Wash your hands, Brother John!

Use of a six step hand hygiene technique as recommended by the World Health Organization is important to ensure thorough cleansing of hands, but learning and memorising the steps is a major barrier to its adoption. We hereby describe a musical mnemonic based on the popular nursery rhyme “Brother John” (also known as “Frère Jacques”) that can help learning and remembering of the proper technique.

Regular hand hygiene education at day care and school is recommended as an effective method to prevent gastrointestinal and respiratory infections, which are common in children.1 Hand cleansing may seem a relatively simple task, and the correct technique can improve the effectiveness of hand hygiene at eliminating microorganisms.2 Numerous studies have investigated the specific effect of school based hand hygiene interventions on infections and school absenteeism; however, few interventions have focused on how hand hygiene technique is taught to children.3

Using songs, in particular musical mnemonics based on popular nursery rhymes, may help children learn the process of hand hygiene techniques by making it more fun, thereby increasing attention and the development of memory and motor coordination.45 Learning through song lyrics, where the instructions are stated before completion of each step, has been shown to produce quicker acquisition of novel skills compared with prose self instruction.6

Children are exposed from an early age to musical mnemonics or cues that assist with learning (the ABC song for the alphabet, and the Head, Shoulders, Knees, and Toes song to identify body parts). However, few musical mnemonics exist to help teach hand hygiene to children. We reviewed a convenience sample of 15 videos online that targeted children to determine the following: presence of a musical mnemonic (with lyrics complementing each step of handwashing); song duration; and demonstration of decreased microbial burden as immediate visual feedback. We found no videos that showed the six step technique using a song mnemonic; the few that showed certain steps had songs that were longer than the recommended duration of handwashing (20-30 seconds) and were not easily reproducible by our school aged co-author.7

Fuelled by these findings, we decided to develop a musical mnemonic that targeted school aged children. We used the melody of a well known children’s song, Brother John (Frère Jacques), and incorporated the six recommended steps for hand hygiene. The lyrics were developed in collaboration with children of preschool and primary school age, ensuring that our intended audience could easily understand them, and leveraged the rhythmic and rhyme patterns of a popular song to improve memory retention.

The six steps to achieve effective hand hygiene, sung to the tune of Brother John (also known as Frère Jacques)
(fig 1, video on bmj.com): CLICK HERE TO SEE VIDEO

1. Are you sleeping // Scrub your palms
2. Are you sleeping // Between the fingers
3. Brother John, Brother John // Wash the back (one hand), wash the back (other hand)
4. Morning bells are ringing // Twirl the tips (one hand) around (other hand)
5. Morning bells are ringing // Scrub them upside down
6. Ding, ding, dong; ding, ding, dong // Thumb attack (one thumb)!Thumb attack (other thumb)! (sung with gusto)

Each line is repeated as is necessary to complete each step.

Fig 1

The six step technique for hand hygiene, as recommended by the World Health Organization, sung to the tune of Brother John (Frère Jacques) for song lyric self instruction in hand washing. Some steps involve doing one hand at a time. R=right L=left (image by N Thampi)

To investigate whether this song lyric self instruction method could be effective in reducing microbial burden, fluorescent marking was applied at the outset and hands were examined after washing with soap and water for residual fluorescence. Figure 2 shows reduction in the presence of fluorescent marking on the hands following handwashing while singing the musical mnemonic, indicative of potential effectiveness at decreasing microbial flora.

 

Fig 2

Fluorescent marking on hands, before and after handwashing using the song lyric self instruction. Fluorescent marks indicate presence of microbial flora. (A) Before handwashing, fluorescent marking under the black light is white and scattered throughout the palmar and dorsal aspects of both hands. (B) After handwashing there is a notable absence of fluorescent marking on palms, back of hands, and fingertips, with traces in the nail bed (image by N Thampi)

This song lyric self instruction has broad implications for school based public health campaigns. We showed that a musical mnemonic developed for preschool and school aged children can teach the World Health Organization hand hygiene technique effectively, potentially reducing infection transmission, with a duration of approximately 20 seconds. Given the longstanding clinical challenges of compliance with the six step technique, there is also potential for this musical mnemonic to be adopted in the healthcare setting; further testing would be required before definitive comparisons can be drawn. We plan to test the song in the classroom setting to determine its social acceptability, and its potential for peer-to-peer learning and long term memory retention. With its catchy tune and clear, lyrical instructions, our technique offers the opportunity to develop hand hygiene muscle memory, self-correction, and public health gains among children.

