Hand washing as a basic protective measure in day-to-day life, in operatories / hospitals, and against the new coronavirus (COVID-19):

The World Health Organization (WHO) recommends (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public) hand washing as one of the best protective measures against the new coronavirus.  WHO recommends that one should wash hands frequently with soap and water or use an alcohol-based hand rub if hands are not visibly dirty. Washing hands with soap and water or using alcohol-based hand rub eliminates the virus if it is on the hands.

This article summarizes the scientific evidence available with regard to hand washing and hand hygiene for common people and surgeons in clinics and operation theaters.

1. Day-to-day Handwashing:

Hand-washing is recommended as one of the best ways to protect yourself and your family from getting sick. There are three sets of guidelines given by the Centers of Disease Control and Prevention (CDC) on how to wash your hands to stay healthy (https://www.cdc.gov/handwashing/when-how-handwashing.html).

1. Wash Your Hands Often :

CDC recommends that you wash your hands often, especially during these TEN key activities when you are likely to get and spread germs:

1. Before, during, and after preparing food
2. Before eating food
3. Before and after caring for someone at home who is sick with vomiting or diarrhea
4. Before and after treating a cut or wound
5. After using the toilet
6. After changing diapers or cleaning up a child who has used the toilet
7. After blowing your nose, coughing, or sneezing
8. After touching an animal, animal feed, or animal waste
9. After handling pet food or pet treats
10. After touching garbage

2. How To Wash Your Hands the Right Way : Follow These Five Steps
Hand Washing is an easy and effective way to prevent the spread of germs. Clean hands can stop germs from spreading from one person to another and in the community— from your home and workplace to childcare facilities and hospitals.

Five steps to follow every time.

1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.
3. Scrub your hands for at least 20 seconds.
   (Need a timer? Hum the “Happy Birthday” song from start to end twice.)
4. Rinse your hands well under clean, running water.
5. Dry your hands using a clean towel or air dry them.

3. Use Hand Sanitizer When You Can’t Use Soap and Water

Washing your hands with soap and water is the best way to eliminate germs in most situations. But when soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol, which will be mentioned on the product label.

Sanitizers can quickly reduce the number of germs on hands in many situations. However,

• Sanitizers do not eliminate all types of germs.
• Hand sanitizers may not be effective on unclean, visibly dirty or greasy hands. Clean them first and dry them before applying the sanitizer.
• Hand sanitizers might not remove harmful chemicals eg. pesticides, heavy metals

1. Handwashing for Surgeons:

Surgical hand hygiene is standard care prior to any surgical procedure, since Peri-operative glove punctures are observed in almost 30% of all interventions, and are considered a risk factor for postoperative infections. Therefore the hygiene products should have a remnant effect to delay the microbial growth under the gloved hand surfaces.  (Widmer AF. Surgical hand hygiene: scrub or rub?. J Hosp Infect. 2013;83 Suppl 1:S35–S39.)

1. Surgical Scrub: Should surgeons scrub with chlorhexidine or iodine prior to surgery?

In the past, Surgical Scrub was the norm i.e. washing hands with antimicrobial soap and water, mainly with chlorhexidine or iodine.

A systematic review (Jarral OA, McCormack DJ, Ibrahim S, Shipolini AR.
Interact Cardiovasc Thorac Surg. 2011;12(6):1017–1021. doi:10.1510/icvts.2010.259796) compared the efficacy of chlorhexidine gluconate with povidone iodine by evaluating a total of 593 papers (published from 1948 to 2011) out of which eight represented the best evidence to answer the clinical question. The authors concluded that although both chlorhexidine and povidone-iodine reduce bacterial count after scrubbing, the effect of chlorhexidine is both more profound and longer lasting.

The studies that analysed the reduction in the bacterial count (colony forming units) following surgical scrub concluded that chlorhexidine was superior. Four studies that went further to analyse cumulative and residual activity by testing for bacterial reduction after using a scrub solution for a number of days, found that chlorhexidine showed consistent advantages over povidone-iodine.

Three conclusions from the study were:

• Both chlorhexidine and povidone-iodine cause an immediate reduction in bacteria,
• However, the reduction when using chlorhexidine is more dramatic.
• Povidone-iodine shows a lack of cumulative and residual activity in comparison to chlorhexidine.

A meta-analysis, which assessed whether preoperative anti-sepsis with chlorhexidine or povidone-iodine reduced Surgical Site infection (SSI), evaluated Six trials with a total of more than 5000 patients, and found that chlorhexidine significantly reduced postoperative SSI in clean-contaminated surgery. (Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic review and metaanalysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 2010;97:1614–1620)

2. Alcohol Based Hand Rub (ABHR)

More recently, alcohol-based hand rub has been successfully introduced, showing greater effectiveness, less irritation to the hands, and requiring less time (Minimum 3 minutes vs Minimum 90 sec) than washing hands.

Operating Room Hand Preparation: To Scrub or to Rub?

A review that critically examined the evidence to compare alcohol rub with traditional scrub, tried to define the evidence for the best methods for hand preparation before surgical procedures. The bacteriologic studies of the surgeons’ hands comparing scrub with rub found alcohol rub to have consistently produced equal or better reductions in bacterial counts on the hand. A comparison of scrub and rub on the frequency of surgical site infections found no difference between scrub and rub. The authors concluded that the alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures. (Fry DE. Operating Room Hand Preparation: To Scrub or to Rub?. Surg Infect (Larchmt). 2019; 20(2):129–134.)

In another study, 128 healthcare workers used either an alcohol-based hand rub or a conventional surgical scrub as preoperative hand antisepsis during their routine practice. Hand sampling for cultures were performed before and after operations, and positive culture plates were further processed for pathogen identification. The study found that alcohol-based hand rub was more efficacious for surgical antisepsis due to its sustained efficacy, compared to conventional surgical scrub. The authors recommended alcohol-based hand rubs as an alternative surgical antiseptic in the operation theaters. (Shen NJ, Pan SC, Sheng WH, et al. Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center. J Microbiol Immunol Infect. 2015;48(3):322–328.)

3. WHO Recommendation: Surgical hand preparation:

3. (Allegranzi, B., Bischoff, P., de Jonge, S., Kubilay, N. Z., Zayed, B., Gomes, S. M. et al (2016).
   New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. The Lancet Infectious Diseases, 16(12), e276–e287. )
4. The panel recommends that surgical hand preparation be done either by scrubbing with a suitable antimicrobial soap and water or using a suitable alcohol-based hand rub (ABHR) before donning sterile gloves (strong recommendation, moderate quality of evidence).
5. The overall evidence (rated as moderate quality) showed no difference between hand rubbing and hand scrubbing in reducing SSI incidence.