serratia marcescens, Morganella morganii and Streptococcus porcinis. In dermatology unit 6 bacterial strains were isolated namely; Aeromonas veroni, Aeromonas veroni, Micrococcus lylae & Aeromonas sorbia. On the other hand, 8 bacterial strains were isolated from school (2 Proteus vulgaris, 2 Staphylococcus aureus, Morganella morganii, Pseudomonas species, Staphylococcus epidermidis, & Aeromonas veronii). In addition 5 bacterial strains were isolated from bank (Staphylococcus aureus, Staphylococcus capitis Proteus pannier, Proteus vulgaris & Aeromonas veronii) and lastly 7 strains were isolated from the environmental air of all places [54Survey of hand washing behaviour (trended) 2010.-69Weber DJ, Sickbert-Bennett E, Gergen MF, Rutala WA. Efficacy of selected hand hygiene agents used to remove Bacillus atrophaeus (a surrogate of Bacillus anthracis) from contaminated hands. JAMA 2003; 289(10): 1274-7.[http://dx.doi.org/10.1001/jama.289.10.1274] [PMID: 12633189] ]

Table 3
Number and distribution of samples tested from different places of the study.


4. DISCUSSION

The study was carried out in four different places of public concern (hospital, school, bank and office) in Tripoli city-Libya, during the routine practices of volunteers. High rate of contamination was demonstrated with potential nosocomial pathogens. Approximately, 70% of specimens taken from volunteer's hands (especially HCWs) were found contaminated with at least one pathogen during their routine work. These findings agree with previous studies concerning hand hygiene which indicated that, the frequent contamination of HCWs hands [70Albert RK, Condie F. Hand-washing patterns in medical intensive-care units. N Engl J Med 1981; 304(24): 1465-6.[http://dx.doi.org/10.1056/NEJM198106113042404] [PMID: 7248048] -74Khodavaisy S, Nabili M, Davari B, Vahedi M. Evaluation of bacterial and fungal contamination in the health care workers’ hands and rings in the intensive care unit. J Prev Med Hyg 2011; 52(4): 215-8.[PMID: 22442928] ].

The results have shown that hand rubbing with an alcohol-gel is more effective than hand washing with either antiseptic soap or non-antiseptic soap in reducing bacterial contamination of volunteer's hands. This was might be due in part to the inadequate time spent in hand washing conventionally, high bacterial contamination of washing water (especially in TMC), and microbial contamination of the environmental air.

Several studies in which hands were artificially contaminated with different microorganisms have shown that hand rubbing with alcohol based products is more effective than hand washing with non-antiseptic soap or antiseptic soap [75Austin DJ, Bonten MJM, Weinstein RA, Slaughter S, Anderson RM. Vancomycin-resistant enterococci in intensive-care hospital settings: Transmission dynamics, persistence, and the impact of infection control programs. Proc Natl Acad Sci USA 1999; 96(12): 6908-13.[http://dx.doi.org/10.1073/pnas.96.12.6908] [PMID: 10359812] -89Ayliffe GAJ, Babb JR, Davies JG, Lilly HA. Hand disinfection: A comparison of various agents in laboratory and ward studies. J Hosp Infect 1988; 11(3): 226-43.[http://dx.doi.org/10.1016/0195-6701(88)90101-6] [PMID: 2899107] ]. Most of these studies incorporated supervised hand hygiene techniques to ensure conformity to usual recommendations or at least insisted on the quality of techniques. In this study, these specifications were in some instant difficult to be controlled by the students. Despite these specifications, standard techniques of hand washing were always found to be less efficient than hand rubbing in removing transit contamination on hands. Although this study was designed not to interfere with the actual practice of volunteers in terms of compliance with and quality of hand hygiene, the main objective being to evaluate the efficacy in routine work before and after performing various hand hygiene techniques Table 4.

Table 4
Phoenix identification of bacterial strains isolated from volunteer’s hands.


The results of this study show that hand washing with antiseptic soap was at least as ineffective as washing with non-antiseptic soap. As indicated in Table 5, the reduction of CFUs of volunteer’s hands actually significantly higher after hand rubbing with alcohol gel than after soap washing. In contrast, hand washing with antiseptic soap for 60 second showed an acceptable reduction in CFUs of volunteer’s hands but was not as good as hand rubbing with alcohol based gel. In a study carried out by, Larson et al. found that hand rubbing was equivalent to hand washing with antiseptic soap in reducing hand contamination [11World Health Organization (WHO). WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary 2006.]. However, the contents of a product regarding percentage of alcohol and the type of antibacterial agents are very important factors for its efficacy in reducing hand contamination. A study by Girou et al., showed that hand rubbing products contained 75% alcohol more effective than once contained 61%., also the study added the interference of the method of hand sampling and the types of hand hygiene techniques with the efficacy of hand hygiene techniques [68Girou L. Sabrina Loyeau, patrik legrand, francoise oppein brun-buisson. Efficacy of hand rubbing with alcohol based solution versus standard hand washing with antiseptic soap: Randomised clinical trial. BMJ 2002; 325: 1-5.[http://dx.doi.org/10.1136/bmj.325.7360.362] [PMID: 12098707] ].

Table 5
Bacterial contamination of the hands before and after different hand hygiene techniques.


