Clean Hands - Safe Animals

Key points on Hand Sanitation

•  Hand sanitation is a key pillar of infection control
• Favour use of hand rubs
  • when hands are not visibly soiled
  • use products with >70% methylated spirits
  • don't forget the dorsum of your thumbs and inter-digital spaces
  • 30 seconds application is sufficient (meaning product needs to remain wet on your skin for that time)
  • a volume of at least 2-3ml is needed to achieve this (small versus big hands)
• Hand wash
  • washing hands when visibly soiled
  • in case contact with oocysts or spores is expected (cryptosporidium)
  • do not "overwash"
  • use a neutral skin friendly soap, there is no need or benefit to medicated soaps (chlorhexidine or iodine) - only down sides in the long run
• Skin care is an essential part of good hand hygiene
  • medicated soaps can induce allergies and dermatitis, so does "overwashing"
  • alcohol rubs less irritant to your skin than washing with soap and water
  • use skin moisteners frequently
• Although every reasonable person understands the necessity of proper hand hygiene, compliance remains largely unsatisfactory

The full version

Hand hygiene has been a research and teaching interest of Denis Verwilghen, University of Sydney, Australia, for a long time, so he has compiled further information to answer some of the questions he has received on what to do and how to do it:

As Ignaz Semmelweis discovered many years ago, hand hygiene plays an important role in the prevention of transmission of disease. Although hugely successful; Semmelweis' discovery directly confronted with the beliefs of science and medicine in his time. His colleagues and other medical professionals refused to accept his findings mainly because they did not find it convincing that they could be responsible for spreading infections. Still now this is known as the Semmelweis paradox or effect:  a metaphor for the reflex-like tendency to reject new evidence or new knowledge because it contradicts established norms, beliefs, or paradigms

WHO recognizes Hand Hygiene as the first fundamental pillar in prevention of infectious diseases.

Whereas the “5 moments of hand hygiene – Clean Hands Safe Animals” are (or should be) anchored in our day-to-day routines to prevent spread of nosocomial infections in our practice of veterinary medicine,new challenges in our professional and private life have recently come along bringing the importance of proper hand hygiene to light in our daily personal routines and social interactions.

As mentioned proper hand sanitation is undebatably necessary, yet here are some culprits to be taken into account. Particularly for us as healthcare workers that are/can be considered “wet workers” since our profession requires us to frequently wash and disinfect our hands. 

Repeated hand washing deplenishes the protective layers of your skin and causes a rapid shift in your skin microbiome, eventually leading to hand eczema, or what can be regarded as occupational dermatitis in our profession. Using medicated soaps (those that contain ingredients like chlorhexidine, iodine, triclosan,…) are far more irritant than neutral pH soaps. The added benefit of the antiseptic is also hugely debatable for a sanitary wash, yet the contraindications are clear. So whereas the short immediate benefit of washing cannot be debated, the long term consequences can be devastating for people working in our sector. First of all, because of the eczema development but also because hands with skin conditions can be difficult to disinfect in the first place. So the entire purpose becomes defeated.

Luckily there are solutions. 

Whereas it may sound strange, alcohol solutions are in fact much less irritant to the skin, than water and soap. As the protective fat layers, although being dissolved during the rubbing process will not be washed away, but instead reincorporated in the skin when drying. Also, those products, if of sufficient quality, do contain emollients.

In any case, regular use of hand moisturisers and hand creams is beneficial to avoid the downsides of frequent sanitation. It is not the quantity of application here that will matter, rather the frequency. Thick application of cream on your hands before you go to bed is likely to only end up on your sheets or on your partner. Instead apply small quantities as often as you can.

The downside of hand sanitizers by rubbing is that their efficacy is very technique dependent. Much more than that of hand washing.  Areas as the dorsum of the thumb, the interdigital spaces and tip of fingers are often missed during application. 

This video shows proper application of a hand rub. 

Another one is that they may not be efficient to all pathogens we are encountering, particularly not those seen in the veterinary environment. If there is a risk of cryptosporidium contact, or any other oocyst forming bug or spores of any kind. Hand washing and thoroughly drying is needed to be safe. In this case it is the mechanical removal (the solution to pollution is dilution) and drying that will be important, not the actual disinfection component.

Not all over the counter hand sanitizers do what they say. There are norms for efficacy testing. A good guideline is to check whether or not the product you have is conform the prEN1500 norm or similar. And in the current case of COVID-19, the coronavirus being an enveloped virus (lipophilic) it is actually very sensitive to alcohol sanitizers as long as they contain a volume % over 70. Isopropanol based formulations have better activity against coronavirus. In case of non-enveloped viruses, ethanol based products >85% are recommended (for our dog lovers with parvo).

With the shortage of products in mind during this crisis, some have opted to go the DIY way. Concocting some alcohol based recipes found online. The WHO has two published formulations, one based on ethanal the other on isopropanol and a mix of hydrogen peroxide, water and glycerine. Whereas both original recipes have shown to be efficient against corona virus, they failed to pass the hygienic 30 seconds prEN 1500 testing (60 seconds rub needed) and surgical preparation prEN 12791. Modifications to the alcohol content of the original recipe are therefore needed to guarantee efficacy in the currently accepted and recommended time frames of disinfection (30 seconds for hygienic – 90 seconds for pre-surgical preparation). Due to increased community and healthcare use, Germany seems to have accepted pharmacists to “brew” alcohol sanitizers according to the WHO recipe, yet only for community use and not within healthcare.

In case you have not yet seen them. The posters on hand hygiene from the veterinary hand hygiene initiative are available for you:

• Small animal format 
• Equine Format 
• Exotics format 
• Bovine Format 
• Surgical hand asepsis

Additionally for a good review on disinfection of corona on inanimate objects, see this recent one by Kamp et al.