Hand hygiene is a general term that applies to hand sanitizers or surgical hand sanitizers.  The Centers for Disease Control and Prevention (CDC) defines these activities as follows:
- Wash your hands – wash your hands with plain (i.e. non-antibacterial) soap and water.
- Hand Sanitizer – Refers to hand sanitizer or hand sanitizer.
- Surgical hand antiseptics – Hand sanitizers or antiseptic hand sanitizers administered by surgical personnel prior to surgery eliminate transient hand flora and reduce resident hand flora.
Good hand hygiene is an important aspect of protecting yourself and others from the spread of infection. It is one of the most effective ways to prevent hospital care-associated infection rates.  Failure to perform proper hand hygiene is believed to result in Healthcare-associated infections and the spread of multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) , have been implicated as important factors in outbreaks. 
For visibly soiled hands, hand washing with soap and water is recommended , which is the best way to remove germs in most cases. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. These disinfectants are the most Effective in reducing the number of bacteria and viruses on hands and recommended for routine hand decontamination for all clinical indications unless hands are visibly soiled. 
Cleaning your hands is a simple and effective way to reduce the spread of infection from one person to another and throughout your community, from your home and workplace to childcare facilities and hospitals. 
Importance of Hand Hygiene
Normal human skin is teeming with microbes, and while those microbes vary from person to person, they are generally relatively stable for any given person. There are two types of plants on hand :
- Transient flora – usually acquired during direct contact with patients or contaminated surfaces. It colonizes the superficial layer of the skin. It is most commonly associated with healthcare-associated infections and can be removed by hand washing.
- Resident Flora – Attaches to the deeper layers of the skin. It is less likely to be removed and is less likely to be associated with healthcare-associated infections.
When these microorganisms are pathogenic, they may pose a potential risk to patients and healthcare facilities by:
- Transmitting microorganisms to patients.
- Colonization or infection of health care workers by organisms acquired from patients.
- Morbidity, mortality and costs associated with healthcare-associated infections.
Transmission of a pathogen from one patient to another requires the following sequence of events:
- Organisms present on the patient’s skin or spilled onto inanimate objects near the patient can be transferred to the hands of the caregiver.
- These creatures must be able to survive in the hands of personnel for at least several minutes.
- Subsequent hand washing or hand sanitizing by caregivers must be inadequate or omitted entirely, or the reagents used for hand hygiene must be ineffective.
- Finally, the contaminated hands of the caregiver must come into direct contact with another patient or an inanimate object that will come into direct contact with the patient.
Teaching people to wash their hands helps them and their communities stay healthy.
Handwashing Education in the Community:
- Reduce the number of people suffering from diarrheal diseases by 23-40%
- Reduced diarrheal disease in people with weakened immune systems by 58%
- Reduce respiratory illnesses such as colds by 16-21% in the general population
- Reduced absenteeism due to gastrointestinal disorders in school children by 29-57%
Indications for Hand Hygiene
CDC  describes the following indications for hand washing and hand sanitizing:
- Wash hands with non-antibacterial soap and water or antibacterial soap and water when hands are visibly soiled or contaminated with proteinaceous material or visibly soiled with blood or other body fluids.
- If hands are not visibly soiled, use alcohol-based hand rub for routine hand disinfection in all other clinical situations described in the item.
- Sanitize hands before coming into direct contact with patients.
- When inserting a central intravascular catheter, sanitize hands before putting on sterile gloves.
- Disinfect hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery.
- Decontaminate hands after touching the patient’s intact skin (for example, when taking pulse or blood pressure and lifting the patient).
- Decontaminate hands after contact with body fluids or excreta, mucous membranes, broken skin, and wound dressings (if hands are not visibly soiled).
- Decontaminate hands if moving from contaminated to clean body parts during patient care.
- Decontaminate hands after touching inanimate objects near patients, including medical equipment.
- Sanitize hands after removing gloves.
- Wash your hands with non-antibacterial soap and water or antibacterial soap and water before eating and after using the toilet.
- Antibacterial-impregnated wipes (i.e., towelettes) may be considered an alternative to washing hands with non-antibacterial soap and water. Because they are not as effective as alcohol-based hand sanitizers or washing your hands with antibacterial soap and water to reduce the number of germs on your hands For healthcare workers, they are not a substitute for using alcohol-based hand sanitizers or antibacterial soaps.
