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American Journal of Infection Control 41 (2013) 1007-11

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American Journal of Infection Control

journal homepage: www.aj ic journal .org

American Journal of Infection Control

Major article

Acceptability and tolerability of liquid versus gel and standard versus virucidalalcohol-based hand rub formulations among dental students

Fritz Stauffer MD a, Marion Griess DMDb, Gabriele Pleininger a, Anara Zhumadilova DDS, PhD c,Ojan Assadian MD, DTMHd,*aDivision for Infection Control, Bernhard Gottlieb University Clinic of Dentistry, Vienna, AustriabGeneral Outpatients Clinic, Bernhard Gottlieb University Clinic of Dentistry, Vienna, Austriac School of Science and Technology, JSC Nazarbayev University, Astana, KazakhstandClinical Institute for Hospital Hygiene, Medical University of Vienna, Vienna, Austria

Key Words:Hand hygieneEpidemiologyDentistryComplianceComparisonWHO

* Address correspondence to Ojan Assadian, MD,Clinical Institute for Hospital Hygiene, Vienna Generaof Vienna, Waehringer Guertel 18-20, 1090 Vienna, A

E-mail address: ojan.assadian@meduniwien.ac.at (Supported by the Bernhard Gottlieb University ClConflicts of interest: None to report.

0196-6553/$36.00 - Copyright � 2013 by the Associahttp://dx.doi.org/10.1016/j.ajic.2013.05.004

Background: Hand hygiene is effective to prevent the transmission of microorganisms in health caresettings, but compliance remains low, even when easy access to hand cleaning agents is provided.Objective: Formulation of alcohol-based hand rub (ABHRs) may influence staff compliance to handhygiene. The aim of this prospective longitudinal study (1 week) was to investigate possible differencesof 4 different gel or liquid ABHR formulations, with or without virucidal claim among dental students.Methods: Participants were randomly assigned to dental treatment cubicles, equipped with either a gelor a liquid based ABHRs, with our without a virucidal claim. Participants assessed the subjectiveacceptability and the tolerability of test formulations on their hands over a period of 1 week using the 14item, 7-point Lickert scale World Health Organization questionnaire.Results: All tested ABHRs passed the subjective acceptability criteria of �50% above 4 for the items “colorand fragrance” and for all other items of >75% above 4 and may be regarded as “good.” Significantdifferences were observed between the 2 gels but not between the 2 liquid ABHRs. For subjective skintolerability, no significant difference was observed between the liquid formulations after 1 consecutiveweek of application. However, the difference between the 2 gels was highly significant.Conclusion: Virucidal ABHR formulations may be better accepted and tolerated over prolonged periodsby dental students than anticipated. The user acceptability of ABHRs depend more on the specificproduct’s formula than its general category.

Copyright � 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.

Hand hygiene (HH) prevents effectively the transmission ofmicroorganisms in health care settings; however, compliance stillremains low.1-7 Although easy access to fast-acting HH agents isavailable, usually, average compliance ranges between 35% and45%.8-11 HH promotion and campaigns can increase compliance to70% to 85%, yet the effect shows no sustainability.9,11

Compliance with HH depends on 2 factors: “hardware” such assufficiently and conveniently located sinks, appropriate dispensersfor alcohol-based hand rubs (ABHRs) and soap, water faucets, andsufficient paper towels and “software” such as staff knowledge on

DTMH, University Professor,l Hospital, Medical Universityustria.O. Assadian).inic of Dentistry.

tion for Professionals in Infection C

guidelines and protocols, active participation in HH promotion atindividual and institutional levels, presence of role models for HH,and institutional priority for HH. Key reasons given for not dis-infecting hands includes the lack of time, limited access to handrubs, the perception that peers and supervisors do not follow HH asrecommended, and the belief that frequent hand disinfection irri-tates the skin of the hands and may lead to chronic irritation andhand eczema.12

In recent years, the formulation of ABHRs, being in liquid or gelform, was identified as one factor influencing staff compliance toHH, with conflicting results.13,14 Additionally, the availability ofa broad range of different liquid and gel-based ABHRs now includesstandard formulations against bacteria and formulations with theadditional claim to be virucidal.15,16 Standard ABHRs are suitable forthe control of bacterial organisms and are generally only recom-mended in situations where viral organisms may be of lessconcern.17 Because of the required higher ethanol concentration

ontrol and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

F. Stauffer et al. / American Journal of Infection Control 41 (2013) 1007-111008

together with a resulting desiccant and deleterious effect ofethanol, virucidal hand rubs should not be used on a routine basiswithout prior assessment of a specific formulation. Practically, thishas resulted in the strategy to provide one standard ABHR for dailyroutine and provision of a virucidal ABHR in patients with knownviral infections, eg, such as norovirus.

