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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 120-124

Impact of COVID-19 pandemic on individual hand hygiene infection control practices among healthcare workers: A questionnaire-based survey


1 Department of Pulmonary Medicine, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Community Medicine, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Microbiology, AIIMS, Rishikesh, Uttarakhand, India
4 Department of Internal Medicine, AIIMS, Rishikesh, Uttarakhand, India
5 Department of Pathology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission04-Dec-2020
Date of Decision16-Feb-2021
Date of Acceptance19-Apr-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Mihir Raman Gangakhedkar
Flat 306, Swastik Apartment, Barrage Colony, Near Hotel Heritage, Off Virbhadra Road, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_194_20

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  Abstract 


Background: COVID-19 is primarily transmitted by droplets, aerosols and fomites. While adequate hand hygiene (HH) practice has already been proven to reduce transmission of pathogens and prevent infection, its role in checking cross-contamination with SARS-CoV-2 appears paramount. Aim: To assess the impact COVID 19 has had on individual HH practices among health care workers (HCW) at a tertiary health care center. Patients and Methods: A cross-sectional survey was conducted among HCWs for a period of 15 days from May to June 2020. The survey was distributed online via Google Forms after acquiring permission from Institutional Ethics Committee. Results: Two hundred and three completed survey questionnaires were received, primarily from nursing officers (42.4%) and residents (38.9%). Comparison of pre- and post-COVID-19 habits revealed a significant change in awareness regarding hand washing steps (87%–100%), practicing all steps of hand washing (66%–99%), washing hand before and after touching patient (55%–92% and 77%–100%, respectively), washing hands before going home (30%–91%), washing hands despite wearing gloves (21%–80%) and after touching patient's surroundings (46%–92%). Another significant finding observed was that almost 72% of the respondents took time to educate someone close by in HH and washing steps. Conclusion: The pandemic has seen an improvement in practices of HH. This change will not only impact the transmission of SARS-CoV-2, but every infectious disease spread similarly. Moreover, educating the general public would help in curbing the spread of COVID-19.

Keywords: COVID-19, hand hygiene, my five moments, preventive medicine, respiratory communicable diseases


How to cite this article:
Sharma P, Gangakhedkar MR, Bahurupi YA, Gupta PK, Prakash V, Dua R, Sharma K, Saini LK. Impact of COVID-19 pandemic on individual hand hygiene infection control practices among healthcare workers: A questionnaire-based survey. J Med Evid 2021;2:120-4

How to cite this URL:
Sharma P, Gangakhedkar MR, Bahurupi YA, Gupta PK, Prakash V, Dua R, Sharma K, Saini LK. Impact of COVID-19 pandemic on individual hand hygiene infection control practices among healthcare workers: A questionnaire-based survey. J Med Evid [serial online] 2021 [cited 2021 Sep 25];2:120-4. Available from: http://www.journaljme.org/text.asp?2021/2/2/120/324958




  Introduction Top


The medical community has come a long way since the extra-ordinary sacrifice of Semmelweis in the late 19th century. Nearly four decades after his death, we had the infamous 'typhoid mary'. Poor hand hygiene (HH) has been identified to be responsible for puerperal sepsis, the transmission of faeco–oral infections, catheter-related bloodstream infections, resistant and sensitive Staphylococcus aureus infections, surgical site infections and the list goes on.[1],[2],[3],[4],[5] One would anticipate that with such an abundance of literature relating to the ill effects of poor HH practices, there would be sufficient 'health literacy' among the healthcare professionals (HCPs). However, similarly, there is abundant literature to show the contrary being true.[6],[7],[8]

The coronavirus pandemic of 2020 has forced the hand of health administrators and HCPs towards enforcing appropriate HH practices. Adequate practice of HH in the hospital setting is a well-known method to prevent cross-transmission of various microorganisms and decrease chances of healthcare-associated infections. The extraordinary steps taken worldwide to control this pandemic have also led to panic-driven hoarding of consumables such as sanitisers, disinfectant soaps and even toilet paper![9],[10] The fear of contracting the illness or contributing to the spread has even led to commercial establishments making hand washing mandatory.