Footnotes
Acknowledgments The authors wish to acknowledge the children who provided early feedback on the musical mnemonic, particularly Ajay Villeneuve for demonstrating its ease of acquisition, use, and social acceptance among the preschool age group. We would like to thank Paddy Moore, Rhonda McIntosh, and Andre Coutu from CHEO Communications for producing and developing the video content, and the children who shared our enthusiasm for handwashing in song. A video demonstrating the six step technique using the musical mnemonic can be found at bmj.com.

Contributions NT and LNV conceived the musical mnemonic, YL contributed to the video, LNV performed the demonstration, NT and YL drafted and revised the manuscript. NT is guarantor.

Funding None received

Competing interest statement All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Guarantor N Thampi

Patient and public involvement The musical mnemonic was field tested among the co-author’s classmates and paediatric family members. All volunteered freely to participate.

Provenance and peer review: not commissioned; not externally peer reviewed.

References
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Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review.BMJ2009;339:b3675. PubMed doi:10.1136/bmj.b3675

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2. Price L,
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A pragmatic randomized controlled trial of 6-Step vs 3-step hand hygiene technique in acute hospital care in the United Kingdom. Infect Control Hosp Epidemiol2016;37:661-6. PubMed doi:10.1017/ice.2016.51

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1. Willmott M,
2. Nicholson A,
3. Busse H,
4. MacArthur GJ,
5. Brookes S,
6. Campbell R
Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis. Arch Dis Child2016;101:42-50. PubMed doi:10.1136/archdischild-2015-308875

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1. Thaut MH,
2. Peterson DA,
3. McIntosh GC,
4. Hoemberg V
Music mnemonics aid verbal memory and induce learning—related brain plasticity in multiple sclerosis. Front Hum Neurosci2014;8:395. PubMed doi:10.3389/fnhum.2014.00395

5
1. Lee RL,
2. Leung C,
3. Tong WK,
4. Chen H,
5. Lee PH
Comparative efficacy of a simplified handwashing program for improvement in hand hygiene and reduction of school absenteeism among children with intellectual disability. Am J Infect Control2015;43:907-12. PubMed doi:10.1016/j.ajic.2015.03.023

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1. Bloom LB,
2. Kettering TL,
3. Walker D
A comparison of song-lyric and prose self-instruction procedures for increasing novel skills in children. J Appl Behav Anal2019. PubMed doi:10.1002/jaba.548

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World Health Organization. Hand hygiene: why, how & when? 2009. https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf

Published by: British Medical Journal – https://www.bmj.com/content/367/bmj.l6050


CDC reminds people hand-washing is effective prevention against coronavirus

With the threat of a coronavirus pandemic looming, health officials are reminding people that hand-washing — done the right way — is one of the most effective means to keep it at bay.

This hands-on guide describes the best technique to accomplish the simple task.

The Centers for Disease Control and Prevention advises people to spend at least 20 seconds scrubbing their hands, especially after going to the bathroom and before eating — as well as after blowing their nose, coughing or sneezing.

Follow these steps every time:

— Wet your hands with running water and apply a copious amount of soap.

— Lather your hands, rub the back of your hands and interlock your fingers.

— Scrub and rotate your hands.

— Clean your thumbs, the top of your fingers and your wrists.

— Rinse off the soap and dry your hands with a clean towel.

If soap and water are not available, use a hand sanitizer with at least 60 percent alcohol — but always use soap and water if your hands are visibly dirty.

Keep in mind that sanitizers do not get rid of all types of germs.

By Yaron Steinbuch
Published https://nypost.com
Published in Nypost.com Feb. 27th 2020


Bedre håndvask på store flyplasser kan bremse spredning av smittsomme sykdommer

Bedre håndvask på store flyplasser kan bremse spredning av smittsomme sykdommer.

Hvis flypassasjerer vasker hendene sine oftere og bedre på de ti største flyplassene i verden, kan spredningen av smittsomme sykdommer begrenses kraftig, ifølge ny forskning.

Før i tiden spredte sykdommer seg sakte, og sjelden veldig langt. Svartedauden som starten i Kina i 1334 brukte nesten 15 år på å spre seg til Vest-Europa.

I motsetning spredte det nye coronaviruset seg fra Kina til Europa på under en måned og det global transportnettverket kan spre smittsomme sykdommer til alle deler av verden under 24 timer.

I 2018 var det 4,3 milliarder mennesker som fløy med fly, og det forventes at det antallet vil øke til 7,8 milliarder i 2036. Derfor er hygiene ved transportknutepunkter som flyplasser viktig i kampen mot nye epidemier, skriver forskerne i studien.

