1. Systematic Review on the Effectiveness of Handwashing -interim report- Hiroshi Ikai Stephanie Smith Allison McGeer Department of Infection Control, Mount Sinai Hospital

2. Background (1) Hand hygiene is historically one of the most simple yet effective component of infection control activity. Guideline for hand hygiene was published in 2002 by HICPAC/SHEA/APIC/IDSA, where the efficacy of hand hygiene is discussed as removal of microorganisms from hand.

3. Background (2) Clinical effectiveness of hand hygiene for the prevention of nosocomial infections (NI) varies in quantity (effect size) and quality (study design) among studies.

4. Objective (1)To quantify the preventable portion of nosocomial infections by the implementation / reinforcement of handwashing in hospital settings -And its variation across different categories of infection (2) To quantify the impact of handwashing to the society and the health economy -through the systemic review of previous studies

5. Methods(1): data source Systematic database search –Data source MEDLINE EMBASE Cochrane Database of Systematic Reviews CINAHL Secondary citations from above articles Textbook (Mandell, Mayhall) Guidelines (WHO/SHEA/HICPAC)

6. Methods (2): Search Terms Handwashing Handwashing [MeSH] hand was* hand hygiene hand scrub* hand clean* Nosocomial infections Cross infection [MeSH] bloodstream infection surgical site infection urinary tract infection gastrointestinal tract infection CNS infection / meningitis vertical/horizontal transmission Absenteeism absenteeism [MeSH] sick leave leave of absence absen* AND work Health economics Economics, Medical [MeSH] Health Care Costs [MeSH] Cost of Illness [MeSH] burden of illness economic loss Length of Hospitalization length of: stay/hospitalization/admission time until discharge hospital days

7. Methods (3): Title / abstracts review Titles and abstracts are reviewed by at least two people Inclusion criteria: –Comparative studies before and after handwashing program OR reviews that may mention about such studies –Hospital setting –Either retrospective or prospective design –Peer reviewed journals Exclusion criteria: –Article type Short (1-3 pages) review with no original data Editorials Single case reports

8. Methods (4): Data collection Two independent reviewers extract data on: –Study design Before-after / Cohort study / etc. –Patient population Adults / pediatrics / post-surgical –Care setting Ward / ICU / NICU –Target caregivers Physician / nurse / all HCWs +/- visitor / family –Type / content of handwashing program Education program / monitoring / overall process improvements –Outcomes Improvement of adherence to hand hygiene practice Incidence / absenteeism / economics / length of stay

9. Search results Nosocomial infections AbsenteeismEconomicsLength of stay HH-PubMed21814338170 HH-EMBASE791257459 HH-CINAHL339131124 HH-CDSR18421148102 # titles reviewed 2935244166311 # abstracts reviewed 14051266110 # articles in review 32041029 Secondary citations Adding

10. Variations of study design / results

11. Sample meta-analysis Hilburn 2003 Swobada 2004 Lam 2004 Rosenthal 2005

12. Summary Most of current data on the effectiveness of hand hygiene are based on before-after studies. Most studies show effectiveness of hand hygiene for prevention of nosocomial infections. Effect size are variable, with relative risk ranging from 14% to 94%.

13. Next step Systematic review should also be completed for other outcomes, i.e. absenteeism, length of hospital stay, and health economics. There may be a guideline for reporting observational studies in infection control, so that each data can contribute to future policy making. Controlled study design maybe preferred in the future, if ethically appropriate.