Hand Hygiene Recommendations for Remote and Isolated Community Settings

7 October 2009

Introduction

Eighty per cent of common infections, including influenza, can be spread by contaminated hands. Canadians are subject to considerable variation in the type of water delivery system available to them, which can influence the availability of clean water for normal daily use such as hand washing.

The goals of pandemic preparedness and response include minimizing serious illness and death and minimizing societal disruption among Canadians as a result of an influenza pandemic.  In line with these goals, this document has been developed to provide recommendations and direction to public health authorities, community leaders and the general public on community hand hygiene practices when running water is available, when running water is not available, and when clean water is not available.  This document also contains information on the use of alcohol-based hand rubs in situations when it is indicated for use in the community setting.  The recommendations contained herein, if followed, may contribute to the reduction of transmission of the pandemic (H1N1) 2009 influenza virus in the community. It is anticipated that this guidance will be adapted by public health and other health professionals as necessary to address their local circumstances.

The recommendations made in this guidance document expand upon existing community based measures to prevent transmission of the pandemic (H1N1) 2009 influenza virus.  For further guidance on preventing transmission of the H1N1 virus, please refer to the guidance entitled "Individual and Community Based Measures to Help Prevent Transmission of Influenza-Like-Illness (ILI) in the Community, Including the Pandemic Influenza (H1N1) 2009 Virus".

This guidance has been developed based upon the Canadian situation and thus may differ somewhat from other guidance documents developed by other countries.

Background

The pandemic (H1N1) 2009 influenza virus has rapidly spread across the world. While influenza activity would normally be expected to wane during the summer months, the pandemic (H1N1) 2009 influenza virus has continued to circulate at low levels in Canada and the potential for resurgence in the fall remains.

The pandemic (H1N1) 2009 influenza virus is thought to be spread from person to person in the same way as seasonal influenza where transmission occurs predominantly through coughing or sneezing. Indirect transmission can also occur through self-inoculation after contact with surfaces and objects contaminated with the virus from infected persons.

Recommendations

The following recommendations provide guidance on how hand hygiene should be performed in the community setting.

When Hand Hygiene might be Performed

Examples of when hand hygiene should be performed include the following:

• when hands are visibly dirty;
• before preparing and immediately after handling food;
• before eating food or feeding others;
• before breastfeeding;
• after using the toilet, changing/handling diapers, or helping someone use the toilet;
• after contact with contaminated surfaces (e.g., garbage bins, cleaning cloths);
• after handling pets and domestic animals;
• after wiping or blowing nose, handling soiled tissues, or sneezing into hands;
• after contact with blood or body fluids (e.g., vomit, saliva);
• before and after dressing wounds;
• before and after giving care or visiting someone who is ill, or someone who is less able to fight off infections (e.g. diabetic, cancer patient);
• before preparing and taking medication; and
• before inserting and removing contact lenses.

Routine Hand Hygiene in the Community Setting

When Running Water is Available

When running water^* is available (day-to-day and during an outbreak) in a community, wash hands with plain soap and water and dry thoroughly.  The recommended procedure for hand washing using running water is as follows:

• roll up long sleeves and push up wrist watch
• wet hands up to the wrists
• apply enough soap to cover all hand surfaces, and if a ring is worn, on and under the ring
• work soap under the fingernails and around and between joints and fingers
• rinse off every trace of lather with water
• dry hands with a clean cloth or paper towel while taking special care to dry thoroughly between the fingers
• turn off the tap/spout with a paper towel or cloth

Where plumbed water is unavailable, a closed water container with a spigot can be used.  Hold hands under the spout of a water container, wetting and rinsing the hands. Please note that the container should be dedicated to water used for hand washing and should not be used to obtain drinking water. If required, a pail can be placed below the container to catch the flowing water. The container should be cleaned prior to refilling.  No special disinfectants or waste handling practices are required for influenza; regular household or commercially available cleaning products are sufficient for cleaning the container.  After cleaning, rinse the container with water before refilling and using for hand washing.