Studien ble publisert i Risk Analyse.

Må vaske hendene oftere og bedre

Skitne hender kan være et stort problem. Spesielt på flyplasser hvor mange mennesker fra ulike steder er samlet. Noen steder på flyplasser, som for eksempel check-in automater, kasser ved sikkerhetsinngangen og toaletthåndtak blir berørt av svært mange gjennom dagen.

Ifølge forskerne bak den nye studien har bare 20 prosent av mennesker på flyplasser rene hender, som betyr at hendene har blitt vasket med vann og såpe i over 15 sekunder den siste timen.

Bare 70 prosent vasker hendene sine etter toalettbesøk på flyplasser, av de 70 prosentene så vasker bare halvparten hendene riktig. Bedre håndvask på alle flyplasser kan være vanskelig, men ifølge forskerne bak studien kan vi redusere spredningen av sykdommer med 37 prosent bare ved å vektlegge håndvask ved de ti største flyplassene i verden.

I en annen studie så forskerne på effekten av håndvask og bakteriespredning. De prøvde å spre bakterier på dørhåndtak. Uten håndvask fant de bakterier 44 prosent av gangene. Etter håndvask med vann fant de bakterier 23 prosent av gangene og håndvask med vann og såpe bare 8 prosent.

Det hadde ingen betydning hvilke bakterier forskerne brukte.

Små forbedringer kan gjøre stor forskjell

Hvishåndvaskingen på flyplasser øker med bare 10 prosent, noe forskerne mener er mulig å gjøre hvis de informerer passasjerene bedre, kan spredningen av smittsomme sykdommer reduseres med 24 prosent, skriver forskeren i studien.

– Å få bedre håndhygiene er vanskelig, men nye metoder innen utdanning, mer bevissthet og bruken av sosiale medier har vist seg å være effektivt i håndvaskingskampanjer, sier Christos Nicolaides som er en av hovedforskerne bak studien til MIT News Office.

Hvis vi tredobler antall mennesker med rene hender til 60 prosent, bremser vi potensielt smittsomme sykdommer med 70 prosent, skriver forskeren i studien.

Noen flyplasser er viktige enn andre

Forskerne kartla 120 flyplasser som de mener har størst påvirkning på spredning av smittsomme sykdommer. Et interessant funn er at flyplassene som påvirker spredning mest, ikke nødvendigvis var de travleste.

Forskerne bak studien peker på at flyplassene Narita i Tokyo og Honolulu på Hawaii, som rangerer på 46. og 117. plass i trafikkvolum, har større potensial til å spre sykdommer rundt verden enn større flyplasser. Dette er fordi flyplassene har direkteflyvninger til de største flyplassene i verden og at de har mange langdistanseflygninger.

Hvis det forekommer et sykdomsutbrudd, må man finne de 10 nærmeste flyplassene på listen av de 120 og få dem til å øke håndvaskingen blant passasjerene. Dette var den mest effektive metoden for å hindre spredning av sykdom, skriver forskerne i studien.

Ifølge Nicolaides er det mulig å forbedre håndvasking og hygiene blant passasjerene med å installere vasker bare til håndvask på forskjellige plasser og spesielt utenfor toaletter. Flyplassene kan også kartlegge områder der mennesker ofte er kontakt med objekter og vaske oftere der.

De ti viktigste flyplassene for å stoppe spredning av sykdommer:

•  London Heathrow lufthavn, England (LHR)

•  Los Angeles internasjonale lufthavn, USA (LAX)

•  John F. Kennedy internasjonale lufthavn, New York (JFK)

•  Charles de Gaulle internasjonale lufthavn, Paris (CDG)

•  Dubai internasjonale lufthavn, De forente arabiske emirater (DXB)

•  Frankfurt lufthavn, Tyskland (FRA)

•  Hongkong internasjonale lufthavn, Kina (HKG)

•  Beijing internasjonale lufthavn, Kina (PEK)

•  San Francisco internasjonale lufthavn, USA (SFO)

•  Schiphol lufthavn, Nederland (AMS)

Referanser:

Nicolaides, C. Demetris, A. Cueto‐Felgueroso, L. González, C, M. Juanes, R. (2019). Hand‐Hygiene Mitigation Strategies Against Global Disease Spreading through the Air Transportation Network. Risk Analyse. doi: https://doi.org/10.1111/risa.13438

 

Publisert

 


UNICEF: Novel coronavirus (COVID-19) outbreak: What you should know

UNICEF:
– It’s important to remember that key prevention measures are the same – frequent hand washing, and respiratory hygiene (cover your cough or sneeze with a flexed elbow or tissue, then throw away the tissue into a closed bin).

