8/18/2019 sutton.j.gxp_.14.1

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Hand

Washing

Hygiene

GMP

and

Science

  ott

Sutton

K£Y POINTS

The follOWing key points are discussed in this article

•

Good

personal hygiene is a

requirement

of all pharmaceutical activi

ties, from

operating on

the line

through

laboratory good manufac

turing practice GMP) studies. However,

studies show poor hand

washing

compl iance is the rule in a variety of occupations.

• Poor

hand

washing technique may result in increased absenteeism,

particularly in t ime of a potential HINI pandemic.

• Limited availability to adequate lacilities may lead to

poor

com

pliance

or poor

erficacy of

washing

if performed These facilit ies

include appropriately

constructed and sourced water supply, soap

supply and

perhaps

most importantly, adequate provisions for thor

ough

drying of

hands

This is the basis for the current good

manu-

facturing practice CGMP)

requirement

for adequate facilities.

•

While

 antibacterial label claims

do no

harm they

should not be

relied upon to protect against poor practice.

• Jewelry

can

interfere with adequate cleansing and

should

be removed

berore

washing

Jewelry should be discouraged in areas where

hand

cleanliness is

important.

•

Training for

compliance in

hand washing

is dif licul l. There have

been

numerous repons

of the difficulty in

training

and the subse

quent

monitoring

of healthcare workers lor compliance with hand

washing requirements

Suggestlons for training

and

a potentially

useful monitoring

tool are

provided

• Many studies use extended periods of time during the wash

05 2

minutes

in some). This is not a practical regimen. A hand wash-

 Microbiology Topics

discusses

various topiCS In

microbIology

of practical use

In validation an compliance We intend this

column

to I le a useful resource for

dally

work

applications

Reader comments questions and suggestions are needed to help us fulfill

 f

u objective

for

his column Please

send your comments and

suggestions  

column

coordinator Scott

Sutton

at

scott

suttonCimlcroblol org

or

journal COOrdl

nating editor Susan

Halgney

at shaigneyOadvanstar com

 

Ci

w

 

u

a;

is

i

w

 

v no

8/18/2019 sutton.j.gxp_.14.1

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ing regiment

is

suggcstcd

for

pharmflceutical

industry workers based on CeI1lt fs lor Disease

Control

(CDC)

h a nd w as hi ng

protocol.

• Personnel should carefully evaluate common

pranices when

microbial control is required.

It is likely that simple processes,

such

as

hand

washing, are generally

assumed

to be

under

controL They may, however, be an undC lccted

source of product

or

sample

contamination.

• [tm d scrubs are not l urrently covered by

GX P

b ut t he re ma y be a role

for

t heir u se in a compli

ant facility

in addition to hand

washing.

EVERYONE KNOWS

HOW

T

WASH HIS

  HER

HANDS RIGHT

The

US

current good

manufacturing

practice (CGMP)

guidelines have clear expectations for hygiene

an d

cleanliness. 21 Code Ol federal Regulations (CfR) 211

St::ltc-; the following:

 2JCFR 21128 Personnel responsibililies

 (a)

rersonnel

engaged

in the manufacture,

pro

cessing, packing, or holding of a drug product shall

wear clean

clothing appropriate

for the duties

they

perform, Protective apparel,

such

as head, fflce, hand,

an d

ar m

coverings, shall be

worn

as ncccssary to

protect

drug products

from

conram

ination.

 (b) Personnel shall practice good sanitation and

health habits

 (c)

Only

personnel

authorized

by

supervisory

personnel

shall

enter

those areas of

th e

buildings and

facilities deSignated as Iimited-access areas.

 (d) Any

person shown

at any time (ei the r by

medicfll examination

or supervisory

observation) to

have an

apparent

illness

or open

lesions that may

adversely affect

th e

safety or

quality

of

drug products

shall be ex.cluded from direct c on ta ct w it h c o mp o

nents,

drug product containers, closures, in-process

materials,

an d drug products until

th e

condition

is

c on ec te d o r determined

by

competent

medical per

sonnel

no t

to

Jeopardize

th e

safety

or

quality

of

drug

products, All personnel shall be

instructed

to report

to

supervisory personnel

any health

conditions that

may

have an adverse effecl on drug producls 1)

This

is a bas ic

contamination

control issue

for

the

quality of

ou r

finished product, in both the ster-

ile an d the non-sterile process.