When Running Water is Not Available

In the absence of running water, hand washing can be performed by using two separate open containers (e.g. pail, bowl): one for holding the water supply, and a second for washing one’s hands in.  Moving hands around in a container of water can mimic the action of running water. The recommended procedure for washing hands in a container of water when running water is not available is:

• roll up long sleeves and push up wrist watch
• pour sufficient water to cover hands into the hand washing container
• wet hands up to the wrists
• apply enough soap to cover all hand surfaces, and if a ring is worn, on and under the ring
• work soap under the fingernails and around and between joints and fingers
• remove all soap and dirt residue by moving your hands around to replicate the action of running water
• dry hands with a clean cloth or paper towel while taking special care to dry thoroughly between the fingers
• throw out the water from the hand washing container following each individual use

It is important that the container used for hand washing be cleaned and dried after each use, especially if the community is experiencing an outbreak of H1N1. No special disinfectants or waste handling practices are required for influenza; regular household or commercially available cleaning products are sufficient for this purpose.

The degree of cleanliness achieved when washing hands with untreated water is not yet fully understood¹ , but the mechanical process of washing hands with soap and water - regardless of its quality – will always remove organic matter and some germs. Therefore, performing hand hygiene with soap and water is always the first choice in the community setting.

Hand Hygiene Measures When Interacting with High-Risk Individuals

In circumstances when there will be interaction with high-risk individuals, it is recommended that clean water and soap be used for hand washing.  The procedures for hand washing are as indicated above.  However, when clean water is not available, either treat the available water before hand washing, or use an alcohol-based hand sanitizer.  These options are described below.

Examples of high-risk individuals are:

• an immunocompromised individual (e.g., diabetic, cancer patient)
• an individual with an open wound or tubing (e.g., catheter)
• an individual with a known infectious disease (e.g., pandemic (H1N1) 2009 virus)^{2, 3}
• a pregnant woman

When Clean Water is Not Available

When there will be interaction with individuals at high risk for complications of influenza, and clean water is not available (e.g., during a boil water advisory or when water quality/source unknown), the following options are recommended for cleaning water before hand washing:

• treat water by boiling water for one minute.  It is important that it be a rolling boil.  Allow the water to completely cool before use; or
• treat water with chemicals (e.g. chlorine bleach in liquid or tablet form)^†.

Once the water has been cleaned accordingly, directions for hand washing are the same as those recommended when running water is not available, using a container (see above).

Hand Sanitizer Use

Hand sanitizers are an excellent means of ensuring clean hands when travelling outside the home where access to soap and water for hand washing is not an option.  When there will be interaction with individuals at high risk for complications of influenza, and clean water or the means to clean water is unavailable, it is recommended that a waterless hand sanitizer be used.

The hand sanitizer must be alcohol-based^‡, and should contain at least 60%, by volume, of alcohol (e.g. ethanol, isopropanol or n-propanol), and may contain emollients and other active ingredients. Alcohol-based hand rubs come in liquid, gel and foam forms and there is no reported difference in the effectiveness of each form as long as they have adequate alcohol content.  A benefit of alcohol-based hand rubs, if used correctly, is that the drying time of approximately 20 – 30 seconds ensures adequate contact to kill the majority of contaminating micro organisms. However it is imperative that all visible dirt is removed before use of hand sanitizer for it to be effective.

The recommended procedure for applying alcohol-based hand rub is:

• roll up long sleeves and push up wrist watch
• wash hands with soap and available water if hands are visibly dirty (e.g., contaminated with dirt, oil, blood, body fluids, etc.), and dry hands completely after washing as wet hand will dilute the alcohol
• place enough alcohol-based hand rub into the cupped palm of one hand sufficient to wet both hands completely
• rub the liquid into the palms, backs of hands, between fingers and under nails, and if a ring is worn, on and under the ring

It is recommended that manufacture’s advice be read and followed, regarding the storage of alcohol-based hand rubs to avoid the loss of alcohol by evaporation and to reduce the possibility of flammability.

Some religious and cultural groups have raised concerns regarding the use of alcohol-based hand rubs.  Research has shown that alcohol used in the hand rubs is not absorbed into the skin.  While the World Health Organization recommends the use of alcohol based hand rubs, based on scientific evidence, it also outlines some possible options if there is a concern about using this product⁴.

---