– Continue to follow good hand and respiratory hygiene practices like regular handwashing, and keep your child up to date with vaccinations – so that your child is protected against other viruses and bacteria causing diseases.

– Instead of keeping children out of school, teach them good hand and respiratory hygiene practices for school and elsewhere, like frequent handwashing, covering cough or sneeze with a flexed elbow or tissue, then throwing away the tissue into a closed bin, not touching their eyes, mouths or noses if they haven’t properly washed their hands.

– On 17 February, UNICEF appealed for US$42.3 million to scale up support for efforts to contain the novel coronavirus outbreak. The preliminary funds will support UNICEF’s work to reduce the transmission of the virus including by strengthening risk communication and tackling misinformation so that children, pregnant women and their families know how to prevent COVID-19 spread and where to seek assistance.

https://www.who.int/docs/default-source/coronaviruse


UNICEF urges political heads to commit to firm ODF targets

Mole (S/R), Feb. 19, GNA – The United Nations Children’s Fund (UNICEF) has called on political heads at the regional and local levels to commit to firm Open Defecation (OD) targets.

They are also to work with Assemblies through Assembly Members to mobilise the citizenry to take ownership of sanitation to achieve the targets.

Madam Margaret Gwada, Chief of UNICEF Field Office, Tamale, who made the call, expressed the need for Metropolitan, Municipal and District Assemblies to enact by-laws and sanctions to correct defaulting citizens.

She said this would help to achieve the President’s agenda of a “Clean Ghana,” “A Ghana without filth, a Ghana where children do not lose their lives to preventable diseases such as diarrhoea and polio”.

She was speaking at the Ministers’ Sanitation Summit held at Mole in the Savannah Region, which was a lesson-learning platform to deepen dialogue in the fight against OD as well as share experiences and ideas on dealing with the menace.

It was also to share and receive feedback from amongst the various regions and to come up with constructive ideas and suggestions on the way forward to improve on basic sanitation in the country.

It was organised by the Northern Regional Coordinating Council in collaboration with the Ministry of Local Government and Rural Development, and the Ministry of Sanitation and Water Resources together with its development partners including UNICEF and Canada.

It was attended by some Regional Ministers and Deputy Regional Ministers from five regions in the north, and the Central and Greater Accra Regions and officials from the Ministries of Sanitation and Water Resources, and Local Government and Rural Development, Metropolitan, Municipal and District Chief Executives, Regional Community Development Officers, Regional Environmental Health Officers from those regions and development partners including UNICEF, Canada and the coalition of NGOs in water and sanitation.

According to the 2017 Multiple Indicator Cluster Survey (MICS), one out of five Ghanaians defecated in the open.

Data from the Environmental Health and Sanitation Unit indicates that Northern Region moved from five per cent Open Defecation Free (ODF) coverage in June, 2016 to about 58% in July, 2019.

Madam Gwada attributed the strides in the area of ODF to commitment of leadership to timely release of funds towards sanitation initiatives and behavioural change, hence, her call on the political heads to commit to firm ODF targets.

Mr Michael Gyato, Deputy Minister for Sanitation and Water Resources urged Assemblies to sensitise their people to pick plastic rubbers scattered in their surroundings to help improve sanitation practices in their communities.

Mr John Benam, Deputy Northern Regional Minister said the government had demonstrated commitment towards improving on basic sanitation in the country and called on development partners “To lean on that and work assiduously to achieve more ODF with resources within our reach.”

Mr Eric Chimsi, Development Officer, at Canada expressed the need to institute measures for the effective and sustainable supply of durable sanitation and hand hygiene solutions to accelerate progress towards country-wide ODF by the year 2030.

Mr Attah Arhin, Water, Sanitation and Hygiene (WASH) Technical Coordinator of World Vision Ghana called on development partners to renew their commitment to the WASH sector and the suggested to government to fully release budgetary allocations towards the sector to achieve set targets.

GNA (Ghana News Agency)
By Albert Futukpor, GNA
https://ghananewsagency.org


Study: To slow an epidemic, focus on handwashing

Improving the rate of handwashing at just 10 major airports could significantly slow the spread of a viral disease, researchers estimate.