Aside of logistic and economic issues, such a strategy may beworkable on medical or surgical wards, but, for dental settings,where high intercontact frequencies among patients, instruments,and surfaces are typical, and virus such as hepatitis C virus mayalways be of concern,18,19 the routine use of a well-tolerated andeffective virucidal ABHRs would be of benefit. Because of the broadavailability of different ABHRs on the market together withdifferent considerations and requirements needed to be balanced,selection of an optimal product has become a challenging task,particularly in a dental setting.

The aim of this prospective longitudinal studywas to investigatepossible differences of gel- and liquid-based ABHRs, with orwithout a virucidal claim among dental students. The secondobjective was to assess the feasibility of a new questionnaire tool20

developed by the World Health Organization (WHO) for investi-gating the acceptability and tolerability of ABHRs in a dentalsetting.

MATERIALS AND METHODS

The study was conducted from October 1, 2011, to March 3, 2012,at the Bernhard Gottlieb University Clinic of Dentistry in Vienna,Austria. The School is the largest dental teaching and researchfacility in Austria, teaching approximately 350 students and service25,000 patient treatments per year. For the purpose of thisprospective longitudinal study, 8 identical dental cubicles wereused, providing treatment of comparable patient groups. The dentalcubicles selected for this study were all 3.5 m � 3.5 m in size andincluded 1 dental treatment chair (Sirona C3þ; Sirona DentalGmbH, Wals, Salzburg, Austria) with dedicated equipment forpatient care, such as dental instruments and patient administrationcomputers. Each cubiclewas equippedwith 1 sink and 2 dispensers,1 containing the ABHR and the second dispenser containing a liquidsoap. Additionally, paper towel dispensers were located next to thesinks. Per cubicle, 2 dental students and 1 nurse, supervised by 1dentist cared for the patients.

ABHR

The following ABHR formulations were investigated: (A) a stan-dard liquid ABHRwith the active ingredients (per 100 g) iso-propanol65 g, n-propanol 15 g, Polyhexamethylene Biguanide-hydrochloride1g (Alsoft E; Saraya Co, Ltd, Osaka, Japan), (B) a virucidal liquidABHR with the active ingredients (per 100 g) n-propanol 10 g and96% ethanol 57.6 g (Manorapid Synergy, Antiseptica chem.-pharm;Produkte GmbH, Pulheim, Germany), (C) a virucidal alcohol-basedhand gel containing (per 100 g) ethanol 85 g as the active ingre-dient (Spirigel complete; Ecolab GmbH, Vienna, Austria), and (D)a standard alcohol based hand gel containing (per 100 g) 85 g ethanolas the active ingredient (Sterillium Gel; Paul Hartmann GmbH,Wiener Neudorf, Austria). All selected ABHRs demonstrated to havepassed the European Norm EN 150021 and have been approved bythe local health authority to be used in Viennese health care settings.

Study design

The study was based on the WHO’s protocol for evaluation andcomparison of tolerability and acceptability of different ABHRs,method 2.22 Two dental cubicles each were randomly equipped

with ABHR formulations A, B, C, or D. Dental students wererandomly assigned to one of the 8 dental cubicles and remainedthere and used the available ABHR during the entire period of thestudy. Because of the standardized modalities of the dentalacademic student teaching, the study was not double blind with nocross-over design.

