Hand Washing Before and After Applying Different Hand Hygiene Techniques in Places of Public Concern in Tripoli-Libya

Received: August 13, 2018 Revised: November 15, 2018 Accepted: November 17, 2018 Abstract: Background: Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens. There is substantial evidence that incidence of hospital acquired infections is reduced by applying hand antisepsis. Regarding hand hygiene and public concern, hand washing has revealed that 85% of the observed adults wash their hands after using public toilets.


INTRODUCTION
Hand washing is the first line of defence and is one of the oldest methods of preventing the spread of disease.Public health officials pay attention to the Health Care Workers (HCWs) in hospitals and in places related to human activity by urging people to wash and/or hygiene their hands more frequently to fight occurring of infectious diseases.In terms of definition, hand washing is a process of hand cleaning using water and/or soap for the purpose of physically or mechanically removing dirt and organic material.By contrast hand hygiene is a general term referring to any action of hand cleansing for the purpose of reducing or inhibiting the growth of microorganisms through the application of an antiseptic hand rub or through antiseptic hand washing [1].
One of the most important steps in avoiding getting sick and preventing spread of microbes to others is by keeping hands clean.Neglecting washing hands with soap and clean running water will lead to spread many types of diseases.Centres for Disease Control and Prevention (CDC) [2], revealed that almost 50% of all foodborne illness outbreaks occur due to failing to wash or insufficiently washing hands.A review from 1975 to 1998 showed that unwashed hands of infected food workers are responsible for transmitting pathogens on food and resulting in 93% of the foodborne disease outbreaks [2,3].Additionally, diarrheal disease risks can be reduced by more than 40% when hands washed with soap and that hand washing interventions could save one million lives annually [4].
Thinking Wet, Lather, Scrub, Rinse, and Dry are the five simple and effective steps of hand washing like a "do-ityourself" vaccine.Removing microbes, avoiding getting sick, and preventing the spread of microbes to others can be successfully achieved by applying regular hand washing, particularly before and after certain activities [5].In this respect, the development in the guidance for effective hand washing and use of hand sanitizer was almost based on data from a number of studies [4,6,7].
Since a decade ago approximately in 2002 when CDC published its "Guideline for hand hygiene in Health-Care Settings, and the question that still excite is: Does all that hand washing and gelling work?
Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens.
Although cross infection via the hands of health care personnel is responsible for an estimated 20% to 40% of nosocomial infections, still the patient's endogenous flora considered as a major source of nosocomial pathogens.Noncompliance with hand hygiene, however, remains a major problem in hospitals, and compliance with hand washing in hospital environments is generally less than 50% [8].
The intensity of environmental contamination is strongly correlated with the frequency of positive personnel hand culture [11].For example, 0% to 25% environmental contamination represents 0% hand contamination, 8% when environmental contamination was 26% to 50%, and when environmental contamination was greater than 50% the hand contamination was 36%.
There is a substantial evidence that incidence of Hospital Acquired Infections (HAIs) is reduced by applying hand antisepsis [9 -24].Therefore, patient's safety is fundamentally ensured by the action of hand hygiene as a process of care in a timely and effective manner.However, unacceptably low compliance with hand hygiene is to be taken as universal in health care [25].This contributes to low number of transmission microbes capable of causing HAIs.However, reduction in HAIs can be successful achieved by better adherence to hand hygiene guidelines and policies [26 -32].
