1. ROLE OF HAND HYGIENE IN PREVENTING TRANSMISSION OF INFECTIOUS DISEASES David Jay Weber, M.D., M.P.H. Medical Director, Hospital Epidemiology Professor of Medicine, Pediatrics & Epidemiology University of North Carolina at Chapel Hill

2. PRESENTATION TOPICS  Rationale for hand hygiene  Link between professional and consumer hand hygiene  Indications for hand hygiene in home and community settings  Efficacy of hand hygiene in reducing day care center- associated infections  Uses of hand hygiene products in home health

3. RATIONALE FOR HAND HYGIENE  Many infectious agents are acquired via hand contact with contaminated surfaces Contact transmission: Healthcare (MRSA, VRE), day care (MRSA), home (MRSA, “cold viruses”, herpes simplex Fecal-oral transmission: Day care ( Shigella, E. coli O157:H7), home ( Salmonella, E. coli O157:H7, Cryptosporidium )  Hand hygiene effective in reducing or eliminating transient flora  Hand hygiene demonstrated to be effective in preventing illness (especially fecal-oral diarrheal illnesses) in healthcare facilities, child care centers/homes, and households

5. EFFECTIVENESS OF HAND HYGIENE IN THE HOSPITAL Pittet D, et al. Lancet 2000;356:1307-12.

6. Primary Child Care Arrangements for Children <6 Years of Age Parents (8.6 mill) Center (3.8 mill) Family Day Care (2.0 mill) Child’s Home (1.7 mill) Other (2.5 mill) (Ralph Cordell, CDC)

7. INFECTION CONTROL CONCERNS: INFANTS AND TODDLERS  Infants and toddlers Require diapering or assistance in using a toilet Explore the environment with their mouths Have poor control over their secretions and excretions Have immature immune systems Require hands-on contact with health providers  Toddlers Have frequent contact with other toddlers

8. RELATIVE RISK OF DIARRHEA BY TYPE OF CHILD CARE SETTING AuthorStudy DesignChild Care Center Child Care Home Bartlett, 1985Cohort2.2* (1.3, 3.5)**1.3 (0.7, 2.4) Alexander, 1990Case control3.5 (1.0, 4.8)<1.0 Reves, 1993Case control2.4 (1.6, 3.7)2.0 (1.3, 3.1) Pickering LK & Osterholm MT, 1997 * Relative to care at home, ** 95% CI

9. INFECTIONS ASSOCIATED WITH CHILD CARE CENTERS Enteric syndromes  Diarrheal diseases  Hepatitis Pathogens  Hepatitis A  Norovirus  Rotavirus  E. coli O157:H7  Shigella  Cryptosporidium Respiratory  Otitis media  Sinusitis  Pharyngitis  Pneumonia Pathogens  H. influenzae type B  S. pneumoniae

10. Cost (in millions) of child care-associated illness to businesses and families in the U.S. Haskins.Bull NY Acad Med 1990 Absence from work ($1,300) Treatment of otitis ($420) Treatment of Hib infections($17.3) Long term care ($40) Treatment of respiratory infections ($78)

12. RANDOMIZED CONTROLLED TRIALS DEMONSTRATING EFFICACY OF HAND HYGIENE IN CHILD CARE CENTERS Author, YearDCCInterventionReduction in Diarrhea Kotch J, 199424HH, environmental cleaning, improved diapering, ed Reduction severe diarrhea Uhari M, 199920HH, environmental cleaning, improved diapering, ed 8-9% Carabin H, 199947HH, ed27% Roberts L, 200023HH, ed50% Kotch J, 200646New equipment (diapering, handwashing, food preparation) ~50% (diarrheal days) Ed, education; HH, hand hygiene

13. MODEL OF ENTERIC DISEASE TRANSMISSION IN DAY CARE

14. INDICATIONS FOR HAND HYGIENE IN THE HOME Targeted Hand Hygiene (times & places):  Before and after eating or preparing food >75 million foodborne infections per year (Mead PS, et al. EID 1999;5:607)  Before and after using the bathroom  Before and after diapering Per data from child care centers  After pet/animal contact >300 zoonotic diseases; many contact or fecal-oral transmitted  Before and after providing health care Per data from healthcare facilities

15. HAND HYGIENE STUDIES IN THE HOME  Hand hygiene – home studies No reduction in illness rates in homes randomized to antibacterial cleaning and handwashing products (Larson EL, et al. AIM 2004;140:397-398) ~50% reduction in secondary diarrheal illnesses in homes randomized to an alcohol-based hand sanitizer and education (Sandora TJ, et al. Pediatr 2005;116:587-94)  Studies demonstrating efficacy of hand hygiene are problematic Limited number of studies with small sample sizes Design obstacles Multiple routes of exposure and exposures outside the home Efficacy of hand hygiene using soap and water (efficacy of control group)

16. CONCLUSIONS  Infections acquired in healthcare facilities and day care centers result in substantial morbidity and cost  Infections acquired in healthcare facilities and day care centers often result from person-to-person transmission via the hands of healthcare or day care providers  Hand hygiene may reduce the frequency of nosocomial and day care center infections  Hand hygiene likely provides a benefit with selected (targeted) activities in the home