A new study estimates that improving the rates of handwashing by travelers passing through just 10 of the world’s leading airports could significantly reduce the spread of many infectious diseases. And the greater the improvement in people’s handwashing habits at airports, the more dramatic the effect on slowing the disease, the researchers found.

The findings, which deal with infectious diseases in general including the flu, were published in late December, just before the recent coronavirus outbreak in Wuhan, China, but the study’s authors say that its results would apply to any such disease and are relevant to the current outbreak.

The study, which is based on epidemiological modeling and data-based simulations, appears in the journal Risk Analysis. The authors are Professor Christos Nicolaides PhD ’14 of the University of Cyprus, who is also a fellow at the MIT Sloan School of Management; Professor Ruben Juanes of MIT’s Department of Civil and Environmental Engineering; and three others.

People can be surprisingly casual about washing their hands, even in crowded locations like airports where people from many different locations are touching surfaces such as chair armrests, check-in kiosks, security checkpoint trays, and restroom doorknobs and faucets. Based on data from previous research by groups including the American Society for Microbiology, the team estimates that on average, only about 20 percent of people in airports have clean hands — meaning that they have been washed with soap and water, for at least 15 seconds, within the last hour or so. The other 80 percent are potentially contaminating everything they touch with whatever germs they may be carrying, Nicolaides says.

“Seventy percent of the people who go to the toilet wash their hands afterwards,” Nicolaides says, about findings from a previous ASM study. “The other 30 percent don’t. And of those that do, only 50 percent do it right.” Others just rinse briefly in some water, rather than using soap and water and spending the recommended 15 to 20 seconds washing, he says. That figure, combined with estimates of exposure to the many potentially contaminated surfaces that people come into contact with in an airport, leads to the team’s estimate that about 20 percent of travelers in an airport have clean hands.

Improving handwashing at all of the world’s airports to triple that rate, so that 60 percent of travelers to have clean hands at any given time, would have the greatest impact, potentially slowing global disease spread by almost 70 percent, the researchers found. Deploying such measures at so many airports and reaching such a high level of compliance may be impractical, but the new study suggests that a significant reduction in disease spread could still be achieved by just picking the 10 most significant airports based on the initial location of a viral outbreak. Focusing handwashing messaging in those 10 airports could potentially slow the disease spread by as much as 37 percent, the researchers estimate.

They arrived at these estimates using detailed epidemiological simulations that involved data on worldwide flights including duration, distance, and interconnections; estimates of wait times at airports; and studies on typical rates of interactions of people with various elements of their surroundings and with other people.

Even small improvements in hygiene could make a noticeable dent. Increasing the prevalence of clean hands in all airports worldwide by just 10 percent, which the researchers think could potentially be accomplished through education, posters, public announcements, and perhaps improved access to handwashing facilities, could slow the global rate of the spread of a disease by about 24 percent, they found. Numerous studies (such as this one) have shown that such measures can increase rates of proper handwashing, Nicolaides says.

“Eliciting an increase in hand-hygiene is a challenge,” he says, “but new approaches in education, awareness, and social-media nudges have proven to be effective in hand-washing engagement.”

The researchers used data from previous studies on the effectiveness of handwashing in controlling transmission of disease, so Juanes says these data would have to be calibrated in the field to obtain refined estimates of the slow-down in spreading of a specific outbreak.

The findings are consistent with recommendations made by both the U.S. Centers for Disease Control and the World Health Organization. Both have indicated that hand hygiene is the most efficient and cost-effective way to control disease propagation. While both organizations say that other measures can also play a useful role in limiting disease spread, such as use of surgical face masks, airport closures, and travel restrictions, hand hygiene is still the first line of defense — and an easy one for individuals to implement.

While the potential of better hand hygiene in controlling transmission of diseases between individuals has been extensively studied and proven, this study is one of the first to quantitatively assess the effectiveness of such measures as a way to mitigate the risk of a global epidemic or pandemic, the authors say.

The researchers identified 120 airports that are the most influential in spreading disease, and found that these are not necessarily the ones with the most overall traffic. For example, they cite the airports in Tokyo and Honolulu as having an outsized influence because of their locations. While they respectively rank 46th and 117th in terms of overall traffic, they can contribute significantly to the spread of disease because they have direct connections to some of the world’s biggest airport hubs, they have long-range direct international flights, and they sit squarely between the global East and West.

For any given disease outbreak, identifying the 10 airports from this list that are the closest to the location of the outbreak, and focusing handwashing education at those 10 turned out to be the most effective way of limiting the disease spread, they found.

