Better hygiene through humiliation?

I’ve always been a fan of shame and blame, humility and hubris, carrots and sticks.

People can be complicated.

leadAccording to The Atlantic, a number of companies have designed systems that aim to nudge doctors and nurses into washing their hands regularly. One of these devices, a badge made by Biovigil, aims to exploit a very powerful emotion: shame.

When a doctor enters an exam room, the badge chirps and a light on it turns yellow—a reminder to the doctor as well as an alert to the patient that he is about to be touched by someone with unclean hands. If the doctor doesn’t wash her hands, the light flashes red and the badge makes a disapproving noise. After the doctor waves a freshly sanitized hand in front of the badge, alcohol vapors trigger a sensor that changes the light from red to green. Other systems include HyGreen, which also uses badges; Hyginex, a wristband that can tell when a user dispenses hand sanitizer (and vibrates if he or she doesn’t); and SwipeSense, which includes a hand-sanitizer dispenser that clips onto scrubs.

Each of these devices generates a log that’s uploaded to a database of what HyGreen calls “all hand hygiene events in the hospital”—a rundown of who’s washing up, and who isn’t. The data could help hospitals engage in after-the-fact analysis of how an outbreak occurred, and, with any luck, might help them to prevent the next one.

Handwashing is never enough: Minnesota paper says require handwashing stations at petting zoos

I was talking to my friend John this morning at my church – the ice arena – while the women were skating.

amy.hubbell.skates.jul.13 We talked about getting out of the rat race, and how it was nice we had wives to sorta support us, and he mentioned he was going to the Ekka today, and I said, beware the petting zoo, and got the usual response of, I never heard there was a risk.

As the Post Bulletin in Minnesota writes, every summer, there’s an E. coli outbreak originating from a traveling petting zoo, with the latest occurring at the Olmsted County Fair.

The report that at least 13 people, including three in Olmsted County, have been sickened by Escherichia coli O157:H7 after visiting the Zerebko Zoo Tran exhibit is a reminder that even healthy, well-cared-for animals can be vectors for disease.

The Minnesota Department of Health encourages the installation of hand-washing stations near animal exhibits and the display of posters on hand-washing. Some county fairs and festivals voluntarily comply, but we believe it should go a step further and make it a legal requirement to post signs and hand-washing stations at all livestock exhibits.

Kirk Smith, an epidemiology program manager with the state Health Department, said guidelines are sent to county fair and festival managers every year, but compliance is “modest to poor, so it’s really a frustrating issue for us.”

Five percent to 10 percent of children who get infected go on to develop severe complications, said Smith, pointing an 2012 outbreak in North Carolina, where a child died of an E. coli infection after visiting a county fair.

“If parents understand that there’s any appreciable risk from a bug that can cause kidney failure that’s fatal in 5 percent of the cases, they’ll manage that risk a lot better,” Smith said.

Best practices for planning events encouraging human-animal interactions

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

A table of petting zoo outbreaks is available at http://barfblog.com/wp-content/uploads/2014/04/Petting-Zoo-Outbreaks-Table-4-8-14.xlsx.

Sanitizers or handwashing? Or both?

Installing alcohol-based hand sanitizer dispensers in classrooms may not mean fewer sick days for kids, a New Zealand study has suggested.

genitals.hand.sanitizerThe study, published today in the journal PLOS Medicine, found absence rates at schools that installed dispensers in classrooms as part of the survey were similar at those “control” schools which did not.

The research, led by Associate Professor Patricia Priest and University of Otago colleagues, involved 68 schools in Christchurch, Dunedin and Invercargill and nearly 2,500 pupils.

In schools randomly assigned to the “intervention” group, alcohol-based hand sanitizer dispensers were installed in the classrooms over two winter terms and the children were asked to use the dispensers after coughing or sneezing and on the way out of the classroom for breaks.

Dr Priest emphasizes that the study’s findings were not relevant to the importance of hand hygiene in general, nor did it change the message of cleaning hands before eating or after using the toilet, coughing or touching pets.

