The following statements provide current information on relevant rulings and recommendations associated with hand hygiene and associated practices or products.

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The CDC released guidance on use of personal protective equipment (PPE) to be used during care of patients with suspected or confirmed Ebola virus disease (EVD). In Australia, this guidance has been recommended in the CDNA National Guidelines for Public Health Units, which is endorsed by the Communicable Disease Network Australia (CDNA) and Australian Health Protection Primary Committee (AHPPC).

Amongst other recommendations, the CDC guidance includes disinfection of gloved hands. This has caused some concern in Australia given this practice is discouraged by the National Hand Hygiene Initiative and most previous international guidelines on hand hygiene in healthcare.

Hand Hygiene Australia generally advises against washing or decontamination of gloved hands. This is primarily because of a lack of information regarding the impact that this process may have on glove integrity. Additionally, such practices may result in inappropriate glove use which is associated with unnecessary resource consumption and sub-optimal hand hygiene performance.

Care for patients with suspect or confirmed Ebola virus disease represents an exceptional circumstance with a unique set of risks including high case fatality rate and incidental contamination associated with use of unfamiliar PPE. In this setting, the recent CDC guidance has recommended disinfection of gloved hands with alcohol-based handrub or disinfectant wipe when donning PPE, during patient care and when removing PPE. 

We note that this guidance is specifically for care of patients with suspected or confirmed Ebola virus disease and should not be applied outside of that setting. While we are unable to provide evidence-based guidance, we suggest considering the following issues regarding disinfection of gloved hands:

• Efficacy of ABHR against Ebola virus:
  We are not aware of data regarding the efficacy of alcohol-based handrubs against Ebola virus. Alcohol-based products are, however, generally considered active against enveloped viruses (Ebola virus is enveloped). Nevertheless, use of alcohol-based handrubs on gloved hands should be considered to be, at best, a process of disinfection rather than sterilisation. Alcohol-based handrubsshould be used only as an adjunct to PPE and not as a substitute. 

• Impact of alcohol-based handrubs on glove integrity:
  The impact of disinfection on glove integrity will vary depending on the type of glove. A general recommendation (made without firm evidence) is to use nitrile gloves when disinfection will be performed. Given that such gloves are suitable for use with cytotoxic agents it is presumed that they will be less affected by alcohol-based handrubs than other glove types.

• Indications for hand hygiene:
  The US does not have a national program using the ‘5 Moments for Hand Hygiene’. Australian readers should bear this in mind when reviewing documents originating from the US that may appear to differ from routine HHA recommendations regarding hand hygiene.

In summary, we suggest that if wearing nitrile gloves, use of alcohol-based handrubs is unlikely to be harmful and may reduce the risk of self-contamination by healthcare workers, but is also of unproven efficacy. Use of alcohol-based handrubs is not a substitute for appropriate PPE when caring for a patient with suspected or confirmed Ebola virus disease. Disinfection of gloved hands should be considered a practice applicable only to care for a patient with suspected or confirmed Ebola virus disease.

There is a clear need for research regarding the impact of standardised decontamination procedures on glove integrity and the effectiveness of various hand hygiene and disinfectant products in inactivating Ebola virus. Hand Hygiene Australia will update this commentary as further resources or evidence become available.

Hand Hygiene Australia recommends that healthcare facilities seek advice from their local jurisdictional authorities (see contact details below) regarding the infection control procedures to institute during the care of patients with suspected or confirmed Ebola virus disease.

Jurisdictional public health unit contact details

Along with personal protective equipment, hand hygiene using either soap and water or an alcohol-based handrub can play a vital role in preventing the transmission of the influenza virus on the hands of healthcare workers.

Hand hygiene should be performed at the point of care where potential contact with the virus may occur and will greatly reduce the chance of the virus being transmitted via the hands. As the availability of handwashing facilities and time is often limited, alcohol-based handrubs will often be the best way to achieve this.

Below is the abstract from a paper published in Clinical Infectious Diseases, supporting the important role of hand hygiene using either soap and water or alcohol-based handrub against the influenza A (H1N1) virus.