Nicolaides says that one important step that could be taken to improve handwashing rates and overall hygiene at airports would be to have handwashing sinks available at many more locations, especially outside of the restrooms where surfaces tend to be highly contaminated. In addition, more frequent cleaning of surfaces that are contacted by many people could be helpful.

The research team also included Demetris Avraam at the University of Cyprus and at Newcastle University in the U.K., Luis Cueto-Felgueroso the Polytechnic University of Madrid, and Marta Gonzalez at the University of California at Berkeley and MIT. The work was supported by startup company Smixin Inc and MIT International Science and Technology Initiatives.

By David L. Chandler | MIT News Office
February 6, 2020
https://news.mit.edu/


What to do next to control the 2019-nCoV epidemic?

The 2019 novel coronavirus (2019-nCoV) infection can lead to acute resolved or fatal pneumonia. On the basis of knowledge of other coronaviruses, the main route of human-to-human transmission of 2019-nCoV is probably through respiratory droplets. As of Feb 4, 2020, statistical data show that the outbreak constitutes an epidemic threat in China, where the exponential increase in patients has reached 20438 confirmed cases, with 2788 (13·64%) patients in critical condition and 425 (2·08%) deaths; 23214 additional suspected cases have also been identified so far. The most affected city, Wuhan, and related regions in Hubei province of China have reported 13522 confirmed patients (66·16% of total cases) and 414 deaths from 2019 nCoV infection (97·41%of total deaths in China). 632 patients with confirmed infection have recovered and have been discharged from hospital. However, the downward turning point for new cases of infection has not been observed yet (figure). Notably, 159 confirmed cases have been reported in 23 other countries beyond China, including Japan, Thailand, Singapore, South Korea, Australia, the USA, Malaysia, and Germany. Because of the seriousness of this outbreak, WHO declared it a public health emergency of international concern on Jan 30, 2020, followed by the USA announcing a public health emergency on Jan 31, 2020.

During the epidemic, rapid and robust research is important to help guide clinical practices and public health policies. Zhu and colleagues sampled bronchoalveolar-lavage fluid from three patients and used next-generation sequencing and PCR to characterise the virus, and they identified the pathogen of this outbreak as a novel coronavirus that falls within the subgenus Sarbecovirus of the genus Betacoronavirus and confirmed the cytopathic effects (structural changes in host cells) of this virus.1 Their achievement not only improves methods of diagnosis confirmation in clinics but also promotes the study of the underlying mechanisms of viral infection.2 Subsequently, collaborations between Chinese and international scientists have rapidly unmasked some additional virological features of 2019-nCoV. A specific viral nucleic acid assay using RT-PCR was quickly developed for the diagnosis of 2019-nCoV infection.3,4Additionally, human angiotensin-converting enzyme 2 has been shown to be the putative receptor for the entry into host cells by use of bioinformatic prediction methods and in-vitro testing.2,5,6 Furthermore, bats are speculated to be the original host of this zoonotic virus, but whether an intermediate host facilitated the viral infection in humans is still unknown.7 Lastly, evidence of person-to-person transmission is accumulating,8,9 with an estimated R0 of 2·2 (95% CI 1·4–3·9),10 and the assessment of the full extent of this mode of transmission is urgently needed.

In The Lancet, two retrospective studies from Wuhan Jin Yin-tan Hospital have recently provided the first-hand evidence of epidemiological, clinical, laboratory, radiological imaging, and outcomes among 41 patients11 and 99 patients.12 Of 99 patients with 2019-nCoV pneumonia,12 the average age was 55·5 years (SD 13·1) and 50 (51%) patients had chronic diseases. Clinical manifestations were fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). In view of the findings from both studies, as well as accumulated clinical experience, the next crucial step would be to identify the proper treatment for patients infected with 2019-nCoV.

No fully proven and specific antiviral treatment for the coronavirus exists. Guidance from China’s National Health Commission suggests taking an anti-HIV drug combination of lopinavir and ritonavir and inhaling a dose of nebulised interferon α for the antiviral therapy.13Many efforts, including several clinical trials, such as NCT04246242 and NCT04252664, are in progress to screen existing antiviral drugs to identify those that could be specific and efficient against 2019-nCoV. Notably, the first reported use of remdesivir, in the first diagnosed patient with 2019-nCoV infection in the USA,14 has encouraged additional clinical study of this medication.