Recently, new approaches have been introduced despite improvements in understanding of the epidemiology of hand hygiene compliance [33,34].A group of international professionals from the Centers for Disease Control and Prevention, the Healthcare Infection Control Practices Advisory Committee, the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology have developed guidelines for hand hygiene in healthcare settings [35] and anticipated that these guidelines should improve the standards and practice in healthcare settings.Unfortunately, it has been always documented in several literature studied that the importance of hand hygiene is not sufficiently recognized HCWs [36][37][38] and compliance with recommended practices is unacceptably low [33 -46].Moreover, as the average level of compliance with hand hygiene recommendations is low, also the time spent is usually insufficient.An observational studies showed that the duration time of hand washing or hygienic hand wash spent by HCWs varies from few seconds to more than a minute, and the average is between 4.7 and 24 seconds [35].Despite this short period of washing time, HCWs often fail to cover all surfaces of their hands and fingers [47] and to use an effective technique of hand hygiene, even under observation [48].
Investigations related to outbreaks have suggested an existing correlation between infections and understaffing or overcrowding which consistently linked with reduced compliance with hand hygiene practices [49 -51].Other investigation showed that transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) considered as a risk factor in an Intensive Care Unit (ICU) [52].
Larson and colleagues [53] documented that the prevalence of nosocomial infections decreased as HCWs' compliance with recommended hand hygiene measures improved.Top hospital management and medical and nursing leaders provided active support for a culture change, highlighting and enforcing the expectation for hand hygiene compliance for all HCWs.
Regarding hand hygiene and toilets as an example of a place of public concern related to human activity, an investigation study revealed that 85% of the observed adults wash their hands after using public toilets [54].This habit of washing hands increased from 77% to 83% in years 2005 to 2007 respectively [55].
A study focusing on gender as a contribution factor in hand washing practices showed that, women usually wash their hands more frequently than men.The percentage of hand washing for women is 83%, whereas only 74% was recorded for men, as it had been observed in a study carried out by American Society for Microbiology in 2003 [56].Women showed to be consistently wash their hands more than men during a multiyear study across public attractions.90%, 88%, and 93% were the average observed hand washing percentages for women in the years 2005, 2007, and 2010 respectively.The equivalent percentages for men were 75% in 2005, 66% in 2007, and 77% in 2010 [54].
Regardless of simplicity of hand washing, it is seriously important in schools, where lots of things such as desks, books, pencils, food and even germs are shared.However without adapting a proper hand cleaning regime, students and their families and friends will get quickly infected by germs.A study involved 120 secondary school students [56] revealed that 58% of female students washed their hands after using toilets and only 28% of them used soap.In contrast 48% of male students do so with only 8% of them used soap [57].
In a university campus public toilets a study focusing on the effect of introducing hand washing sign to encourage hand washing found that 61% of women washed their hand regardless to the presence of sign, this washing rate climbed to 97% in the presence of sign, while the hand washing rate for men was 37% without sign and this rate fall to 35% when a sign is displayed [58].In other study carried out in British highland washing service station toilets, showed that 65% of women and 32% of men washed their hands, but after displaying electronic screen sign the hand washing rate increased to as much as 71% for women and 35% for men [59].