Participants were handed a 2-part study questionnaire atbeginning of the study. Only questionnaires from participantshaving used at least 30 mL of the test ABHR per day and whocompleted patient care during a full set of 1 week were eligible forfurther study. Replies from participants who did not use at least30 mL of an ABHR were excluded from further analysis. Part 1 wascompleted once per participant before beginning of the study andasked for basic demographic data such as age, sex, professionalgroup, skin type, climate when the study was conducted, andseason. Participants had to state whether they had nonwork-related activities likely to cause damage to skin; whether theyusually use a protective hand lotion outside the test period;whether they develop or have atopic dermatitis, rhinitis, andallergic conjunctivitis; and whether they are asthmatic or havea known allergy or intolerance to alcohol. Finally, participants hadto give details on the frequency of HH practice.

Part 2 was completed after 1 week of consecutive test ABHR useand included basic data on the frequency of HH practice, a subjec-tive evaluation of the tested ABHR (color, smell, texture, irritation,drying effect, ease of use, application, overall evaluation), anda self-evaluation of the skin condition (appearance, intactness,moisture, sensation, and overall skin integrity). For the items of thesubjective evaluation of the test product and for the subjectiveself-assessment of the skin condition after use of the test product,a 7-point Lickert scale was used.

Statistical analysis and data interpretation

Following theWHO protocol, the criteria for the evaluationwereregarded as good if�50% of the items “Color and Fragrance” rangedabove 4 and for all other items if >75% ranged above 4. Forsubjective skin tolerability,�75% of all items had to be above 4 to beassessed as “good.”

For calculating differences of categorical variables, Fisher exacttest and c2 test were used. For Lickert scale points (1-7), median(Mdn), 25th and 75th quartile, 25% to 75% interquartile range (IQR),and minimum and maximum points were calculated. A 2-sidedheteroscedatic t test was performed to compare statistical differ-ences between the 4 test groups with a significance level of �1%(P � .01).

RESULTS

Ninety-three questionnaires were distributed. Five participantshad to interrupt their participation because of illness (n ¼ 2) orfamily reasons (n ¼ 3), and 6 participants did not fill out thequestionnaires correctly (n ¼ 2), or their questionnaires (n ¼ 4)could not be assigned to the allocated group. A total of 82 dentalstudents provided complete and eligible questionnaires for furtheranalysis. The skin type of 38% (31/82) of participants was fair withor without freckles, and 52% (43/82) light brown, with no statisti-cally significant difference within the 4 test groups (P > .05).Formulation A was tested by 24% (20/82) of participants, formula-tion B by 22% (18/82), formulation C by 31% (25/82), and formula-tion D by 23% (19/82) randomly allocated dental students. Themean age of participants was 28 years � 5 years, with 44% femaledental students (Table 1).

During the test period, a total of 6,833 patients was treated in8 dental cubicles. In average, 487� 75 patients were seen per week,

Table 1Demographic characteristics and factors possibly influencing skin condition for 71 dental students in the test of hand rub formulations

Characteristic A (n ¼ 20) B (n ¼ 18) C (n ¼ 25) D (n ¼ 19) Total (n ¼ 82)

DemographicsAge (mean � SD), y 30 � 7 27 � 5 28 � 4 28 � 4 28 � 5Female sex, n (%) 9 (45) 11 (61) 6 (24) 10 (53) 36 (44)

Position, n (%)Full-time 16 (80) 18 (100) 16 (64) 13 (68) 63 (77)Part-time (50%-90%) 4 (20) 0 (0) 9 (36) 6 (32) 19 (23)

Skin type, n (%)Very fair with freckles 1 (5) 0 (0) 3 (12) 1 (5) 5 (6)Fair � freckles 5 (25) 8 (44) 8 (32) 10 (53) 31 (38)Light brown 13 (65) 9 (50) 14 (56) 7 (37) 43 (52)Brown 1 (5) 1 (6) 0 (0) 1 (5) 3 (4)Dark brown 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)Black 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Influencing conditions, n (%)Irritative dermatitis 0 (0) 1 (6) 0 (0) 0 (0) 1 (1)Atopic dermatitis 0 (0) 1 (6) 0 (0) 2 (11) 3 (4)Rhinitis and/or allergic conjunctivitis 2 (10) 2 (11) 3 (12) 4 (21) 11 (13)Asthma 0 (0) 0 (0) 4 (16) 0 (0) 4 (5)Intolerance to alcohol 0 (0) 0 (0) 0 (0) 1 (5) 1 (1)Non-work-related activities affecting skin 5 (25) 2 (11) 8 (32) 5 (26) 20 (24)