Regular screening and reinforcement of proper HH practices is a must for not only COVID-19 but also for every infectious disease. Each hospital should formulate a policy to regularly conduct a direct contact/survey-based assessment of infection control practices being adequately implemented and followed by healthcare workers (HCWs).

This study aimed to assess the qualitative and quantitative differences in appropriate hand washing techniques among HCPs as compared to pre-pandemic practice at our institute.


  Methodology Top


After requisite permissions from the Institutional Ethics Committee (IEC/20/277 dated 22nd May 2020), an online questionnaire was circulated in the Google Form format amongst HCPs at the institute inclusive of faculty, residents and nursing officers. The survey questionnaire was floated over a period of 2 weeks from 29th May to 12th June 2020. Participation was voluntary and consent was provided on the online platform itself. Questions were framed in the manner of pre- and post-COVID-19 pandemic changes in HH practice followed by an individual.

Statistics

The test results were compared using the McNemar's test (for paired proportions) and Fisher's exact test (for independent proportions) for identifying the significance of the effect of the pandemic on the HH practices.


  Results Top


Demographics

During the 15 days of the study period, 203 respondents participated in the study. Participants were predominantly nursing officers (42.4%) followed by resident doctors (38.9%. The predominant age group of the study participants ranged from 30 to 40 years, with male-to-female ration of 1.2:1. The study participants mainly belong to non-ICU area, as shown in [Table 1] with other demographic profile.
Table 1: Demographic details of participants

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Changes in hand hygiene practices

All the respondents had received training in HH practices, i.e., 66% prior and all (100%) during preparation of hospital to combat COVID-19.

Statistically significant difference was observed amongst respondents considering awareness of steps (87%–100%) and practicing all steps of hand washing (66%–99%) between pre-COVID-19 and post/during COVID-19 spread in the country. HCPs also showed A significant improvement in practicing adequate practices during patient care as suggested by the WHO (my five moments for HH).

Only 30% of HCPs used to wash hand adequately before leaving for home earlier, and 91% started doing so during this time.

Moreover, 71.9% of the respondents had taken the time to educate fellow HCPs, family members, patients or members of the civil society in appropriate HH practices. Nearly all respondents (98%) felt that hand washing was an effective method in combating the spread of COVID-19 disease.

The comparative data of hand washing practices before the pandemic and after it began are shown in [Table 2].
Table 2: Comparison of hand hygiene practices prior and during/after COVID 19

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Respondents living with high risk population (n=28, 14%) had better HH practices in terms of washing hands prior to going home, wore gloves during any procedure and had greater chance at educating society members about benefits of proper hygiene practices in prevention of transmission/contracting COVID 19 than the respondents living independent of such high risk population (though the difference was not statistically significant) [Table 3]. Moreover, respondents living with high risk group had statistically significant change in hand hygiene practices from pre to during COVID 19 pandemic.
Table 3: Comparison of current situation hand hygiene practices between healthcare workers staying with high-risk population and those staying independently

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The respondents uniformly reported better availability of soap and water for hand washing and alcohol-based sanitisers after the pandemic (97.5% and 98%, respectively) as compared with before the pandemic (65% and 94%, respectively).

Four of the five questions asked to gauge the participants understanding as regards the subject of HH had more than three-fourth of the respondents answering appropriately [Table 4].
Table 4: Knowledge based assessment regarding understanding of hand hygiene practices

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  Discussion and Conclusion Top


The COVID-19 pandemic has had disastrous health consequences with more than 15 million cases worldwide and 0.6 million deaths at the time of writing this article. However, the fear of disease and its consequent morbidity have resulted in an international emphasis on the need for appropriate HH measures. WHO, in its interim guidance, has recommended an improvement in the provision of HH facilities at all healthcare centres in its member states and mandatory usage of a public HH station for people travelling publicly and when entering or exiting commercial arenas.[11]

Dialogue and re-emphasis on better HH were absolutely essential given the abysmal findings of the 'WASH in Health Care Facilities' report published by the WHO in 2019, which showed that less than half of the healthcare facilities had hand sanitation measures available at point of care, and nearly 40% of the world's population has no access to HH facilities at their homes.[12]