Regarding duration of washing and effect, previous studies proved that the recommended optimal duration of hand washing is 30 to 60 second. In this study, alcohol hand rubbing and hand washing were actually performed by volunteers for a similar length of time. The 30 second seems sufficient for hand rubbing with alcohol based gel but may not be long enough for hand washing with antiseptic soap and non-antiseptic soap. Most observational studies have shown that hand washing is very rare to be performed for more than 30 second [90Coignard B, Grandbastien B, Berrouane Y, et al. Handwashing quality: Impact of a special program. Infect Control Hosp Epidemiol 1998; 19(7): 510-3.[http://dx.doi.org/10.2307/30141402] [PMID: 9702576] -92Lund S, Jackson J, Leggett J, Hales L, Dworkin R, Gilbert D. Reality of glove use and handwashing in a community hospital. Am J Infect Control 1994; 22(6): 352-7.[http://dx.doi.org/10.1016/0196-6553(94)90034-5] [PMID: 7695114] ], and this study comes in agreement with this finding confirming that 30 second hand washing was ineffective in reducing bacterial contamination of hands. Therefore, the rapid efficacy of alcohol based solutions compared with hand washing, even with an antiseptic agent, is a major argument supporting their use in clinical practice [93Voss A, Widmer AF. No time for handwashing!? Handwashing versus alcoholic rub: Can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18(3): 205-8.[http://dx.doi.org/10.2307/30141985] [PMID: 9090551] ].

5. RECOMMENDATIONS

The use of waterless antiseptic agent is recommended for routine hand hygiene in all clinical situations especially when hands are not visibly soiled. Importantly, antiseptic hand rub has no effect on soil, so visibly soiled hands should be washed with soap and water.

A system change supported by good management would probably be necessary in most hospitals to change a hand hygiene agent, promote and facilitate skin care for HCWs’ hands.

Education especially for HCWs’ hands is of great importance to improve hand hygiene practices and must be promoted at all levels of experience. The potential risks of transmission of microorganisms to patients can be addressed by implementation of proper educational programs towards hand hygiene, as well as potential risks of HCWs colonization or infection acquired from the patient.

Hand washing is simple and particularly important in places related to human activity but very serious, where lots of things are shared for examples; desks, books, pencils, food and even germs. Without proper hand cleaning, a single infection can quickly spread among people.

CONCLUSION

Hand contamination was highest in hospital (TMC), followed by school, then bank and lastly office. The highest hand contamination observed in the hospital can be attributed to the large number of pathogens that usually harbor the hospital’s environment. Both antiseptic and non–antiseptic soaps did not work properly in reducing bacterial counts of worker’s hands at these places, but significantly improved by an application of alcohol based gel. This comes in agreement with previous studies which revealed that; alcohols hygienic hand rub, so-called ‘waterless disinfection’ is significantly more efficient than standard hand washing with non-antiseptic soap and water or water alone [34Sartor C, Jacomo V, Duvivier C, Tissot-Dupont H, Sambuc R, Drancourt M. Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap. Infect Control Hosp Epidemiol 2000; 21(3): 196-9.[http://dx.doi.org/10.1086/501743] [PMID: 10738989] , 35Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005; 165(3): 302-7.[http://dx.doi.org/10.1001/archinte.165.3.302] [PMID: 15710793] ]. Bacterial reduction after hand washing with antiseptic soap (either 10, 30 or 60 seconds) or hand rubbing with alcohol-based gel was significantly greater than that obtained after hand washing with non-antiseptic soap (either 10 or 30 seconds). Therefore results of swabbing technique showed that bacterial contamination occurred on hands before and after hand hygiene procedures in which high chance of contamination (personnel, cotton swab and air) might be occurred.

Reduction in bacterial counts was observed after longer hand washing with antiseptic soap (30 and 60 seconds), but the trends were different after hand washing with non-antiseptic soap (10 and 30 seconds), and antiseptic soap for 10 seconds in which no reduction in bacterial counts was observed and this can be attributed to the water used for hand washing procedures, especially in TMC was found to be highly contaminated. In addition, air contamination was observed in all places of study was another factor affected the hand washing with antiseptic soap and non-antiseptic soap.

The predominant isolated bacteria were from transient flora: Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus capitis, Staphylococcus haemolyticus, Proteus vulgaris, Morganella morganii, and Aeromonas veronii. The specimens obtained after hand hygiene were still culture-positive in many cases of the study places when hand washing applied with non-antiseptic soap for 10, 30 second and antiseptic soap for 10 second. Microbial contamination, especially with MRS bacteria appeared in TMC specimens taken from volunteer’s hands, an environmental air, and washing water suggested a high risk for spreading pathogens and increasing the spread of HAIs, if not properly controlled.

Antibiotic Sensitivity Test (AST) was carried out for some isolated bacterial strains. All strains exhibited resistance against the most of antibiotics.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT OF PUBLICATION

Informed consent were obtained.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We thank all of the people who volunteered to participate in the study, the Technicians in Department of Microbiology and Immunology at Faculty of Pharmacy, University of Tripoli for their valuable help in aspects of microbiological techniques. Gratitude thanks to Diseases Control Centre in Tripoli for providing facilities to identify bacterial isolates using BD Phoenix ID/ASTBD Diagnostic machine.

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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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