In

addition to the

concern

over proccss control , there is a

personnel

consideration as welL Prope r

h an d w a sh in g

tech

nique

is t he m os t effective means to slow t he spr ead

of discase in

ou r

facilities

Proper

hand

washing

IS

particularly important

in

t hi s t im e of increased

concern

over global pandemic. There have

been

a

score of recent articles on th e best ways to mll1imize

th e

spread

of th e

HJ

N1

virus

lfJnsmisSlOn   2,3)

Recent

work

has shown

that

h a nd w a sh in g

maybe

an

ex.tremely effective an d economical way to slow th e

spread

of the

vIrus  4)

An obvious consideration in trying to establish the

efficacy of hand-washing regimens is the

method

to

determine

that clTicacy. An

in-depth

review of

meth

odology is o ut si de t he sco pe of this article, but th e

interested reader is referred to

American

Society for

Testing an d Materials (ASTM)-E1174-00,  tund rd

Test

Method

for

Evaluation

of

the

Ej c clivcllcss of

Health

Care

Personnel

or Con.lrmler

Hand Wash

Formulations,

or th e

two

European

standards

Preliminary

Europe

a n No rm (prEN) 12054   describing suspension tcsts)

an d prEN 12791 (describing the in vivo test) We will

not

discuss

the testing methodologies any further,

but

th e

reader

is

cautioned that all results

reported

by

th e

different

studies

will , of

course,

be

dependent

on h ow t he

regimen

was tested.

FACILITIES

T he C GM P for basic

requirements  S

as follows

 21 CFR 211.52 Washing and toilet facilities. Ad

equate washing facilities shall be provided, including

hot an d cold water,

s oa p o r

detergent,

ai r

driers

or

Single-service towels,

an d

clean toilet facilities easily

accessible

to working

areas

1)

Water

Some aspects of th e availability of

soap

an d water

(in

terms

of sinks) are self-evident.

f ir st o f

all,

there

sho ul d b e

s oa p a n d

wilter available to

those

enter-

ing an d leaving the lab

or

manufacturing area. Th e

water should he of suifIcient quality (at least potable).

The mechanism   operate the water flow should

not

encourage

t he r ec on ta mi na ti on o f t he hands immedi

ately af ter washing. This is commonly accomplished

w r ~ r / l NUnJt lY

~ . .

8/18/2019 sutton.j.gxp_.14.1

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through

the use 01 elbow laucets

or

loot switches

to turn

the water on and

off. The

importance

of

thIs

consideration was emphasIzed

in the

study 01

Griffith et at. (5), who showed a positive correla

tion between

surlace

lilth and

recontamination

01

hands-the

faucets were

the

most consistently

con

taminated

leature

olthe immediate environment.

Current best practice suggests sinks conveniently

located near

entrance

and exit points, with suitable

control

mechanisms, and the

availability

of soap

 oap

The type of soap,

and

in particular the desLgn of the

soap dispenser, is

another

important aspect of the

el-

ficacy of

hand

wash ing We have three major choices:

Bar soap, refillable liquid soap,

and

sealed liquid soap

Bar

soap

is not suitable as it

is

a proven reservoir

for

bacteria

 6 .

This leaves

us

with liquid soap

Liquid soap

dispensers

come in two general

designs In

the

first, liquid soap

can

be added to a

reservoir when required.

Best practice

is   com

pletely clean out

this

reservoir before filling it again

LO prevent bacterial buildup as

microorganisms

can

survive in soap  7, 8).  t is nOl

recommended LO

merely top-off

the

soap

 

refill the reservoLr. So,

in choosing

between

removing the

residual

soap and

thoroughly

washing out the reservoir belore rdilling,

and

the

other

choice of lifting

the

lid and LOpping it

off,

which

is the

more

likely practice? This does

not

even consider the

nozzle

that

gets LOuched by

the

user s hand as soap is dispensed (to prevent that last

drop

from falling

onto

the counter),

and

is very likely

  have

dried

soap

caked

 

ItS

exterior.

