Adoption of alcohol hand disinfection in the United States: a personal perspective
John M. Boyce 11 Yale University School of Medicine, New Haven, CT, USA
Abstract
Even though alcohol-based hand disinfectants have been used for decades as a routine measure in Europe, in the USA until recently handwashing was the procedure of choice. Alcohol-based rub products were recommended only if no handwashing facility or running water was available. It was only during the late 80s and early 90s that the advantages of alcohol-based products began to elicit interest. In 1995 Larsen published new application guidelines for hand disinfection and in 1996 the CDC included alcohol-based hand disinfection in its “Isolation guideline”. However, these recommendations were rarely implemented in practice.
In 1996 Didier Pittet first gave me a demonstration of alcohol-based rub products at his Geneva hospital, and the following year experts at Lausanne University provided me with the products available at that time. In 1998 and 2000 I had the opportunity to exchange information and experiences with numerous European experts, including Dr. Molitor, who also gave me additional insights into the mechanism of action of such products. As a result of myriad scientific demonstrations, interest in these rub products now began to be expressed in the USA too. In 1999 an interdisciplinary working group for hand hygiene was set up, comprising representatives from CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and the Infectious Diseases Society of America, whose intention was to formulate new guidelines for hand hygiene in the healthcare sector. The insights that I gained from Dr. Molitor and from other European experts were of enormous value and helped to weigh up the pros and cons of alcohol-based hand disinfection, both in respect of the different products available and on comparing them with hand washing. The new CDC guideline for hand hygiene was published in 20002 and for the first time in the USA it featured the requirement that alcohol-based rub products be used as the method of choice provided that the hands were not visibly soiled or contaminated with protein-based material. Unfortunately, we have no reliable data, but it is estimated that today up to 95% of doctors and nurses in American hospitals preferentially use alcohol-based rub products – thus reflecting a situation that has long been common practice in Europe.
Text
Although alcohol-based hand rubs have been used routinely by healthcare workers in a number of northern European countries for several decades, washing hands between patients remained the principal method of hand hygiene in healthcare facilities in the United States until recently. A training film produced by the Centers for Disease Control and Prevention (CDC) in 1961 and written guidelines published in 1975 and 1985 recommended that healthcare workers wash their hands with either a non-antimicrobial soap and water or an antimicrobial soap and water before and after contact with patients [1], [2]. Alcohol-based hand rubs were recommended for use only in instances in which sinks or running water were not available. Potential adverse effects of alcohol hand rubs on the skin were listed as the major reason to avoid their routine use [1]. In the late 1980s and early 1990s, Larson and others began to point out the advantages of alcohol-based hand rubs, but few hospitals made them available to healthcare workers [3], [4]. Hand hygiene guidelines published by Larson in 1995 and isolation guidelines released by CDC in 1996 listed alcohol-based hand rubs as alternatives in several settings, but limited data suggest that relatively few health-care facilities adopted their use in the following years [5], [6].
In 1996, Professor Didier Pittet introduced me to the alcohol-based hand rub that was being promoted at University of Geneva Hospitals, and the following year, infection control personnel at University of Lausanne Hospital provided me with a sample of a commercially produced alcohol hand rub product that was in widespread use in their facility. Subsequent exchanges of views with European experts at conferences held in Europe in 1998 and 2000 provided me with further information regarding the advantages of disinfecting hands with alcohol-based hand rubs. At several of these meetings, I had the opportunity to discuss the use of alcohol-based hand rubs with Dr. Molitor, who provided me with additional insight into the beneficial characteristics of such products. In the United States, interest in the use of alcohol-based hand rubs in healthcare settings began to increase as a result of presentations made by a number of individuals at national infection control meetings held between 1999 and 2002. In 1999, a multidisciplinary Hand Hygiene Task Force, which was comprised of representatives from CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control, and the Infectious Diseases Society of America was charged with developing new guidelines for hand hygiene in healthcare settings. The interactions I had with Dr. Molitor and other European experts served as an impetus to carefully review the advantages and disadvantages of alcohol-based hand rubs as well as washing hands with non-antimicrobial or antimicrobial soap and water during the process of preparing the new Guideline for Hand Hygiene in Healthcare Settings, which I coauthored with Professor Pittet. Following input from members of the Hand Hygiene Task Force, the United States Food and Drug Administration and the public, and approval by HICPAC and the other supporting organizations, the final version of the Guideline for Hand Hygiene in Healthcare Settings was published in October 2002 [7]. For the first time in the United States, the guideline recommended that alcohol-based hand rubs should be used routinely by healthcare workers, as long as their hands are not visibly soiled or contaminated with proteinaceous material. In January 2003, the Joint Commission on Accreditation of Healthcare Organizations recommended that healthcare facilities in the United States comply with the new CDC Guideline for Hand Hygiene. Although official data are not available, it has been estimated that approximately 90% to 95% of hospitals in the United States now provide alcohol-based hand rubs to healthcare workers. As a result, alcohol-based hand rubs are now used nearly as frequently in hospitals the United States as they are in European countries where they have been popular for years.
Curriculum Vitae
Professor John M. Boyce, M.D.
Figure 1 [Fig. 1]
Clinical Professor of Medicine, Division of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut.
The international awards received by Professor Boyce would go far beyond the scope of this publication. Here writes one of the most renowned and worldwide acknowledged American infectologists.
Born in Boise/Idaho, John Boyce studies at the University of the Washington School of Medicine, where he graduates in 1970. His scientific career starts at the University of Mississippi Medical Center, Jackson, Mississippi, then he moves on to Brown University School of Medicine in Providence, Rhode Island and finally 2001 to Yale University, School of Medicine (Division of Infectious Diseases), New Haven, Connecticut.
Amongst others, Professor Boyce is a Board-Member of the Advisory Board of Infection Control and Hospital Epidemiology since 1997, has been Chairman of HICPAC/ SHEA/ APIC/ IDSA Hand Hygiene Task Force until 2002 and is Temporary Consultant to the World Health Organization, Geneva, Switzerland.
References
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[3] Larson EL, Eke PI, Laughon BE. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother. 1986;30:542-4.
[4] Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol. 1991;12:654-62.
[5] Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251-69.
[6] Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17:53-80.
[7] Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23:S3-40.