Protective hand lotion, n (%)As often as possible 3 (15) 1 (6) 3 (12) 4 (21) 11 (13)Several time/day 4 (20) 4 (22) 4 (16) 2 (11) 14 (17)Once/day 4 (20) 2 (11) 3 (12) 2 (11) 11 (13)Sometimes 5 (25) 5 (28) 8 (32) 3 (16) 21 (26)Rarely 1 (5) 6 (33) 4 (16) 5 (26) 16 (20)Never 3 (15) 0 (0) 3 (12) 3 (16) 9 (11)

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with aweekly average ABHR usage of 8,766mL� 89mL per cubicle.There was no statistically significant difference in the patientfrequency or the test formulation usage between the 4 groups(P > .05); dental students testing formulation A treated 1,578 (23%)patients in total; those testing formulation B, 1,739 (25%); thosetesting formulation C, 1,819 (27%) patients; and those testingformulation D treated 1,697 (25%) patients during the test period.All dental students completed testing a formulation during 5consecutive days. Seven percent (6/82) of dental students reported1 to 5 patient contacts, 38% (31/82) 6 to 10 patient contacts, 26%(21/82) 11 to 15 patient contacts, and 29% (24/82) more than 15patient contacts per day. Half of the participants (51%; 42/82)reported 1 to 5, 26% (21/82) 6 to 10, 15% (12/82) 11 to 15, and 9%(7/82) > 15 HH performances per hour. There was no statisticallysignificant difference in the number of patient contacts per day(P > .05) or the self-reported number of HH performances per hourwithin the 4 groups (P > .05).

Participants’ acceptability of the test formulations

All tested formulation passed the subjective acceptabilitycriteria of�50% above 4 for the items “Color and Fragrance” and forall other items of >75% above 4 and may be regarded as “good.”However, significant differences were observed between the 2 gelformulations but not between the 2 liquid formulations.

For the 2 liquid ABHRs, none of the 8 acceptability items showeda statistically significant difference. Both formulations scored equalfor color (P ¼ .69), smell (P ¼ .64), texture (P ¼ .41), subjective skinirritation (P ¼ .31), subjective feeling of dryness of hands (P ¼ .36),ease of use (P ¼ .82), speed of drying on hands (P ¼ .81), and ease ofapplication (P ¼ .24). Overall, dental students did not score a stan-dard liquid nonvirucidal (formulation A) or a liquid virucidal(formulation B) product differently (P ¼ .43). Detailed score resultsof the investigated formulations A to D are depicted in Table 2,respectively.

For the gel formulations, a different pattern was observed. Thevirucidal hand rub gel (formulation C), scored statistically

significant worse in comparisonwith a standard nonvirucidal handrub gel (formulation D) in all items, except for texture (P ¼ .24),subjective feeling of dryness of hands (P¼ .27), ease of use (P¼ .47),and speed of drying on hands (P ¼ .53). Participants assessedformulation D’s color (P ¼ .02), smell (P < .01), subjective skinirritation (P ¼ .04), and ease of application (P ¼ .02) better thanformulation C. Overall, dental students assessed the 2 gel formu-lations significantly different (P ¼ .01).

Participants’ self-reported skin tolerability toward the testformulations

For subjective skin tolerability, the 75% quartile of all Lickertscales of the self-assessed items scored above 4 (Table 2). All testformulations may be regarded as “good.” No significant differencewas observed between the liquid formulations A and B forappearance of the skin of hands (P ¼ .52), intactness (P ¼ .32),moisture (P ¼ .58), sensation (P ¼ .22), or overall skin condition(P ¼ .51). However, the difference between the 2 gel formulations,formulation C and D, was highly significant, and favored formula-tion D. The difference was observed in all items: appearance of theskin of hands (P ¼ .03), intactness (P ¼ .04), moisture (P ¼ .02),sensation (P ¼ .02), and overall skin condition (P < .01).

DISCUSSION

This is the first study applying WHO’s protocol for evaluationand comparison of tolerability and acceptability of different ABHRs,method 2,22 in a dental setting. Although the methodology had tobe modified because of the predetermined teaching modalitiesfor dental students, the questionnaire proved itself to be highlyapplicable.