The other variety

of public

area liquid

soap

dispenser has

a

sealed bag with

an integral nozzle.

Regardless 01 the formulation

contained

within the

bag, this system enables a clean startup with each

relill of

the

soap

con ta iner Check out

the nex t

liquid soap

dispenser

you see

and come LO your own

decision alter

you look closely at a few

01

the

nozzles

and compare reservoir-style dispensers to sealed-bag

dispensers. I would urge the use

of

the sealed bag

system

  the

lab and

manufacturing area There is

no sense

in risking

the contamination

of

your hands

by the soap if

this

risk can be minimized

 ntibacterial  dditives

The concept of antibacterial additives to SO:lp

sound

good Take soap, arguably

the most important

medi

cal advance in the last few hundred years,

and

make

it better by adding a biocide

LO

it. The problem with

this

scenario is

that the vendor

is

not

actually requir

LO

show that the biocide works in

the

soap, only tha

it is present

 

the formulation This is not   say th

reputable manufacturers do

not

conduct appropriate

testing, only that this testing is not reqUIred to lahel

your

product as

an

 antibacterial

soar

In addition,

there is the possibility

 

selecting

for

biocide resis

tance in soaps that might be only marginally more

eflicacious than standard soap,

il

morc cilLcacious at

all  9, 10 . However when this works, the resultant

product

can be quite good fuls et

at.

(11) lound

tha

with

a particular

soap containing

triclosan,

the

use

of a greater volume of soap and longer wash time re

su lt ed in a marked superiority of the antibacterial so

over the traditional formulation.

The biocides most

commonly used as soap addi

tives include triclosan, ehlorhexidine, ethylendiam

netetraacetic acid  [OTA , and alcohols. Triclosan

has

come under intense

scrutiny

for potential selec

t ion of

antihiotic-resistant mutant

microorganisms,

particularly in

Europe

This

prompted the Europe

Commission (EC) to formally examine the salety 01

triclosan

and

the Scientific Steering

Committee of

the

European Commission

adopted an ollicial opin

ion in

2002 that

triclosan, used in biocidal

concen

trations, is safe and effective (12) Chlorhcxidine st

has a place in the surgical scrub arena bu t is not a

major

component

in consumer products.

To sum up, biocides

added

to

soap make an

anti

bacterial soap. However,

this

is not a

guarantee tha

the resultant antihacterial soaps are, in fact, anti

bacterial as instances of antibacterial soap suffering

contamination

have been reported (13, 14 .

H N

JEWELRY

Hand

Jewelry (e.g., rings, bracelets, watches,

etc

should be removed

when washing

your

hands.

These

ilems ofjewelry make it very

difficult

t

clean your hands

eflectively. Alp et al.

 2006

(15)

examined the

hand

washing practices of laboratory

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workers, figuring that regular exposure to pathogen