In a related story, the USA Today reports that alcohol-based hand sanitizers are better at killing germs and that soap and water is generally the best option but, hand sanitizers come in handy when you aren’t close to a sink.

50 sickened with E. coli last year in Brisbane; state fair risks poorly managed

For some reason, this colony of convicts refers to its mayors as “The Lord Mayor.”

ekka.petting.zooIt’s almost that time of year again for one of the city’s most loved annual events to roll into town. The Ekka will light up the RNA Show grounds at Bowen Hills from 8-17 August. If you are heading along, don’t forget to drop by Brisbane City Council’s stand in the Woolworths Pavilion. Always fun and interactive, this year’s stand showcases the many roles Council plays in our community as well as some of the things we all love about Brisbane.”

High-five.

Except last year at the Ekka, the equivalent of a U.S. state fair, at least 50 people were stricken with E. coli O157 from the animal contact in the petting zoo.

There has been no public follow up, no reference to what is being done to improve the situation this year, and no chance we’ll be attending.

Best practices for planning events encouraging human-animal interactions

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

http://barfblog.com/2013/09/49-now-sick-with-e-coli-o157-from-brisbane-state-fair-over-100-being-tested/

A table of petting zoo outbreaks is available at http://barfblog.com/wp-content/uploads/2014/04/Petting-Zoo-Outbreaks-Table-4-8-14.xlsx.

Fist bumps are less germy than handshakes

I went to the Apple store in Brisbane to fix my iPhone and got a lot of handshakes.

Then I watched staff shake a lot of other hands.

Wonder_Twins-fist-bumpI was a dumbass.

So says science.

“A short, sweet fist bump will transmit the least bacteria,” and even a high-five is better than a traditional shake, says David Whitworth, a senior lecturer in biochemistry at Aberystwyth University-Ceredigion in the United Kingdom.

Whitworth and a colleague systematically tested the three greetings for a study published Monday in the American Journal of Infection Control.

For the experiment, one of them repeatedly dipped a gloved hand into a container loaded with a not-too-dangerous strain of E. coli bacteria. The dirty-gloved scientist let the film dry, then shook, fist-bumped or high-fived the other person’s clean, gloved hand. Finally, the receiving gloves were tested for bacteria.

Result: The shakes transmitted about 10 times more bacteria than the fist bumps and about two times more than the high fives. The longest, firmest shakes transmitted the most.

In a separate round in which the gloves were dipped in paint rather than bacteria, the researchers found one rather obvious explanation: Bigger areas of the hands touched during the shakes. Handshakes also tended to last longer, but the researchers found more clinging germs even when they compared shakes to fist bumps and high-fives of the same duration.

Whitworth’s findings “are not surprising,” says Mary Lou Manning, an associate professor in the school of nursing at Thomas Jefferson University in Philadelphia and president-elect of the Association for Professionals in Infection Control and Epidemiology.

She is not enthusiastic about replacing handshakes with fist bumps in hospitals. The better, more hygienic idea, she says, is to promote rigorous hand-washing and ban hand-to-hand greetings altogether. “That’s already starting to happen” in a lot of places, she says.

Culture change isn’t about training, education and environment

Over the past decade lots of folks have been throwing around the term food safety culture to describe how a business operates. Education, training, equipment, tools, the environment, investment and support from higher-ups all influence how well an organization addresses risk, there’s something else that binds it together.

The culture, or value system, can be difference between having an outbreak or not. The values dictate decisions from the front-line staff to the CEO.

Maybe it’s the hippie in me but it’s sort of like the vibe of the organization that can be gauged by asking does anyone really care?

images-1

And if they do, do they know what they should be caring about?

The health care world struggles with the same issues, with similar consequences. According to Yahoo News the Vanderbilt University Hospital dealt with a culture change around infection control. And it’s taken six years to turn things around.