Clin Infect Dis. 2009 Feb 1;48(3):285-91.
Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers.

Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C.
Infectious Diseases Department, Austin Health, Heidelberg, Victoria 3084, Australia.

BACKGROUND: Although pandemic and avian influenza are known to be transmitted via human hands, there are minimal data regarding the effectiveness of routine hand hygiene (HH) protocols against pandemic and avian influenza.

METHODS: Twenty vaccinated, antibody-positive health care workers had their hands contaminated with 1 mL of 10(7) tissue culture infectious dose (TCID)(50)/0.1 mL live human influenza A virus (H1N1; A/New Caledonia/20/99) before undertaking 1 of 5 HH protocols (no HH [control], soap and water hand washing [SW], or use of 1 of 3 alcohol-based hand rubs [61.5% ethanol gel, 70% ethanol plus 0.5% chlorhexidine solution, or 70% isopropanol plus 0.5% chlorhexidine solution]). H1N1 concentrations were assessed before and after each intervention by viral culture and real-time reverse-transcriptase polymerase chain reaction (PCR). The natural viability of H1N1 on hands for >60 min without HH was also assessed.

RESULTS: There was an immediate reduction in culture-detectable and PCR-detectable H1N1 after brief cutaneous air drying--14 of 20 health care workers had H1N1 detected by means of culture (mean reduction, 10(3-4) TCID(50)/0.1 mL), whereas 6 of 20 had no viable H1N1 recovered; all 20 health care workers had similar changes in PCR test results. Marked antiviral efficacy was noted for all 4 HH protocols, on the basis of culture results (14 of 14 had no culturable H1N1; (P< .002) and PCR results (P< .001; cycle threshold value range, 33.3-39.4), with SW statistically superior (P< .001) to all 3 alcohol-based hand rubs, although the actual difference was only 1-100 virus copies/microL. There was minimal reduction in H1N1 after 60 min without HH.

CONCLUSIONS: HH with SW or alcohol-based hand rub is highly effective in reducing influenza A virus on human hands, although SW is the most effective intervention. Appropriate HH may be an important public health initiative to reduce pandemic and avian influenza transmission.

On 6 September 2016, the FDA in the United States made a ruling on antibacterial soaps that has received attention in Australia. This document aims to clarify what was decided and why, and how this relates to the National Hand Hygiene Initiative in Australia.

What has the FDA decided?

This week the FDA has moved to end the sale of any many over-the-counter (OTC) antibacterial soaps in the United States. The ruling applies to products used for hand or body wash that contain any of 19 specified active antibacterial ingredients, including triclosan and triclocarbon. Manufacturers marketing these products in the United States will have one year to comply with this decision.

Why did the FDA make this decision?

In 2013, the FDA requested evidence to demonstrate the efficacy and safety of OTC antibacterial soaps. The FDA has subsequently concluded that available evidence does not support the ongoing marketing of these products. The FDA have explained that “there isn’t enough science to show that over-the counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water”, while also noting that “the wide use of these products over a long time has raised the question of potential negative effects on your health.” They note that such negative effects could include selection for drug-resistant bacteria.

Does this ruling include products used in health care?

No, this ruling applies to over-the-counter products and is therefore focussed on consumer use in the community. It does not affect antibacterial products used in health care settings.

Does this ruling include alcohol-based handrubs?

No, this ruling applies to soap-based products that are used with water.

Is this decision consistent with the National Hand Hygiene Initiative (NHHI) in Australia?

Yes, although it is important to remember that this ruling relates to over-the-counter consumer products used in the community in the US, rather than products used in Australian health care organisations. However, we nonetheless note that this ruling is consistent with the NHHI recommendations. Hand Hygiene Australia recommends using alcohol-based handrub for all clinical situations where hands are visibly clean. Washing with soap and water is recommended when hands are visibly dirty or contaminated, contaminated with body fluids, or if exposure to potential spore forming organisms is strongly suspected or proven.

Further resources:

• FDA Final Rule
• FDA News Release
• FDA Consumer Update
• Media Release from ASID and ACIPC