ic organisms would make them aware or the dan

gers Compliance was 100 ror the act itselr altC f

training,

bu t

36.7 wore a ring, 46.9 a watch, and

6.1 a bracelet, all  

which

harbored pathogenic

organisms arter hand wash ing This was corrected

by repeated interventions Fagernes et al (16), in a

study or healthcare workers, examined the impact or

wearing

a single plain

ring

(rather like the

wedding

ring

many

or us are no longer able to remove). The

good news is tha t the total bioburden arter washing

was not dirrerent between r ing wearing and no r ing

suhJects, although the study

showed

a clear increase

in

 nterb ctcri c e contamination

when

compared

to

the subjects

without

rings

DRYING

Several

teams

have looked at paper towels vs hot aIr

dryer

in regards

to

cleaning

and

transmission or con

taminat ion. Matthews and Newsom (17) compared

hot air driers and papcr towels ror the potential to

spread

anborne

microorganisms during the drying

process

Their

deSign rocused

on

air

sampling using

Casella slit-to-agar sampler ror

anhorne

bacteria dur

ing

drying

(in the somewhat controlled environment

or a biological sarety cabinet). They round minor

dirrerences

in

airborne viable counts

in

a comparison

between one model or

dryer and

paper towcls, and

significantly less airborne viable counts ror two other

models in comparison to paper towels. Blackmore

expanded this comparison, conducting a study

 8

on the

drect

or

drying

by air blower, by paper towel,

and

by cloth towel

on

a

continuous

roller. The

finger tips or the left

hand

were sampled by touching

to nutrient agar and then the hands were washed

Arter washing, the hands were dried by

one

or the

three

methods and sampled

again. The expelled air

rrom the air driers was sampled by blowing it Onto

 nutrientagar from 6 inches ror a controlled period

or t ime (dirrering by cycle time or the model or air

dner) The paper and

cloth

towels were

sampled

by

touch plates. Blackmore

repons that

the air blow

ers tested

(in

public locatiolls) harbored bacteria and

could serve as a source ror recontamination or hands

arter washing. The situation with continuous cloth

 

drying

was not encouraging

either

The cloth roller

towels were very good when new but over the course

or three

months

(the length or t ime studied) they be

came

contaminated In addit ion, she found (in 1989)

that these

continuous

cloth towcls are laundered and

re-used, the laundered m:nerial was contaminated as

well (range or 10-60 CFU/touch plme) as installed in

the roller dispenser.

One

explanation for the appar

ent contradiction in the results is orrered by Meers and

Long (19) who did a limited study to evaluate the pur

chase or hot-air dryers ror their hospital and sampled

the air before, during, and arter drying, finding an in

crease in counts only arter drying Thcy concluded that

it

was di{ficult

ror

small particles

 

cscape rrom skin

while moist (covered with water)

What

was important

was that the skin he thoroughly dried.

Harrison Ct

at

(20) took a closer look at

transmis

sion or bacteria bell.veen hands and paper towels.

They looked at

both

directions or transmission, rea

soning that the concern over a contaminated towel

transmitting to the hand is clear, but there i,; also a

possibility

ror

a contaminated hand to transfer bac

teria to the

dispenser

while

rreeingiammed

towels

Using a wall-mounted paper towel dispenscr

and

a

range or paper towels, volunteCfs (With either clean

or contaminated hands) were asked to clear pmmed

towels rrom the dispenser (the dispmser

either

clean or contaminated) They round that while the

contaminated

hands

only marginally contaminated

the dispenser (001 -064 ) the dispenser was rairly

efrective at contaminating hands (12.4-13.1 )

In looking at the potential lor

diny hands

to con

taminate surraces we should also consider dryness.

Patrick et al (21), in

studying

this issue, concluded

that  .. . bacterial numbers translocating on touch

contact decreased progressively as

drying

with

an

air or cloth towel system removed residual moisture

rrom the

hands . . .

Careful

hand drying

is a critical

ractor determining the level or touch-contact-associ

ated bacterial transrer arter

hand washing and

its

recognition

could make

a significant contribution

towards improving

hand

c:lre practices in clinical

and public health sectors.

Reinrorcing this consideration is the recent study

ofYamamoto et a . (22) who looked at drying by

  1II ,r..,20 0 14

lJ

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paper towel, by

hot

air,

and by hot

air

supplemented

with

ultraviolet (UV) light. In addition, the hot air

drying was performed cit her by holding the hands

stationery

or by rubbing

the

hands together. After

looking at all variables they concluded

that

the hot

air dryer is erlective il the

hands

were held motion

tess

 ie ,

not rubbed until dry. The UV light also

seemed to help in decreasing residual viable cells

for the hot air dryer. Paper towels were

shown

to be

more

effective when

measured

by fingertip sampling,

but equivalent by other measures.

TR INING  ND

MONITORING

All budgetary resources

spent

on a

personnel

hygiene program will be inerlective

i l t raining and

management

attention

is incomplete

or

indifferent.

Compliance

is universally

the major problem

in

hand

washing programs

(23) The first problem to

address is to

determine

a suitable procedure for

hand

washing. Several are available,

although

none are

specifIcally directed   the pharmaceutical worker.