Dr. Gerald Hickson had two primary concerns after his wife’s double-knee replacement operation at Vanderbilt University Hospital in July 2008: making sure she received appropriate pain control and getting her moving as quickly as possible to avoid blood clots. But as he sat with her during her recovery, Hickson made a disturbing discovery. Most of the nurses, doctors and other hospital workers filing in and out of the room to care for his wife, who was at risk of contracting an infection after surgery, were not washing their hands.

A compulsive person by nature, Hickson started counting. He found 92 instances when staff members should have soaped up or used antiseptic foam. The total number of times they actually did? 32. Hickson did not want to humiliate anyone, but he was also fiercely committed to protecting his wife. With polite Southern collegiality, he calmly pointed out the 60 opportunities when staffers could have provided safer care but didn’t. Some staffers were immediately embarrassed. Several wondered if he was kidding, got defensive and offered explanations for their lapses. 

Hickson reported his findings to Dr. Tom Talbot, VUMC’s chief epidemiologist, and Talbot ran with it, spearheading an ambitious clean hands initiative that was launched in July 2009. Since then, hand-washing rates at Vanderbilt have jumped from 58 percent to 97 percent; at the same time, the number of several stubborn infections has dropped, one of them by as much as 80 percent. “We get into bad habits, all of us do, and sometimes we need somebody to remind us to get back on the right pathway,” says Hickson. “That’s the key to transforming health care.”

Talbot orchestrated a number of practical changes right away, including installing additional hand sanitizer dispensers at the entrance and exit of every patient’s room or bay and within easy reach inside. Staffers were instructed to clean their hands before and after every encounter with patients, even if all they planned to do was have a conversation. Even the smallest details were addressed. Clinicians who complained that their skin had become irritated by excess antiseptic gel were told to cut back to a dime-size portion, and moisturizing lotion dispensers were added throughout the hospital.

That was the easy part. Talbot knew that it would take an all-out culture shift to see dramatic improvement. A prior hand-washing program, which focused largely on education and random surveillance, had done little to boost rates. This time, Talbot drilled down on what he believed would be the keys to success: training, communication and shared accountability up and down the staff hierarchy.

Because the hospital’s top leadership would be the ultimate enforcers, Hickson and Talbot knew they needed buy-in before the program was officially launched. The old days of giving high-performing doctors a pass on unprofessional conduct — “Oh, that’s just Dr. So and So, that’s how he is” — would be over. Every hospital worker, no matter his or her rank, would be held to the same high standards. “We had to have support from leadership, so if we had pushback, we would elevate that up and they wouldn’t blink,” says Talbot. “Instead, they would say, ‘That’s not the kind of behavior we expect here.’”

Competition is a big motivator at Vanderbilt, too. Hand-washing scores for individual units and departments are tallied up from highest to lowest, and results are posted every month in break rooms and other staff areas so that everyone can see how his or her team compares with the one down the hall. “You want to look better than other services when that scorecard comes out,” says Johnson. “You don’t want to be at the bottom. That’s just human nature.”

Today, after more than 200,000 hand-washing observations, Vanderbilt’s overall hand-washing compliance rate has almost doubled. At the same time, three major types of infections linked to the insertion of tubes and catheters have been reduced considerably, according to Talbot. Urinary tract infections related to catheters in intensive care units have dropped by 33 percent; pneumonia linked to ventilators by 61 percent; and bloodstream infections associated with central lines — the tubing that delivers fluids and medications to patients — by 80 percent in ICUs.

Culture change is not about mission statements and core values written on a poster. It’s about fostering feelings within the organization from top-to-bottom that this stuff matters.

Sanitizers not enough says UK; wash hands after visiting the farm

The UK Public Health Agency (PHA) is reminding families about the importance of washing hands after visiting the farm.

petting.zoo.handwash.10All animals naturally carry a range of organisms, some of which can be transmitted to people. Some organisms which may be contracted on farms present a serious hazard and can potentially cause severe infection, particularly in young children.

To reduce the risk of illness, both adults and children should wash their hands thoroughly using soap and water after they have handled animals or touched surfaces at the farm and always before eating or drinking.