The results of this study revealed 2 aspects: although, for liquidABHRs, manufacturers generally highlight that formulations witha virucidal efficacy and a high ethanol concentration shall not beused on a routine basis and are designed for use in high-risk areasand during viral outbreaks, the 2 tested virucidal formulations did

Table 2Summary of the subjective assessment of the test formulations’ acceptability and tolerability after 1 week of consecutive application

Item

Formulation A Formulation B Formulation C Formulation D

Median IQR Median IQR Median IQR Median IQR

Color 5.77 5-7 5.56 4-7 6.00 5-7 7.00 6-7Smell 4.92 4-7 5.22 4-7 5.50 4-6 7.00 6-7Texture 4.62 4-5 5.11 4-7 5.00 4-6 5.00 4-7Irritation 4.85 3-6 5.56 4-7 6.00 4-7 7.00 6-7Dying 4.00 3-5 4.44 4-6 4.50 3-6 5.00 4-7Use 5.92 5-7 6.06 5-7 7.00 6-7 7.00 6-7Speed 4.62 4-6 4.72 4-5 6.00 5-6 5.00 5-7Application 4.92 4-6 5.61 5-7 6.00 5-6 7.00 7-7Overall acceptability 4.54 4-6 5.00 4-6 4.50 4-6 6.00 5-7Appearance 6.00 4-7 6.00 5-7 7.00 4-7 7.00 7-7Intactness 5.00 4-7 6.00 5-7 7.00 5-7 7.00 7-7Moisture 5.00 4-6 6.00 4-7 6.00 4-7 7.00 7-7Sensation 5.00 4-7 6.00 6-7 6.00 4-7 7.00 7-7Overall tolerability 5.00 4-6 5.00 4-6 5.00 4-6 6.00 5-7

IQR, Interquartile range.NOTE. IQR ¼ 25% to 75% interquartile range Lickert scale scores of test formulations A to D.

F. Stauffer et al. / American Journal of Infection Control 41 (2013) 1007-111010

not significantly differ in acceptability and skin tolerability during1 week of consecutive use. The virucidal test formulation B wasspecifically formulated for a better skin tolerability by containinga blend of moisturizers including glycerol and particulates ofpropane-1,2-diol. Although the formulation was designed fora broad virucidal efficacy together with good skin tolerability, themanufacturer explicitly recommends to “. care for your hands,especially on frequent use.” Our results indicate that duringconsecutive use over a period of 1 week, this liquid virucidal handrubwill not cause a deterioration of skin integrity and was acceptedby dental students during routine patient care. However, because ofthe study design, our results do not allow the conclusion that thisvirucidal hand rub may be used as a general replacement forstandard hand rubs on a routine basis over prolonged periods.However, our observations encourage investigating the long-termapplicability of virucidal ABHRs in future studies, which couldbring attractive benefits for health care settings with potentiallyconsistent exposure to virus, such as the dental setting.

Second, some authors reported an improved health careworkers’HH compliance using gel formulations, and identified gels,among other factors, as independent factor associated with highercompliance (odds ratio gel vs liquid formulation: 1.33; 95%confidence interval: 0.97-1.82; P ¼ .072).13 This observation wasexplained with better skin care properties and dermal tolerance ofgels compared with liquid formulations. The liquid formulationused in this study contained 75% iso-propanol (wt/wt), 0.5% chlo-rhexidine gluconate, and isopropyl myristate. The gel formulationcontained the identical active ingredients, but a gelling agent wasadded. However, in a 3-month prospective cohort study, the addi-tional introduction of a gel formulation next to the establishedstandard of HH by washing hands with 2% chlorhexidine soapshowed little to no increase in HH compliance.14 In 2008, Ruppet al23 published the results of a prospective, cross-over studyinvestigating the effect of a gel formulation on HH compliance in 2medical-surgical intensive care units. After provision of an ABHRgel, HH compliance rates significantly and sustainably increased.However, as was correctly pointed out by others,24 the results ofthe positive effect of the gel formulation may have been biasedthrough the simultaneously performed multimodal HH promotioncampaign, making it difficult to distinguish the effect of the gel anda HH education intervention.