Training

becomes

the next issue. Training by

rote is always an op tion , but thi s is not a particularly

erfective

one

as everyone knows how to

wash

their

hands

and any changes madc solely to meet standard

operating

procedure

(SOP) requirements will be

transitory

at best There are several tools available

lor assistance in training, particularly in the evalu

ation of

cleaning efficacy. A common

method

is to

app ly a f luorescent gel as a marker

prior

to washing.

After washing, the hands are held under UV light to

determine

efficacy of

cleaning

One such activity is

available

on

the

Internet

at

http://www.bamgov/

teachers/activities/epi_

4_hand_wash.pdf

 down

loaded 9/27/09) This activity guide is usefu l in

supplying a teaching resource for hand

washing

that

includes a lesson outline and three separate

sources

of

the

fluorescent gel to

use

as a marker.

The l inal issue is monitoring compliance. This

is

particularly

difficult as

self-assessment

is

notoriously

inaccurate, at least among healthcare workers who

consistently sel f-repon

more

conscientious hygiene

behavior

than

what

is

observed independently

 24-27

On

the other hand, Stevenson et al. (28)

report a tool for

self-reponing

that is directed at

the

general population that

might

have

use

as a

moni

toring

method, perhaps coupled with observation

Observation of behavior should be included in any

evaluation, however else compliance is measured i

your faCility.

 

SUGGESTED

H ND

W SHING

PROTO OL

The follOWing stepwise procedure is recommended

for hand

washing

in the pharmaceutical environ

ment. The following protocol is based

on

a CDC

(Centers for Disease Control hand washing protoc

• Remove jewelry from hands and wrists.

•

Consider

the

sink, including

the laucet control

contaminated.

Avoid

touching

the

s ink and

laucet controls

with your hands.

• Turn water on using elbow controls (or foot co

trol). If these are

not

avatlable,

use

a

paper

tow

and

then wet your hands

and

wrists.

• Apply soap from a

dispenser

(do not use

bar

soap

which will certainly be contaminated wit

microbes

Assume the control levCT for the so

is

contaminated. Work

soap into a lather.

• Vigorously rub together all surfaces of the lath

ered hands for at least 20

seconds

Friction hel

remove dir t and microorganisms. Wash aroun

cuticles, in the linger webbing, the back

olthe

hands,

and under fingernails in addition to rub

bing

the

palms

together

• Rinse

hands thoroughly under

a

strcam

of wat

Running water

carries

away

din

and debris.

Point fingers down

so

water and contaminatio

won t

drip

toward elbows

• Dry hands completely (leave water running

• Use a clean

dry

paper

towel

  caware

that

if

the towel

jams

and you need to work to release

you should re-wash your hands if you touch th

dispenser.

• Use a hot-air blower (preferably one

that

has

an integral UV light Start the uni t

with

your

elbow (not your weI hands Do not rub your

hands

together while drying them completely

under

the

hot air flow.

• Use

elbow or foot to

turn faucet off If

approp

ate faucet controls are not avatlable, use a clean

paper towel to turn off the faucet.

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• Do not top off the soap dispenser This leads

to

contaminated reservoirs in addition

to

the con

tamination in the nozzle.

If

possible, use a soap

dispenser that is refliled in a scaled container

that mcludes the soap in a plastic bag and a fresh

nozzle

• Do not assume ant ihacterial soaps are clTica-

cious. Treat all soaps as potentially contami

nated and cxercise sanitary practices in regularly

cleaning dispcnsers

IMPLI TIONS

FOR  OMPLI N E

Personnel properly trained in routine cleanliness arc an

obvious need for all manufacturing and testing. This

need

is

heighted in high risk nunufacturing such as

in aseptic processing. This need is also heighted in

situations wherein microbial testing

is

part of valida

tion testing but is not usually conducted in routine

manufacturing. For example, preparation of granulat

ing liquids

for

solid products does nor usually include

microbial testing Preparation of aqueous coating

liq-

uids does not usually include microbial tesung. Clean

equipment storage does not usually include microbial

testing. All of these examples would likely include

microbial testing

for

process validation or cleaning vali

dation. The two aforementioncd formulation examples

likely do not contain preservatives in their respective

formulations Depending on the formulation, microbi

al growth could

be

easily supported in these situations

Clean equipment hold time validauon should include

microbial testing Drug dispenSing practices may

not routinely include microbial testing even though

liquid materials that support microbial growth may

be

routinely dispensed

for

use in manufacturing com

mercial product Validation personnel should carefully

evaluate personnel practices when microbwl testing

is

required in validation protocols it

is

likely that

Simple processes, such as hand washing, are generally

assumed to

be

under control when they may

be

an

undetected source of product contamination.

