Hand hygiene and dispenser systems in focus: Interview with Prof. Axel Kramer

Hand disinfection is considered the most important tool for infection prevention in hospitals and clinics. Awareness of the benefits of hand hygiene in public spaces is also on the rise due to the novel coronavirus (Covid-19). We spoke with Prof. Dr. Axel Kramer from the Institute for Hygiene and Environmental Medicine at the University Medicine Greifswald to discuss the current Covid-19 development and how hand hygiene solutions are used as a preventive measure.

Markus Theißen: Professor Kramer, we are regularly confronted with pandemics. While in the first decade of the 21st century it was swine flu, in this decade it’s the coronavirus covid-19. Added to this is the growing development of resistance in bacterial pathogens. How are we currently handling infectious diseases – and what is the importance of hand hygiene as a preventive measure?

Prof Axel Kramer: The classic infectious diseases are under control, with the exception of the flu. According to estimates, the exceptionally strong wave of influenza in 2017/18 cost the lives of around 25,100 people in Germany alone.  During the SARS epidemic from November 2002 to July 2003, more than 8,000 people in about 30 countries on 6 continents contracted the virus. The mortality rate was almost 10% however. Since 2004 no further SARS cases have been reported worldwide. Almost 96,000 cases of Covid-19 have been reported worldwide since December 2019. Of these, almost 3,300 people have died. (Update, 30.03.2020, Source WHO: 697,244 infections und 33,257 fatalities). The ability of both influenza and corona viruses to mutate means that, for example, a virus that initially occurs in animals (bats) and is harmless to humans can, after repeated changes of host, change its contagiousness, virulence and pathogenicity and become the starting point for an epidemic. The risk is particularly high when live poultry is put on display in a confined space in markets – this creates the ideal conditions for transmission to humans. Explosive epidemics are therefore always possible in the future, provided the virus is transmitted by inhalation, droplets or direct contact. In contrast, the number of new HIV infections in Germany has been declining continuously since 2015 because transmission is only possible through birth or sexual activity.

The infectiological challenge of the 21st century, however, is the pandemic spread of multi-resistant bacteria. This does not spread like an epidemic, but rather gradually and continuously. This is difficult to control due to the increasing spectrum of resistance by various bacteria and the associated therapeutic consequences. MRSA is an exception in that it can be suppressed by antiseptic decolonisation, which is why a decline can be observed. The spread of multi-resistant bacteria is favoured by the increase in the need for care of our ageing populations, the introduction of new surgical procedures with initially unknown infection risks, the growing proportion of immunosuppressed or immunocompromised patients, international transfer and the less stressed immune system with the associated increased susceptibility to infection [1].

Hand hygiene is the most effective measure for the prevention of nosocomial infections. Whenever gastrointestinal and respiratory infections spread epidemically in the population, the effectiveness of general disinfection has also been proven to be effective in the workplace [2].  In kindergartens, too, the frequency of gastrointestinal and respiratory infections could be reduced by hand disinfection [3,4]. In addition, hand disinfection, possibly as a less effective alternative to thorough hand washing, is recommended before every meal and, in epidemic situations, also before entering the home.  Likewise, hand-eye contact, which is particularly common among those who wear glasses, should be avoided during epidemics [5].

Markus Theißen: What about hand hygiene, especially when we look at hospitals and clinics?

Prof. Axel Kramer: Compliance has improved significantly (in Germany), especially thanks to the “Clean Hands” campaign. The data on compliance collected in 109 hospitals as part of the national hand disinfection campaign in 2014 showed that compliance is increased significantly with an average of 73%, but there is still of room for improvement [6]. In this context, achieving better results has a significant effect. One such method has been the suggestion that 15 seconds instead of the 30-s rub-in technique, may be similarly effective. This significantly improves compliance through a psychological effect [7-10].

Markus Theißen: As is well known, good hand hygiene requires good infrastructure in the form of sufficient available disinfectant dispensers. Availability is one thing, but what else do you think a hygiene dispenser needs to have in order to ensure compliance? 

Prof. Axel Kramer:

• A dispenser should be equipped with a non-refillable container (disposable container), ideally this would be an airtight pouch made of biodegradable or recyclable material instead of the rigid disposable container, which releases the disinfectant by means of negative pressure (thus the pump and the solution within can be dispensed without air flowing into the package); another variant, however less environmentally friendly, is the firm connection of the pump with the bag, so that both can be disposed of.

• Dispensers should have the possibility to use containers from different manufacturers.

• Dispensers should allow the user to be able to observe the fill level during operation.

• Touchless or automatically operated dispenser systems are preferred because of the lower probability of contamination and transmission, and because the greater ease of use has a positive influence on usage compliance [11].