Setting and Study Design
This study was a prospective microbiological evaluation.The study was performed on volunteers from four different places of public concern in city of Tripoli, Libya namely; TMC Teaching Hospital, Zawiat El-Dehmani School, El-Wahda Bank, and Sook El-Juomah Education Bureau.Three units in TMC were studied: the surgical unit, the medicine unit, and the dermatology unit.All volunteers were screened for hand contamination within 24 hours twice per week.Colonized volunteers were placed under contact precautions.Each volunteer performed six hand hygiene techniques in random order: hand hygiene with non-antiseptic soap for 10 and 30 second (s); hand washing with antiseptic soap for 10, 30 or 60 s; and hand rubbing with alcohol-based hand antiseptic.The six hand hygiene techniques were typically performed over four week by each volunteer.
The non-antiseptic soap, the antiseptic soap and the alcohol-based antiseptic used in this study are listed in Table 1.Before each monitoring period, a selective agar media were used (Nutrient agar NA; MacConkey agar MCA; Blood agar BA & Mannitol salt agar MSA), each volunteer in this study was invited to informed consent.The information included; age, sex, job category, health condition of the hands and use of antibiotics in the past month were collected from each volunteer.

Microbiological Techniques
After a procedure, three fingertips on the dominant hand of the volunteer were pressed on the surface of agar plate for approximately 15 second.In order to obtain identical conditions for each specimen, the agar was applied on to the fingers by the help of the students to obtain identical pressure.The hand hygiene technique was then performed, and a second imprint of the fingertips was obtained one minute later.Plates were incubated at 37 o C under aerobic conditions, and Colony-Forming Units (CFUs) were counted after 48 hours.The maximum count was 300 CFUS; beyond this figure, it was considered too many to count (TMTC).Potential pathogenic bacteria from transient were identified using standard microbiological techniques (Gram staining biochemical tests) and Phoenix reading using Phoenix machine (BD Phoenix ™ ID/ASTBD Diagnostic, Dickinson and Company, Sparks, MD 21152-0999) at Diseases Control Centre in Tripoli-Libya.

RESULTS
A total of 93 volunteers took part in the study Table 2; 18 from TMC surgery unit (5 physicians, 7 nurses, 3 patients, and 3 health workers HCWs); 19 from TMC medicine unit (8 physicians, 5 HCWs, 4 patients, and 2 nurses); 20 from TMC dermatology unit (4 physicians, 13 nurses, and 3 patients) 16 from school (7 teachers, 5 students, 2 officers, 1 security man, and 1 kitchen worker); 11 from bank (6 accountants, 3 security men, 1 cleaner, and 1 kitchen worker); and 9 from office (7 employees, 1 cleaner, and 1 kitchen worker).There were 53 women and 21 men, with average age of 13-50 years.All volunteers performed six hand hygiene techniques.In an investigation carried out by gram staining technique on different places of the study, the number and distribution of identified bacteria (as gram positive or gram negative) revealed that a total of 874 specimens were collected: 437 before and 437 after hand hygiene.627 (71.74%) were cultured-positive (i.e.growth) and 247 (28.26%) were cultured-negative (no growth).507 (80.86%) of positive-culture specimens were gram positive bacteria, and 120 ( A total of 44 potential pathogenic bacterial strains were isolated and identified.These bacterial strains are listed in Table 3

DISCUSSION
The study was carried out in four different places of public concern (hospital, school, bank and office) in Tripoli city-Libya, during the routine practices of volunteers.High rate of contamination was demonstrated with potential nosocomial pathogens.Approximately, 70% of specimens taken from volunteer's hands (especially HCWs) were found contaminated with at least one pathogen during their routine work.These findings agree with previous studies concerning hand hygiene which indicated that, the frequent contamination of HCWs hands [70 -74].
The results have shown that hand rubbing with an alcohol-gel is more effective than hand washing with either antiseptic soap or non-antiseptic soap in reducing bacterial contamination of volunteer's hands.This was might be due in part to the inadequate time spent in hand washing conventionally, high bacterial contamination of washing water (especially in TMC), and microbial contamination of the environmental air.
Several studies in which hands were artificially contaminated with different microorganisms have shown that hand rubbing with alcohol based products is more effective than hand washing with non-antiseptic soap or antiseptic soap [75 -89].Most of these studies incorporated supervised hand hygiene techniques to ensure conformity to usual recommendations or at least insisted on the quality of techniques.In this study, these specifications were in some instant difficult to be controlled by the students.Despite these specifications, standard techniques of hand washing were always found to be less efficient than hand rubbing in removing transit contamination on hands.Although this study was designed not to interfere with the actual practice of volunteers in terms of compliance with and quality of hand hygiene, the main objective being to evaluate the efficacy in routine work before and after performing various hand hygiene techniques Table 4.The results of this study show that hand washing with antiseptic soap was at least as ineffective as washing with non-antiseptic soap.As indicated in Table 5, the reduction of CFUs of volunteer's hands actually significantly higher after hand rubbing with alcohol gel than after soap washing.In contrast, hand washing with antiseptic soap for 60 second showed an acceptable reduction in CFUs of volunteer's hands but was not as good as hand rubbing with alcohol based gel.In a study carried out by, Larson et al. found that hand rubbing was equivalent to hand washing with antiseptic soap in reducing hand contamination [11].However, the contents of a product regarding percentage of alcohol and the type of antibacterial agents are very important factors for its efficacy in reducing hand contamination.A study by Girou et al., showed that hand rubbing products contained 75% alcohol more effective than once contained 61%., also the study added the interference of the method of hand sampling and the types of hand hygiene techniques with the efficacy of hand hygiene techniques [68].Regarding duration of washing and effect, previous studies proved that the recommended optimal duration of hand washing is 30 to 60 second.In this study, alcohol hand rubbing and hand washing were actually performed by volunteers for a similar length of time.The 30 second seems sufficient for hand rubbing with alcohol based gel but may not be long enough for hand washing with antiseptic soap and non-antiseptic soap.Most observational studies have shown that hand washing is very rare to be performed for more than 30 second [90 -92], and this study comes in agreement with this finding confirming that 30 second hand washing was ineffective in reducing bacterial contamination of hands.Therefore, the rapid efficacy of alcohol based solutions compared with hand washing, even with an antiseptic agent, is a major argument supporting their use in clinical practice [93].