The pivotal findings of Semmelweis eventually did bring about a change, but we still find HH not getting its due respect universally. Tyagi et al., in their observational study, showed a poor compliance with HH (35%) while doing per vaginal examinations across 35 labor rooms in two southern states of India.[6] In the same study, they identified a meagre 12% of contact with new-born children was in compliance with all steps of HH, across 30 public sectors' neonatal units. Nair et al. administered the WHO HH questionnaire to medical students and nursing students, only to identify a paltry 9% having adequate knowledge with a better understanding amongst the nursing students.[13] Similarly, a study done amongst 523 undergraduate medical students by Modi et al. identified that only 12% had good HH knowledge with 57% participants having never received formal training in HH practices.[14]

Goyal et al. found that with nearly 92% of their participants having received formal HH training within 3 years, the overall correct knowledge score was about 71.6%, which further shows the importance of formal training.[15]

Our institute includes a HH workshop as mandatory training for all HCPs. This contributed to the large 76% having received the training before the pandemic itself and the fulfilment to 100% after the pandemic had begun with further intensive training.

Similarly, being professionals involved in clinical care at an apex institute, we had a high number of participants being aware of appropriate HH practices, but that did not necessarily translate into practice. The pandemic, however, made even that one-third of the participant population keen on compliance with all steps of hand washing. Goyal et al. also showed that vigilance played an important role in ensuring appropriate HH practice.[15]

All the WHO recommendations on HH clearly state that regardless of the use of gloves, HH must be performed at each of the 'five moments of hand hygiene'.[16] Despite adequate knowledge as regards HH practices, one in every five respondents did not adhere to appropriate HH after removal of gloves, in our study. This is in line with several studies that have reported that glove usage is associated with poorer HH, possibly out of complacency.[17] Gloves should not be considered as a replacement of HH.

In a throwback to the times of typhoid mary, the HH practice study, performed by Water Aid in rural India in 2017, showed that when asked to recall within the previous 24 h, a staggering 70% reported to have not washed their hands before serving food and nearly 50% reported not having washed hands before making a meal.[18] This thereby emphasised the need for educating the general population regarding HH practices and also the lack of availability of appropriate facilities at every home.

More than 70% of our participants attempted to educate other individuals in HH practices, which is an encouraging sign as voluntary dissemination of such crucial information is vital to social involvement in healthcare policy. Dissemination of HH habit in the society helps in prevention of not only COVID transmission but also other infectious diseases endemic in this region of country. Although the number of participants reporting absence of alcohol-based sanitisers before the pandemic was only 6% (which improved to 2%), the dramatic improvement in the availability of soap and water for cleaning hands (from 65% to 97%) with the pandemic reflects well on the hospital infection control committee's focus to improve HH practices in the institute. Moreover, the difference reported could be due to increased awareness towards regular hand washing rather than availability.


  Conclusion Top


With steadily rising incidence statistics globally, the end of the COVID-19 pandemic is not yet in sight. Global efforts for a vaccine are yet to bear fruit, and a definite pharmacological solution for treating the patients is still to be identified. Such challenges force us to fall back on the very basics of disease control science and that is prevention via appropriate HH practice.

Our study has shown that appropriate training and education definitely brings about a change in practice, even with high pre-intervention proportions of good practice. In addition, it also shows that even with appropriate knowledge often, its practice lags behind until an individual is motivated suitably to follow the same. The pandemic has proved to be a morbid motivator for much needed improvement in health hygiene practices.

Clinical implications/future directions

A pandemic of the proportion presently being experienced by the world makes us take a step back to prepare for a similar eventuality in the future in a better manner. The first step towards such a preparation is improving health literacy. This literacy is not limited to the general public; in fact, it is vital to achieve this in the HCWs who will be the first responders to these catastrophes and thereby, sadly, the potential units of further spread. Our study can serve as a guide to identifying the effects of policies or events on a particular institute's prevention practices, HH being the most important of them.

