Hand hygiene – 10 years of the World Health Organisation’s global healthcare campaign

S3 Global, consultants to WHO

Healthcare-associated infections (HAI) affect hundreds of millions  of individuals worldwide. Performing hand hygiene at the right moment is an essential infection prevention and control (IPC) action for healthcare workers and plays a role in the prevention of HAI. In the last 20 years, how we approach hand hygiene improvement has changed drastically, including through the availability and use of alcohol-based hand rubs at the point of patient care. Their presence, where and when they’re needed, affects the behaviours of healthcare workers.  But let’s examine some of the broad milestones from the last two decades that have affected global, regional and local actions to stop people getting infections through improved hand hygiene.

The World Health Organization (WHO) launched the World Alliance for Patient Safety in 2004. In 2005, the First Global Patient Safety Challenge program: Clean Care is Safer Care, whose flagship was hand hygiene promotion, was launched. WHO published the first draft of the Guidelines on Hand Hygiene in Health Care in 2006 with a final, post-pilot version, in 2009. Importantly for improvement on the front line, WHO outlined what they termed a Multimodal Hand Hygiene Improvement Strategy. This consists of five elements to be addressed in parallel during implementation of hand hygiene improvement strategies: system change, training/education, evaluation and feedback, reminders in the workplace and the institutional safety climate. Translating this into simple language, the strategy reads; “build it, teach it, check it, sell it, live it”. WHO also provided an array of tools for facilitating implementation, aimed at affecting structural and behavioural change at the point of care in the context of a favourable safety culture. This included the 5 Moment for Hand Hygiene.

As an extension of the Clean Care is Safer Care program, WHO also stepped up its advocacy and campaigning work with the 2009 launch of the SAVE LIVES: Clean Your Hands global campaign on the 5 May, marking the first international day of hand hygiene in healthcare, 10 years ago. As explained by Vermeil T, et al, the date chosen is a reference to the symbolic power of five – the 5 moments for when to perform hand hygiene, the 5 elements of the multimodal strategy, and all centred around the five digits of a hand. This annual commemoration focuses on the continued global promotion, visibility and sustainability of hand hygiene. Each year, WHO selects a theme and develops tools and promotional materials as necessary. For 2019, the theme is ‘Clean care for all – it’s in your hands’, focused on linking IPC and hand hygiene with the topical  ‘health for all’ global development agenda. Previously the campaign has linked with safe surgery, sepsis prevention and antimicrobial resistance (AMR).

To date, more than 140 countries have pledged, promising to endorse hand hygiene, raise awareness of the burden and impact of HAIs, and commit to the implementation of the WHO Guidelines along with other selected actions from WHO strategies. And more than 20 000 health facilities from 182 countries have signed up to the SAVE LIVES: Clean Your Hands campaign. This is important in demonstrating commitment and should be used by people in all countries to garner even further support for action.

In 2016, the Clean Care is Safer Care program transitioned into the WHO IPC Global Unit. This important move has supported the embedding of the hand hygiene improvement strategy within a range of IPC and AMR programs.

Coming back to the 5 Moments for Hand Hygiene, it is not an overstatement to say that this concept has emerged over the 20 year hand hygiene journey as something that has reached all corners of the globe and stimulated much hand hygiene discussion. Did you know that the 5 Moments is rooted in behavioural sciences? The concept is well explained in two documents focused both on acute health facilities and other areas where care is delivered. These are important as they explain what is termed ‘the patient zone’ and the ‘healthcare zone’ and an understanding of this is important for minimizing cross-transmission of microorganisms, the ultimate goal of hand hygiene in healthcare.

To bring this to life – imagine a delivery suite which is cleaned rarely and in fact water, sanitation and the ability to perform hygiene (WASH) and IPC is limited. Every time the midwife moves outside of the safe space defined by the dotted line depicted by the 5 Moments image (the ‘patient zone’), she/he brings back to the vulnerable mother and baby potentially harmful microorganisms. Cleaning hands at the right times (the 5 Moments) stops this. Hand hygiene in such a challenging setting is a challenge itself and requires some adaptation of the 5 Moments, particularly the zone, and we haven’t even talked about the important link with environmental cleanliness. The bottom line is that in every delivery suite around the world, as per this example, this concept is critical in saving lives. Giorgia Don and colleagues have published more on this work.

And recalling the multimodal strategy, steps taken based on the local situation will allow such settings to become safer. One of the five important improvement elements is the use of assessment tools, for both IPC and WASH a number of these are available – the Hand Hygiene Self Assessment Framework (HHSAF), the IPC assessment framework (IPCAF), IPC Assessment Tool (IPCAT2), and WASH FIT.

Today, in 2019, hand hygiene is not any more the sole responsibility of individual health workers, but has become an integral responsibility of healthcare leaders and a key indicator of quality in health systems. So, what will the next 10 or even 20 years hold for hand hygiene? The time is ripe for the WASH in health care facilities and IPC agendas to unite and even merge. The recent WHO/UNICEF report on this topic highlights that both hygiene and IPC more broadly cannot be safely delivered without WASH. WASH in the general community has gained attention with many organisations and foundations committing to improving public health sanitation systems, waste management, critical for AMR management, and access to safe clean water. But it is time for everyone to come together to ensure the all aspects of hygiene in health care is high on all global agendas for the years to come– it’s in your hands.