RECOMMENDATIONS
The use of waterless antiseptic agent is recommended for routine hand hygiene in all clinical situations especially when hands are not visibly soiled.Importantly, antiseptic hand rub has no effect on soil, so visibly soiled hands should be washed with soap and water.
A system change supported by good management would probably be necessary in most hospitals to change a hand hygiene agent, promote and facilitate skin care for HCWs' hands.
Education especially for HCWs' hands is of great importance to improve hand hygiene practices and must be promoted at all levels of experience.The potential risks of transmission of microorganisms to patients can be addressed by implementation of proper educational programs towards hand hygiene, as well as potential risks of HCWs colonization or infection acquired from the patient.
Hand washing is simple and particularly important in places related to human activity but very serious, where lots of things are shared for examples; desks, books, pencils, food and even germs.Without proper hand cleaning, a single infection can quickly spread among people.

CONCLUSION
Hand contamination was highest in hospital (TMC), followed by school, then bank and lastly office.The highest hand contamination observed in the hospital can be attributed to the large number of pathogens that usually harbor the hospital's environment.Both antiseptic and non-antiseptic soaps did not work properly in reducing bacterial counts of worker's hands at these places, but significantly improved by an application of alcohol based gel.This comes in agreement with previous studies which revealed that; alcohols hygienic hand rub, so-called 'waterless disinfection' is significantly more efficient than standard hand washing with non-antiseptic soap and water or water alone [34,35].Bacterial reduction after hand washing with antiseptic soap (either 10, 30 or 60 seconds) or hand rubbing with alcoholbased gel was significantly greater than that obtained after hand washing with non-antiseptic soap (either 10 or 30 seconds).Therefore results of swabbing technique showed that bacterial contamination occurred on hands before and after hand hygiene procedures in which high chance of contamination (personnel, cotton swab and air) might be occurred.
Reduction in bacterial counts was observed after longer hand washing with antiseptic soap (30 and 60 seconds), but the trends were different after hand washing with non-antiseptic soap (10 and 30 seconds), and antiseptic soap for 10 seconds in which no reduction in bacterial counts was observed and this can be attributed to the water used for hand washing procedures, especially in TMC was found to be highly contaminated.In addition, air contamination was observed in all places of study was another factor affected the hand washing with antiseptic soap and non-antiseptic soap.
The predominant isolated bacteria were from transient flora: Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus capitis, Staphylococcus haemolyticus, Proteus vulgaris, Morganella morganii, and Aeromonas veronii.The specimens obtained after hand hygiene were still culture-positive in many cases of the study places when hand washing applied with non-antiseptic soap for 10, 30 second and antiseptic soap for 10 second.Microbial contamination, especially with MRS bacteria appeared in TMC specimens taken from volunteer's an environmental air, and washing water suggested a high risk for spreading pathogens and increasing the spread of HAIs, if not properly controlled.
Antibiotic Sensitivity Test (AST) was carried out for some isolated bacterial strains.All strains exhibited resistance against the most of antibiotics.

Table 5 . Bacterial contamination of the hands before and after different hand hygiene techniques. Places of Study Hand Washing Process Hand Hygiene Techniques (Finger Imprint) Using
Before hand hygiene; A, After hand hygiene; CFUs, colony forming units (average of finger imprint).