Acknowledgement

We wish to thank all the respondents for providing their inputs honestly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Semmelweis I. Etiology, Concept, And Prophylaxis Of Childbed Fever. 1st. Carter KC, Madison WI: The University of Wisconsin Press; 1983. p. 120-147.  Back to cited text no. 1
    
2.
Mortimer EA Jr., Wolinsky E, Gonzaga AJ, Rammelkamp CH Jr. Role of airborne transmission in staphylococcal infections. Br Med J 1966;1:319-22.  Back to cited text no. 2
    
3.
Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Crit Care Med 2009;37:2167-73.  Back to cited text no. 3
    
4.
Shahid NS, Greenough WB 3rd, Samadi AR, Huq MI, Rahman N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res 1996;14:85-9.  Back to cited text no. 4
    
5.
Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2016;(1):CD004288. Published 2016 Jan 22. doi: 10.1002/14651858.CD004288.pub3. PMID: 26799160.  Back to cited text no. 5
    
6.
Tyagi M, Hanson C, Schellenberg J, Chamarty S, Singh S. Hand hygiene in hospitals: An observational study in hospitals from two southern states of India. BMC Public Health 2018;18:1299.  Back to cited text no. 6
    
7.
Engdaw GT, Gebrehiwot M, Andualem Z. Hand hygiene compliance and associated factors among health care providers in Central Gondar zone public primary hospitals, Northwest Ethiopia. Antimicrob Resist Infect Control 2019;8:190.  Back to cited text no. 7
    
8.
Hussain SA. Hand hygiene amongst health workers in a teaching hospital - A Kap study. Ann Epidemiol Public Health 2018;1:1005.  Back to cited text no. 8
    
9.
Lazarus D. Stockpiling sanitizer, toilet paper is understandable. But is it rational? Los Angeles Times. Business Column; March 5, 2020. Available from: https://www.latimes.com/business/story/2020-03-05/column-coronavirus-panic-buying. [Last accessed on 2020 Dec 03].  Back to cited text no. 9
    
10.
Ferguson D. Panic Buying Depletes Supplies of Disinfectant Wipes Distributed by Langley Homeless Assistance Agency. Langley Advance Times. Local News; Mar 18, 2020. Available from: https://www.langleyadvancetimes.com/news/panic-buying-depletes-supplies-of-disinfectant-wipes-distributed-by-langley-homeless-assistance-agency/. [Last accessed on 2020 Dec 03].  Back to cited text no. 10
    
11.
World Health Organization. WHO Interim Recommendation on Obligatory Hand Hygiene against Transmission of COVID-19; April, 2020. Available from: https://www.ircwash.org/resources/who-interim-recommendation-obligatory-hand-hygiene-against-transmission-covid-19. [Last accessed on 2020 Dec 03].  Back to cited text no. 11
    
12.
World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) 2019. WASH in Health Care Facilities: Global Baseline Report 2019. Available from: https://apps.who.int/iris/bitstream/handle/10665/311620/9789241515504-eng.pdf?ua=1. [Last accessed on 2020 Dec 03].  Back to cited text no. 12
    
13.
Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur, India. ISRN Prev Med 2014;2014:608927.  Back to cited text no. 13
    
14.
Modi PD, Kumar P, Solanki R, Modi J, Chandramani S, Gill N. Hand hygiene practices among Indian medical undergraduates: A questionnaire-based survey. Cureus 2017;9:e1463.  Back to cited text no. 14
    
15.
Goyal A, Narula H, Gupta PK, et al. Evaluation of existing knowledge, attitude, perception and compliance of hand hygiene among health care worker in a Tertiary Care Centre in Uttarakhand. J Family Med Prim Care 2020;9:1620-7.  Back to cited text no. 15
  [Full text]  
16.
World Health Organization. Hand Hygiene: Why, How & When? Revised August, 2019. Available from: https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf. [Last accessed on 2020 Dec 03].  Back to cited text no. 16
    
17.
Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, et al. “The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol 2011;32:1194-9.  Back to cited text no. 17
    
18.
WaterAid India. Spotlight on Handwashing in Rural India. Findings from a Study on Hand Hygiene Related Knowledge and Practices in Four Indian States; 2017. Available from: https://www.outlineindia.com/othermedia/1531392037.Hand-hygiene-study.pdf. [Last accessed on 2020 Dec 03].  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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