- If exposure to Bacillus anthrax is suspected or confirmed, wash your hands with non-antibacterial soap and water or antibacterial soap and water. The physical act of washing and rinsing hands is recommended in this situation because alcohol, chlorhexidine iodophor and other preservatives The agent is less active against spores.
Methods of Hand Hygiene
Get the poster here
Get the poster here
Washing with Soap
There are 5 steps to proper hand washing :
- Wet your hands with clean running water (warm or cold), turn off the tap and apply soap.
- Rub hands with soap to work up a lather. Apply lather to back of hands between fingers and under nails.
- Scrub hands for at least 20 seconds. Need a timer? Hum “Happy Birthday” twice from beginning to end.
- Rinse hands thoroughly under clean running water.
- Dry hands with a clean towel or air dry. Turn off the tap with a towel!
Water temperature did not affect microbial removal. A report  investigated the effect of a temperature range of 5°C to 50°C on the removal of different types of bacteria, showing that heat did not affect transient or residual flora. Instead rub thoroughly rinse and Contact time was identified as the most important factor for effective hand washing.
Which soap should be used? Antibacterial soap is no more effective than regular plain soap at preventing Covid infection.   Therefore, in household and public non-healthcare settings, plain soap is recommended. Taking the time to wash your hands is effective. When to Use Liquid Soap Preferable to a bar of soap because it reduces the risk of spreading an infection from one person to another. However, soap or liquid soap will do, according to the CDC. 
What you need to know from the CDC about hand washing:
Handwashing Video from the WHO:
Alcohol-Based Hand Sanitiser
When using alcohol-based hand sanitiser:
- Apply product to palm of one hand and rub hands together
- Cover all surfaces of hands and fingers until feeling dry
- This should take around 20 seconds
Surgical Hand Antisepsis
This is performed by the surgeon preoperatively to eliminate transient and reduce resident hand flora:
- Remove rings, watches and bracelets before starting a surgical hand scrub
- use a nail cleaner under running water to remove debris from under the nail
- Prewash hands and forearms with non-bacterial soap for 40-60 seconds, then dry hands and forearms with a single-use towel.
- Apply an alcohol-based product according to the manufacturer’s instructions and allow hands and forearms to dry thoroughly before putting on sterile gloves.
If skin health is affected, lotions and creams are recommended to prevent irritation.
Factors Affecting Adherence
There are many factors that affect healthcare professionals’ adherence to hand hygiene practices. Adapting the findings of Pittet , the CDC proposes the following reasons for variable adherence.
Observed risk factors for non-adherence to recommended hand hygiene practices:
- Physician status (rather than a nurse)
- Nurse Aide Status (not Nurse)
- Male sex
- Working in an intensive-care unit
- work during the week (vs. weekends)
- Wearing gowns/gloves
- Automated sink
- Activities with high risk of cross-transmission
- Hand Hygiene Opportunities Abound for Hourly Patient Care
Factors for poor self-reported hand hygiene compliance:
- Hand sanitizers can cause irritation and dryness
- Inconvenient sink location/shortage of sinks
- Lack of soap and paper towels
- Often too busy/insufficient time
- The patient needs to take priority
- Hand Hygiene Affects Healthcare Worker-Patient Relationship
- low risk of infection from the patient
- Gloves/glove use obviates the need for hand hygiene
- Lack of guidance/protocol knowledge
- Not thinking about it/forgetfulness
- No role model for colleagues or supervisors
- Doubts about the value of hand hygiene
- Disagreement with the recommendations
- Lack of scientific information on the clear impact of improved hand hygiene on rates of healthcare-associated infection
Other perceived barriers to proper hand hygiene:
- Lack of active participation in hand hygiene promotion at individual or institutional level
- Lack of role model for hand hygiene
- Lack of institutional priority for hand hygiene
- Lack of administrative penalties for violators/rewards for compliance
- Lack of institutional safety climate
Addressing these predictors of poor adherence in your healthcare setting can promote good hand hygiene practices among your workforce. An easy win would be:
- Provide education and uphold culture through performance feedback.
- Easy access to hand hygiene materials. For example, place alcohol-based hand products at every bedside or in every consulting room.