Antibacterial hand gels and wipes are not a substitute for washing hands with soap and water, as gels and wipes may be unable to remove contamination in the way that running water can. However, using such gels after hand washing with soap and water may reduce further the risk of picking up these infections.


Dr Philip Veal, Consultant in Health Protection at the PHA, said: “Farm animals often carry a range of organisms which can be passed to children and adults. These organisms can include serious infections such as E. coli O157 which is extremely contagious and easily passed from animals to children and then within the household.

“Hand washing with soap and water will reduce the risk of picking up these infections, which can be particularly harmful to young children. By being aware and by doing these simple things we can help to avoid illness and enjoy a fun day out.”

Best practices for planning events encouraging human-animal interactions

03.Apr.14

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of

zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

Hawthorne effect: hand hygiene rates increase three-fold when auditors visible

Hand hygiene rates were found to be three times higher when auditors were visible to healthcare workers than when there were no auditors present, according to a study in a major Canadian acute care hospital.

handwash_south_park(2)The study, titled, “Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study,” published today on-line in the BMJ Quality & Safety Journal, by first author Dr. Jocelyn Srigley, who did the study as part of her Master’s thesis while a Clinical Fellow in Infection Prevention and Control at University Health Network and University of Toronto and senior author Dr. Michael Gardam, Director, Infection Prevention and Control, University Health Network and Women’s College Hospital. Link: http://qualitysafety.bmj.com/cgi/rapidpdf/bmjqs-2014-003080?ijkey=JPbRe7gYzAFsm1Z&keytype=ref

The study examined the Hawthorne effect, also known as observation bias – the tendency of people to change their behavior when they are aware of an observer – using an electronic monitoring hand hygiene system in real-time, eliminating many of the biases inherent to human observation. Ultrasound “tags” on soap dispensers transmitted a signal to a nearby receiver each time the levers were pushed, and a time-stamped hand hygiene wash was recorded in a central data base.

Two inpatient units in University Health Network were electronically monitored, with 60 healthcare workers volunteering to be part of a study of the electronic monitoring system. Staff were aware that data would be used in a variety of studies, but were “blind” to the questions asked in the studies. Auditors did not announce their presence during audits but wore white lab coats. Auditors were also blinded to the questions asked in the research. Hand hygiene dispenses were electronically measured while the auditors were visible, and were compared to the same locations prior to the arrival of the auditors at one, two and three weeks before the audit, as well as to a different area of the unit not visible to the auditor. Auditors typically did not go into patient rooms, so separate hand washing rates were determined for dispensers inside patient rooms and those in hallways. Twelve audits were included between November 2012 and March 2013.

handwash.water.jpgThe study found that there was an approximately three-fold increase in the rate of hallway hand washes per hour amongst healthcare staff when an auditor was visible (3.75 per hour), compared to a location where the auditor was not visible (1.48 per hour) and to the previous weeks (1.07 per hour). Hand washing rates with the auditor present were compared to separate groups at different time periods and locations to ensure that the differences found were not due to hand hygiene patterns that could be attributable to time of day or location. In each instance, the hand washing rates were significantly higher when the auditors were present, with the increase occurring after the auditors’ arrival, suggesting that the arrival of the auditor triggered the increase in hand hygiene.

“The difference in hand hygiene rates, when an auditor is present compared to those times when one is not, is huge in this study, and we showed this effect to be very consistent,” says Dr. Gardam, who is also an Associate Professor of Medicine at the University of Toronto.

“The magnitude of what we found calls into question the accuracy of directly observed hand hygiene rates and the usefulness of measuring and reporting them,” says Dr. Gardam. “That said, human auditing of hand hygiene has been helpful to draw attention to this important preventative measure—we just can’t stop focusing on it because our posted rates are not nearly as high as we think they are.”

Dr. Srigley says that although the researchers were “surprised at the tripling effect” of having an auditor present, there may still be some value in doing audits as there could be opportunities for in-the-moment education with health care staff. Dr. Srigley is the Associate Medical Director of Infection Prevention and Control at Hamilton Health Sciences, composed of seven hospitals in the Hamilton area.