H ND

SCRU S

The producL

caLegory of

 antibanerialhand

scrubs

should

be

considered. Even though antibacterial

hand scrubs are not covered in the CFR, their enor-

mous popularity has made them a common fixture

in m:my companies. Recent literature studies \vould

suggest that they can be vcry useful. Suchomel,

M,

et al.  29 looked at three commercial products with

alcohols propanols or ethanol at no

-

78 and

found propanol prepamtions more c1fcctive, passing

the requirements of

EN

1279] after a 90-second rub

An earlier study by Rotter,

 v L

ct

al.

 30 evaluated

a series of alcohol-based sanitizing rubs and found

several that performed suitably under   12791

when applied

for

90 seconds. They made the strong

recommendation, however, that their results not be

generalized to all alcohol-based rubs as they did see

differences among those tested. Each rub needs

to

be

qualified for its application Finally, Witt

 31

ar

gues that the use of hand sanitizns as an adjunct

to

hand washing can be extremely effective, particularly

if coupled with effective technique Jn d aw:ntion to

those portions of the hands most commonly over

looked on hand washing

What

we

are left with then is that

it

would he

prudent to include a hand sanitizer in the hygiene

practice. This can be used with a 90-second rub as

a sanitization step between

hand

washings or after

hand washing once the skin is completely dry. The

sanitizing rub should cover the entire hand, but

provide particular auention to the fll1gcrtips, hack of

the thumbs (to the base , and webbing of the fingers

 areas sometimes neglected during

h::md

washing .

SU RY

Hand washing is an activity that is frequently taken for

granted. Every pharmaceutical process that includes

some aspect of human intervention is subject

to

contamination and the integrity of well-designed and

controlled phJrmaceutical processes may be compro

mised by careless hJnd waShing. Employee awareness

of this potential coupled with effective training will

minimize inadvertent contamination due

to

careless

hand washing techniques.

There are several key points to ensure effective hand

washing. It

is

important to use proper technique in

storing

Lhe

soap

in a cll Jl

manner

(to

prevent exces

sive

contamination , remove alljewelry,

to

use enough

soap to do the job, wash thoroughly time and applica-

8/18/2019 sutton.j.gxp_.14.1

7/8

MI RO IOLOGY TOPI S

tion), and

to

completely dry your hands while prevent

ing recontamination.

As for drying method, there does not seem to be

strong, unambiguous data showing superiority for ei

ther paper towel drying or hot air drying (although

UV

irradiation when used with hot air seems preferahle).

Techniquc and

procedure

are paramount in

minimizing t ransmiss ion Once trainee , ongoing

compliance with thc hand washing

procedure should

be monitored as pan of an ongoing

conwminatlon

control program for the faCility, and an aid to mini

mize employee ahsence due to illness.

R F R N S

FDA,

21CFR21128,

Code of Federal Regulation Title 21,

Volume

4, Title

21-fuod

And

Drug .

Chapter

I-Food

And

Drug Adminislration, Department

Uf

Hcalth And

Iluman

Servia

Subchapter C-Dru

'5:

General.

Pan

211-Current

Good Manufacturing Practice

 01

l'imshed 'hurmdceutic b,

Subpart B-OrganizatLon

and

Personnel, Revised as ofApril

1,2009.

2.

Gallaher, WR., Towards

d

Sane and Rational Approach to

Management of

InnuenlJ

HINI

2009,

Virology

6')1-57,

200' .

3. IIellemans, A.,   Bealing the Flu in a

Singk

Shot, Sci Amer,

lutlc: 104 - 107, 200S.

4. G r ~ y s n M,

et

aI ,

 Elfrcacy

of

Soap and Water and Akohol

Based Hand-Rub Prcparations against

Live HINI

InllUl.:nza

Viruson the Hands of

Human

Volunte('r .'· Clin

Inferl

Dis,

48285 - 291, 2009.