- Potential for hand contamination due to undetected holes in examination gloves
- Contamination may occur when gloves are removed
- Wearing gloves does not replace the need for hand hygiene
- Failure to remove gloves after caring for a patient may result in the spread of microtissues from one patient to another
Hand Hygiene Considerations in Disasters and Conflicts
Sanitation is especially important in disaster and conflict settings such as floods, cyclones or earthquakes, but clean and safe running water is sometimes difficult to find. If your tap water is unsafe to use, wash your hands with soap and boiled or sanitized water. Temporary hand A large jug filled with clean water, such as boiled or sterilized water, can be used to create a washing station. 
Gloves are often used inappropriately in disaster and conflict settings. Even in short supply, gloves are single-use and should be disposed of safely after contact with patients and not reused. Exam gloves should only be used where there is a risk of direct blood contact Liquid excretions or items soiled with such materials. Routine patient contact does not require gloves when there is no risk of contact with blood or body fluids or a contaminated environment. 
- Centers for Disease Control and Prevention. Wash your hands: Clean hands save lives.
- CDC’s downloadable poster promoting handwashing
- Downloadable WHO hand hygiene 5-minute poster
- Hand Hygiene: Why, How & When? from WHO
- WHO Guidelines for Hand Hygiene in Health Care – First Global Patient Safety Challenge – Clean Care is Safer
- How to wash your hands videos from the NHS (UK)
- ↑ Jump up to:1.0 1.1 1.2 Centers for Disease Control and Prevention. Handwashing: Clean hands save lives. Available from:https://www.cdc.gov/handwashing/index.html (accessed 13 March 2020)
- ↑ World Health Organization. Evidence of hand hygiene to reduce transmission and infections by multi-drug resistant organisms in health-care settings. WHO. 2014.
- ↑ Centers for Disease Control and Prevention. MRSA. Available from:https://www.cdc.gov/mrsa/index.html (accessed 14 March 2020)
- ↑ Jump up to:4.0 4.1 4.2 Boyce, J.M. and Pittet, D., 2002. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control & Hospital Epidemiology, 23(S12), pp.S3-S40.
- ↑ Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, Van Driel ML, Foxlee R, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. Bmj. 2009 Sep 22;339:b3675.
- ↑ Ejemot‐Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane database of systematic reviews. 2008(1).
- ↑ Jump up to:7.0 7.1 Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. American journal of public health. 2008 Aug;98(8):1372-81.
- ↑ Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, Prüss‐Ustün A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. Systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine & International Health. 2014 Aug;19(8):906-16.
- ↑ Huang DB, Zhou J. Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. Journal of medical microbiology. 2007 May 1;56(5):659-63.
- ↑ Wang Z, Lapinski M, Quilliam E, Jaykus LA, Fraser A. The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review. American journal of infection control. 2017 Jun 1;45(6):682-9.
- ↑ Recommendations from the CDC Guideline for Hand Hygiene in Healthcare Settings, by the Healthcare Infection Control Practices Advisory Committee, 3MHealthCarehttps://multimedia.3m.com/mws/media/309799O/cdc-guidelines-reprint.pdf
- ↑ “Handwashing – Clean Hands Save Lives | CDC.” https://www.cdc.gov/handwashing/index.html. Accessed 13 Mar. 2020.
- ↑ The WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft)https://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5B3%5D.pdf Accessed on 13/March/2020.
- ↑ Jump up to:14.0 14.1 CDC. What You Need To Know About Handwashing Transcript. Reviewed 23 July 2019
- ↑ Minnesota Department of Health. Which Soap is Best? Last updated 9 March 2020
- ↑ Centers for Disease Control and and Prevention.What You Need To Know About Handwashing. Published on 16 December 2019. Available from https://www.youtube.com/watch?v=d914EnpU4Fo&feature=emb_logo. [last accessed 17 March 2020]
- ↑ World Health Organisation. WHO: How to handwash? With soap and water. Published on 20 October 2015. Available fromhttps://www.youtube.com/watch?time_continue=1&v=3PmVJQUCm4E&feature=emb_logo. [last accessed 17 March 2020]
- ↑ WHO: How to handrub? With alcohol-based formulation, World Health Organisation, Oct 2015, https://www.youtube.com/watch?v=ZnSjFr6J9HI
- ↑ Pittet D. Improving compliance with hand hygiene in hospitals. Infection Control & Hospital Epidemiology. 2000 Jun;21(6):381-6.
- ↑ Jump up to:20.0 20.1 Lathia C, Skelton P and Clift Z. Early Rehabilitation in Conflicts and Disasters. Humanity and Inclusion. 2020