Markus Theißen: In the KRINKO recommendation for hand hygiene from 2016, which you played a leading role in developing, there is a plea for an open dispenser format. In your opinion, what are the main advantages of a manufacturer-independent disinfectant or soap dispenser?

Prof. Axel Kramer: It should be possible to change manufacturers within the same dispenser for the following reasons:

• Acceptance of different disinfectants varies from person to person. This can also change during the course of use and make a change of product necessary. If that is the case, there is no time to change the entire dispenser system.

• A new formulation can be developed, which should first be individually tested and then introduced if necessary.

• Finally, economic aspects can also be reasons for a change; in this case it is advantageous that only the containers/manufacturers have to be changed and not the dispensers.

Markus Theißen: Finally, we would like to know from you: What does the future of hand hygiene look like, especially with regard to electronic monitoring?

Prof. Axel Kramer: The direct observation of personnel by trained observers is considered the “gold standard” for monitoring compliance with hand hygiene measures. Since this is very personnel-intensive, electronic systems have been developed to take over hand hygiene monitoring. At present, these systems mainly count only the number of hand disinfections carried out and partly also record qualitative aspects of hand hygiene, such as the required extraction quantity for hygienic hand disinfection.

In the future, electronic systems will be developed that are able to recognize the 5 moments of hand disinfection of the WHO, i.e. before patient contact, before aseptic activity, after contact with potentially infectious material, after patient contact and after contact with the immediate patient environment. If any of these steps are omitted, the system can immediately remind staff that it is necessary to use hand disinfectant by providing direct, fully automatic feedback [12]. Only by means of such feedback can you influence compliance. It goes without saying that the identities of the staff must remain hidden by these compliance systems.

The expected effectiveness is comparable to the traffic light system. If a traffic light changes from red to green after hand disinfection, and an acoustic signal is given, the patient can be treated.

Markus Theißen: Prof. Dr. Axel Kramer, thank you very much for the interesting conversation.

Sources

1. Bekeschus S, Schleibinger H, Razavi B, Maintaining health by balancing microbial exposure and prevention of infection: the hygiene hypothesis versus the hypothesis of early immune challenge. 2013;83 Suppl 1:S29-34.
2. Hübner NO, Hübner C, Wodny M, Kampf G, Kramer A. Effectiveness of alcohol-based hand disinfectants in a public administration: impact on health and work performance related to acute respiratory symptoms and diarrhoea. BMC Infect Dis 2010, 10: 250.
3. Sandora TJ, Taveras EM, Shih MC, Resnick EA, Lee GM, Ross-Degnan D, Goldmann DA. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. pediatrics 2005, 116(9):587-94.
4. Lee GM, Salomon JA, Friedman JF, Hibberd PL, Ross-Degnan D, Zasloff E, Bediako S,  Goldmann DA. Illness transmission in the home: a possible role for alcohol-based hand gels. Pediatrics 2005, 115(4):852-60.
5. Kramer A. Was schützt? Angst vor Coronavirus-Infektionen rückt Hygienemaßnahmen in den Fokus. Dt   Apoth Z  2020; 160(7): 20-4.
6. Wetzker W, Bunte-Schönberger K, Walter J, Pilarski G, Gastmeier P, Reichardt C.Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany. J Hosp Infect 2016; 92: 328–31.
7. Pires D, Soule H, Bellissimo-Rodrigues F, Gayet-Ageron A, Pittet D. Hand hygiene with alcohol-based hand rub: how long is long enough? Infect Control Hosp Epidemiol 2017;38(5):547-52.
8. Kramer A, Pittet D, Klasinc R, Krebs S, Koburger T, Fusch C, Assadian O. Shortening the application time of alcohol-based hand rubs to 15 s may improve frequency of hand antisepsis. Inf Contr Hosp Epidemiol  2017; 30:1-5.
9. Paula H, Krebs U, Becker R, Assadian O, Heidecke CD, Kramer A. Wettability of hands during 15s and 30s contact intervals: a prospective, randomized cross-over study. Inf Contr Hosp Epidemiol 2018; 46(9):1032-5.
10. Harnoss JC, Dancer SJ, Kaden CF, Baguhl R, Kohlmann T, Papke R, Zygmunt M, Assadian O, Suchomel M, Pittet D, Kramer A. Hand antisepsis without decreasing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds. J Hosp Inf 2019.
11. Kramer A. Requirements for hygienically safe, environmentally friendly dispensers for hand disinfectants and hand washing preparations. GMS Hyg Infect Control. 2020;15:Doc02.
12. Meng, M., Sorber, M., Herzog, A., Igel, C., & Kugler, C. Technological innovations in infection control: A rapid review of the acceptance of behavior monitoring systems and their contribution to the improvement of hand hygiene. Am J Infect Contr 2019; 47(4): 439–47.