Despite these scant and difficult to compare data on the effect ofgel formulations, gels are increasingly promoted and offered byvirtually all HH product manufacturers because it is believedthat health care workers prefer gel formulations. Indeed, the results

of our study showed that a gel-based formulation (product D)performed best in terms of user acceptability and subjectiveskin tolerability. Both the formulation’s overall acceptability andsubjective skin tolerability scored a median of 6 in a 7-point Lickertscale (25%-75% IQR: 5-7, each), and surpassed two liquid formula-tions by approximately 1 Lickert scale point. This observation alonewould have supported previous reports on better acceptability ofgel formulations. However, we also tested a second gel (formulationC), which contained the same active ingredient as formulation D:85% (wt/wt) ethanol in a gel formulation. Formulation C demon-strated the lowest user acceptability with a median for the overallacceptability of 4.50 (25%-75% IQR: 4.00-6.00). Pertaining to users’acceptability of gel formulations, our results highlight the influenceof the formulation and warrants caution in generalizations basedon single observations. In any future study comparing gel and liquidformulations, not only the broad category should be analyzed, butthe formulation of the products assessed must also be considered.

The applied standardizedWHO questionnaire did not only allowan objective comparison of subjective opinions of users on acce-ptability and tolerability of different ABHR formulations within 1study but may also allow interstudy comparison of different ABHRs.Pittet et al20 published a study where participants used the samequestionnaire in a medical intensive care unit, assessing 3 ABHRformulations during 3 to 5 consecutive working days. Their form-ulation “A” contained ethanol 85% (vol/vol) and glycerol, formula-tion “B” contained iso-propanol 75% (vol/vol) and glycerol, andformulation “C” contained iso-propanol 75% (vol/vol) and iso-propyl myristate. All 3 formulations additionally contained 0.125%H2O2 as a preservative. Whereas the appearance, intactness,moisture, sensation, and overall integrity of health care workers’hands for formulations “A” and “B” was comparable with the 3tested formulations in our study (median of all 5 tolerability itemsapproximately 6), formulation “C” scored for all tolerability itemsbelow the scores of our test products. Although promising, thepotential interstudy comparability of this WHO instrument shouldbe validated in future studies.

Our study has a number of limitations. First, because of thepredetermined academic teaching scheme for dental students,WHO method 2 had to be modified, and a complete blindedrandomization and cross-over design was not possible. Second, wedid not observe objective assessment scores in this study. Indeed,we experienced that measuring objective skin integrity scoresaccording to WHO’s method 2 was the most difficult feature to befollowed and would have required a significant increase in thenumber of trained study observers. However, as was correctly

F. Stauffer et al. / American Journal of Infection Control 41 (2013) 1007-11 1011

pointed out in theWHO’s Guidelines on HH in Health Care,12 healthcare workers’ subjective acceptance of a specific ABHR product isprobably of higher importance for compliance toward HH than itsobjective measurable effects on the integrity of the skin. Further-more, we believe that any potential detrimental effect on theintegrity of the skin would also have a negative impact on thesubjective assessment of the participants; however, we acknowl-edge that an objective positive effect on the skin integrity may havebeen overlooked.

In conclusion, the results of our study indicate that virucidalABHR formulations may be better accepted and tolerated by dentalstudents than anticipated and that user acceptability of ABHRformulations depend more on the specific product’s formulationthan its general category. The applied WHO questionnairedemonstrated to be a valid and easily applicable tool for the iden-tification of the most accepted ABHR in a dental setting.

Acknowledgment

The authors thank Renate Stiebellehner, who did an excellentjob analyzing and providing patients’ demographic data, and Sus-anne Großberger, Irene Horvath, and Karoline Schweinberger foroutstanding support during data collection.

References

1. Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston AK, Annis L, et al.Comparative efficacy of alternative hand-washing agents in reducing nosoco-mial infections in intensive care units. N Engl J Med 1992;327:88-93.