Dr. Gardam suggests that a “front-line staff ownership” approach which engages rather than “nags” staff is a good option. This approach was first brought to University Health Network about six years by Dr. Gardam, in which front-line staff have developed their own reminders to influence staff to wash their hands, including: pancake breakfasts, public unit reporting, pledges, posters, and holding each other accountable.

“We need to change how we look at these complex problems,” says Dr. Gardam, “We need to help people change by engaging them and having them come up with local solutions.”

Tea towels should only be used once, then washed?

hitchiker.towelNever be anywhere without a towel.

A tea towel (or dish towel).

But do I need 50 clean ones a day?

New South Wales Food Authority chief scientist Lisa Szabo said last week that, “Tea towels should be replaced after every use. … It’s best to wash tea towels after each use and have a good supply of fresh ones to hand.”

That’s a lot of washing for anyone who has cooked from scratch.

So I reached out to friend of the barfblog, Dr. Don ‘Data’ Schaffner, who offered what seems to be reasonable advice: use disposable paper towels towelyafter a handwash where pathogens may be present, and a dish towel for other things. He has a paper coming out on the topic, but is a strong believer, like me, in peer-review and publish before press release.

Toilet psychology: why do men wash their hands less than women?

By hiding in toilet cubicles for a new study, psychologists observed how long people spend using the loo, and how long they wash their hands for afterwards. That men usually wash their hands less conscientiously than women is a well-established finding. Thomas Berry and his colleagues wanted to find out more about the reasons for this gender difference.

toilet.hideFor one day, between 10am and 4pm, a male researcher secreted himself inside one of three cubicles in a gents toilet facility at a U.S. University. For optimal observational purposes he chose the cubicle adjacent to a row of three urinals. Nearby, in a similarly designed female toilet facility, a single female researcher positioned herself in one of the three cubicles available. Don’t worry, both researchers were provided with a “customised wooden bench” for comfort.

They were also equipped with stopwatches. The researchers used an “unobtrusive sight procedure” – that is, they spied on other visitors to the lavatories using the gaps beneath and by the side of the cubicle doors (for some reason, US toilet cubicles always have a gap of about a centimetre either side of the door). The researchers also used an “acoustic procedure”. That is, they listened to the visitors’ actions. The study authors explained:

“… research assistants recorded the facility [urinal or cubicle], and then started a stopwatch when the patron’s feet stood relatively still. For the men, the research assistants also recorded the orientation of the feet to gauge the patron’s use of the commode (i.e. as a commode or a urinal). When research assistants heard the flushing of the patron’s commode or urinal the stopwatch was turned off … and the duration of the restroom event was recorded.”

Similar procedures were followed for recording each visitor’s “hand washing event” if there was one. A clever twist was that for part of the study, the researchers put “out-of-order” signs over the men’s urinals. This was to see how much they’d hand wash if they were forced to urinate in a cubicle, rather than at a urinal.

The psychologists managed to observe the toilet behaviour of 34 women using cubicles; 32 men who used a cubicle to defecate; 40 men who had no choice but to use the cubicles for urinating (because of the out-of-order signs); and 64 men who used a urinal. The bare statistics show that the hand-washing rates for these four groups were 91 per cent, 87.5 per cent, 75 per cent and 59.4 per cent, respectively.

The difference in hand washing rates between women using a cubicle and men using a cubicle (for defecating) was not statistically significant. In contrast, both women using a cubicle, and men using a cubicle (for defecating), showed significantly higher hand-washing rates than men who used a urinal.

The data are somewhat compromised because, as the researchers delicately put it – the women’s “facility use is a constant (i.e., commode) and their behaviour (urination, defecation, or menstrual care) is confounded within the one environment.” However, taken together, the results suggest that the reason men wash their hands less than women overall, is not because of gender norms (i.e. men are less bothered about being clean), but because of the differences in the toilet environment and toilet behaviour for men and women. In fact, after using a toilet cubicle to defecate, men tended to wash their hands for longer than women (but remember we don’t know what the women had been doing).