More importantly, patients in critical conditions often develop serious complications, such as acute respiratory distress syndrome (17 [17%] of 99 patients),12and thus medical groups should include physicians with expertise in both infectious diseases and critical care. It is noteworthy that patients in critical condition often show a reduction in peripheral blood lymphocytes.11,12 Whether immune cells infiltrate into the lungs and then cause serious lung lesions (as occurred in patients with severe acute respiratory syndrome [SARS])15 is not clear. Therefore, it is important to understand the lung microenvironment and the map of immune responses against 2019-nCoV infection, which might help to define clinical stages and uncover the pathogenesis of the disease. Recent data showed that mostdeaths were due to respiratory failure;11,12 however, no reports of lung pathology in patients who died from 2019-nCoV infection have been reported so far. Notably, elderly men with 2019-nCoV infection and other underlying diseases often have a higher fatality rate than that of elderly women or younger and more healthy patients;11,12more studies are needed to determine the associated influencing factors underlying this finding.

The development of more efficient and quicker methods for the detection of viral nucleic acids is needed to ensure the accuracy of diagnosis. Several challenges remain for basic research, including viral mutation rateand transmission, infectivity dynamics, and viral infection-associated pathogenicity in vivo. Some evidence has suggested that the virus can spread during the incubation period9,16 and is detectable during the convalescent period.16 Notably, the virus was found in the loose stool of a patient in the USA,14 suggesting potential transmission through the faecal–oral route. It is of high priority to ascertain whether persistent asymptomatic carriers of 2019-nCoV exist and to reach an accurate definition of when a patient can be considered cured. Moreover, no certainty exists about the source of the outbreak, and a prophylactic vaccine is still under development.

WHO has acknowledged the efforts made by the Chinese Government to investigate and contain the outbreak.17 For example, authorities rapidly initiated the first measures to isolate Wuhan, which were then extended to the whole Hubei province, stranding 35 million residents during the heavy-travel Chinese Spring Festival holidays. At the same time, the two new-built hospitals in Wuhan have been put into use, with 2600 beds for the confirmed and suspected patients with pneumonia. The decision makers also extended the holiday period and postponed school openings. Additionally, at least 68 medical teams, including more than 8000 physicians and nurses, from other provinces and cities went to the most affected Hubei province to fight against the disease side by side with the local medical staff.18 The Chinese Government has initiated at least 13 research programmes as an emergency measure to study the different aspects of the outbreak such as the diagnosis, treatment, and prevention of 2019-nCoV-associated disease.19 Novel therapeutic approaches, including treatment with allogeneic mesenchymal stem cells, are expected to progress to clinical trials involving patients with 2019-nCoV infection in a critical condition when the projects meet both ethical requirements and the principle of informed consent (eg, NCT04252118). Furthermore, therapeutic drugs, protective equipment, and charitable funds from inside and outside of China are transported to the epidemic area to support the response. All these measures are aimed to maximise prevention and minimise the occurrence of new infections, which will help the in-time diagnosis and treatment of patients and protect the healthy population against viral infection not only in China but also in the rest of the world. China also faces other challenges, including asymptomatic carriers with 2019-nCoV might be a new potential source of infection; there will be a huge increase in people returning from trips after the Chinese Spring Festival vacation; and it may be difficult to control the outbreak due to the lack of adequate medical resources in epidemic communities and rural areas of Hubei province.

First-line medical staff and scientists in China have had a leading role in fighting the outbreak of 2019-nCoV-associated pneumonia. The basic and essential strategies that we should stick to remain the early detection, early diagnosis, early isolation, and early treatment of the disease. With the huge efforts from medical professionals to treat patients, substantial public health prevention measures, and accelerated research, we hope the downward turning points for both new cases of 2019-nCoV and the resulting fatal events might come soon.

We declare no competing interests.

*Fu-Sheng Wang, Chao Zhang
fswang302@163.com

www.thelancet.comVol 395 February 8, 2020

Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing 100039, China

1
Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; published online Jan 24. DOI:10.1056/NEJMoa2001017.

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Zhou P, Yang X, Wang X, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; published online Feb 3. DOI:10.1038/s41586-020-2012-7.

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Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill 2020; 25: 2000045.

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WHO. Laboratory testing of human suspected cases of novel coronavirus (nCoV) infection: interim guidance, 10 January 2020. Geneva: World Health Organization, 2020.

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Xu X, Chen P, Wang J, et al. Evolution of the novel coronavirus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission. Sci China Life Sci 2020; published online Jan 21. DOI:10.1007/s11427-020-1637-5.