5.

Grilhth,

CJ et

ul.,

 environmental

Surface Cleanlincss and the

Potential

for

Contamination

During Handwashing,

Amer)

Infect

Conlrol

31(2):93-96, 2003.

6 Hegde, P, et aI., Microbial

Contamination

of in use Bar Soap

in Dental Clinic '-

Ind) Dent

Re;. 17(2)70 -

73,2006

7. Buffet-Balaillon, 5,

el

aI., Outbreak of

Serratia marce;cens

in a

Neonatal Intensive Care l:nit: Contaminated Cnmedicated

l.iquLd Soap and Risk F:Klor ' ) Hasp

Infect. 7217

- 22,

2009

8. Sar tor, C, et al

 

Nosocl1Inial

Serralia mWU,(l ns

Infections As

sociate with

L\trinsic

Contamination ofa Liquid

NonmcJi

cated Soap,

Infecl (onlrol Ho,p

tpidonk11

21(3)196 - 199,

2000

9 Aiello, A.E., Larson, E.L., Levy, S.B., Consumer Antibacterial

Soaps:

EITective

or Just Risky?

ClimcallnffCli lu.1 Olscu_

8/18/2019 sutton.j.gxp_.14.1

8/8

Prob lonals, ] Hosl 111{ ·(1.,

63:418 - 422, 2006

25

Haa,. JPam FL

Larson,

  MeJSUlTmenl of

Compliance

with

Hand HY,C,len':] H ,I IrU1 C1

,

666-14.2007.

26. Larson,   Jn d r I.u,k, ' ::vJlu3ting H3ndw3shing Technique,

] Ad\

N'trsil1>;, ,,3(1)-+0-50,2008.

27 Cule

M

Exploring the

H3nd

Hygiene

Compelence of Student

Nurses:

A Case of f'iJwecl

Self

Assessmcnt, NtH , fdl wlion

10duy,   9 ~ 8 - 188, 2009

2B. Slc rnson, R, el aI. ,  A ::'c k

f(lr

\>Jca uring Hygi l1c Bchdvior:

1 ~ \ l · l o p l 1 1 l l 1 l RelielbililY,

e1ml

V liuily. ,Imcr] In{ecl Conlml.,

37 7h,/- 64,2009

29 Suchomel, M, el aI.,

 Surgical Hand

D i s i n r c ~ l t o n

Using

Alcohol:

The

nrccl '

01 Alcoliol Typc. \lode and Dur31ion of

Application, ]  0 1 tn{ed., 71:228 - 233, 2009

3

ROller . ML et aI. ,   Long-Ierm ErfcTI of a 1.5 minute S u r g i ~ a l

Hanu

Rub wilh a

Propanol-based

Product on the Re uenl

Hand

f·lora.'·] 11 ,1' InJce ,

66 1 84-85,2007.

11 Will, H., E:neuI\I' Use

of

Alcohol

Hand

Sanitiz , ,

  onlrol ed

lnvimn.,

11 8 26,2008.  X

RTICLE

 CRONYM LISTING

 STM American Society for Testing and Materials

CDC

Centers for Disease Control

CFR Code of Federal Regulations

  MP Current Good Manufacturing Practice

  European Commission

EOT Ethylendiaminetetraacetic Acid

 MP Good Manufacturing Practice

prEN Preliminary European Norm

SOP

Standard Operating Procedure

 

Ultraviolet

 OUT

THE  UTHOR

SCOll SlillclO, Ph.D.. i a consulunt an d o p e r a t ~ Th e Microbiolo

gy

  let

work (www.microhiol.org). which

provides

consulling and

training   contamination ClItHrol, C1l'\'ironmenlat

monitoring,

GMP. investigations of

bioburden-rd::necl

manulacturing issues,

and QC

microbilJlclgy

laborJlory operations.

Tile Microhiology

Network also   perales the c-m i l

cli 'ussiun groups

the Piv ['LiSl

(microbiology) and the

I'SLJGList (stability issur5) Dr.

5ullon can

be

reached at SCOlL.sullon@mierobiol.urg.