2. Jarvis WR. Handwashing: the Semmelweis lesson forgotten? Lancet 1994;344:1311-2.

3. Albert RK, Condie F. Hand-washing patterns in medical intensive-care units.N Engl J Med 1981;24:1465-6.

4. Helder OK, Weggelaar AM, Waarsenburg DC, Looman CW, van Goudoever JB,Brug J, et al. Computer screen saver hand hygiene information curbs a negativetrend in hand hygiene behavior. Am J Infect Control 2012;40:951-4.

5. Thompson BL, Dwyer DM, Ussery XT, Denman S, Vacek P. Handwashing andglove use in a long-term care facility. Infect Control Hosp Epidemiol 1997;18:97-103.

6. Pittet D, Mourouga P, Perneger TV, members of the Infection Control Program.Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-30.

7. Larson EL. APIC Guidelines Committee. APIC guideline for handwashing andhand antisepsis in health care settings. Am J Infect Control 1995;23:251-69.

8. Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashingin prevention of endemic intensive care unit infections. Infect Control HospEpidemiol 1990;11:589-94.

9. Graham M. Frequency and duration of handwashing in an intensive care unit.Am J Infect Control 1990;18:77-80.

10. Donowitz LG. Handwashing technique in a pediatric intensive care unit. Am JDis Childhood 1987;141:683-5.

11. Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. Increasing ICU staffhandwashing: effects of education and group feedback. Infect Control HospEpidemiol 1990;11:191-3.

12. Pittet D, Allegranzi B, Boyce J. World Health Organization World Alliance forPatient Safety First Global Patient Safety Challenge Core Group of Experts. TheWorld Health Organization guidelines on hand hygiene in health care andtheir consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611-22.

13. Traore O, Hugonnet S, Lübbe J, Griffiths W, Pittet D. Liquid versus gel handrubformulation: a prospective intervention study. Crit Care 2007;11:R52.

14. Camargo LF, Marra AR, Silva CV, Laselva CR, Moura Junior DF, Cal RG, et al. Lowcompliance with alcohol gel compared with chlorhexidine for hand hygiene inICU patients: results of an alcohol gel implementation program. Braz J InfectDis 2009;13:330-4.

15. Iwasawa A, Niwano Y, Kohno M, Ayaki M. Virucidal activity of alcohol-basedhand rub disinfectants. Biocontrol Sci 2012;17:45-9.

16. Steinmann J, Becker B, Bischoff B, Paulmann D, Friesland M, Pietschmann T,et al. Virucidal activity of 2 alcohol-based formulations proposed as hand rubsby the World Health Organization. Am J Infect Control 2010;38:66-8.

17. Meyer B, Matthies W, Nicholson JE, Shelanski MV. Skin compatibilityof two ethanol based virucidal hand disinfectants. Int J Infect Control 2010;v6:i2.

18. Corstjens PL, Abrams WR, Malamud D. Detecting viruses by using salivarydiagnostics. J Am Dent Assoc 2012;143:S12-8.

19. Reznik DA. Screening for infectious diseases in the dental setting. Dent ClinNorth Am 2012;56:809-18.

20. Pittet D, Allegranzi B, Sax H, Chraiti MN, Griffiths W, Richet H. World HealthOrganization Global Patient Safety Challenge Alcohol-Based Handrub TaskForce. Double-blind, randomized, crossover trial of 3 hand rub formulations:fast-track evaluation of tolerability and acceptability. Infect Control HospEpidemiol 2007;28:1344-51.

21. European Committee for Standardization (1997) Chemical disinfectants andantiseptics. Hygienic handrub. Test method and requirements. EN 1500.Brussels: European Committee for Standardization (CEN); 1997.

22. World Health Organization World Alliance for Patient Safety First GlobalPatient Safety Challenge Core Group of Experts. Protocol for evaluation andcomparison of tolerability and acceptability of different alcohol-based han-drubs: Method 2. Available from: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/. Accessed September 9, 2011.

23. Rupp ME, Fitzgerald T, Puumala S, Anderson JR, Craig R, Iwen PC, et al.Prospective, controlled, cross-over trial of alcohol-based hand gel in criticalcare units. Infect Control Hosp Epidemiol 2008;29:8-15.

24. Mermel LA, Boyce JM, Voss A, Allegranzi B, Pittet D. Trial of alcohol-based handgel in critical care units. Infect Control Hosp Epidemiol 2008;29:577-9.