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Letko MC, Munster V. Functional assessment of cell entry and receptor usage for lineage B β-coronaviruses, including 2019-nCoV. bioRxiv 2020; published online Jan 22. DOI:10.1101/2020.01.22.915660 (preprint).

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Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019novel coronavirus: implications for virus origins and receptor binding. Lancet2020; published online Jan 30. https://doi.org/10.1016/S0140-6736(20)30251-8.

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Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med 2020; published online Jan 28. DOI:10.1056/NEJMc2001272.

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Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020; published online Jan 24. https://doi.org/10.1016/S0140-6736(20)30154-9.

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Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; published online Jan 29. DOI:10.1056/NEJMoa2001316.

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Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; published online Jan 24. https://doi.org/10.1016/S0140-6736(20)30183-5.

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Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online Jan 29. https://doi.org/10.1016/S0140-6736(20)30211-7.

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Chu CM. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax 2004; 59: 252–56.

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Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020; published online Jan 31. DOI:10.1056/NEJMoa2001191.

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de Wit E, van Doremalen N, Falzarano D, Munster VJ. SARS and MERS: recentinsights into emerging coronaviruses. Nat Rev Microbiol 2016; 14: 523–34.

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Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020; published online Jan 30. DOI:10.1056/NEJMc2001468.

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Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol 202; published online Jan 29. DOI:10.1002/jmv.25689.

18
Huaxia. 68 medical teams sent to Hubei to aid coronavirus control. 2020.Xinhuanet, Feb 3, 2020. http://www.xinhuanet.com/english/2020-02/03/c_138752003.htm (accessed Feb 4, 2020).

19
Ministry of Science and Technology of the People’s Republic of China. Emergency scientific programs on prevention and control of the novel coronavirus-induced pneumonia. Jan 25, 2020. http://www.most.gov.cn/kjbgz/202001/t20200125_151233.htm (accessed Feb 4, 2020).


Antibacterial Soap? You Can Skip It, Use Plain Soap and Water

When you buy soaps and body washes, do you reach for products labeled “antibacterial” hoping they’ll keep your family safer? Do you think those products will lower your risk of getting sick, spreading germs or being infected?

According to the U.S. Food and Drug Administration (FDA), there isn’t enough science to show that over-the-counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water. To date, the benefits of using antibacterial hand soap haven’t been proven. In addition, the wide use of these products over a long time has raised the question of potential negative effects on your health.

After studying the issue, including reviewing available literature and hosting public meetings, in 2013 the FDA issued a proposed rule requiring safety and efficacy data from manufacturers, consumers, and others if they wanted to continue marketing antibacterial products containing those ingredients, but very little information has been provided. That’s why the FDA is issuing a final rule under which OTC consumer antiseptic wash products (including liquid, foam, gel hand soaps, bar soaps, and body washes) containing the majority of the antibacterial active ingredients—including triclosan and triclocarban—will no longer be able to be marketed.

Why? Because the manufacturers haven’t proven that those ingredients are safe for daily use over a long period of time. Also, manufacturers haven’t shown that these ingredients are any more effective than plain soap and water in preventing illnesses and the spread of certain infections. Some manufacturers have already started removing these ingredients from their products, ahead of the FDA’s final rule.

“Following simple handwashing practices is one of the most effective ways to prevent the spread of many types of infection and illness at home, at school and elsewhere,” says Theresa M. Michele, MD, of the FDA’s Division of Nonprescription Drug Products. “We can’t advise this enough. It’s simple, and it works.”

The FDA’s final rule covers only consumer antibacterial soaps and body washes that are used with water. It does not apply to hand sanitizers or hand wipes. It also does not apply to antibacterial soaps that are used in health care settings, such as hospitals and nursing homes.

What Makes Soap ‘Antibacterial’

Antibacterial soaps (sometimes called antimicrobial or antiseptic soaps) contain certain chemicals not found in plain soaps. Those ingredients are added to many consumer products with the intent of reducing or preventing bacterial infection.

Many liquid soaps labeled antibacterial contain triclosan, an ingredient of concern to many environmental, academic and regulatory groups. Animal studies have shown that triclosan alters the way some hormones work in the body and raises potential concerns for the effects of use in humans. We don’t yet know how triclosan affects humans and more research is needed.

“There’s no data demonstrating that these drugs provide additional protection from diseases and infections. Using these products might give people a false sense of security,” Michele says. “If you use these products because you think they protect you more than soap and water, that’s not correct. If you use them because of how they feel, there are many other products that have similar formulations but won’t expose your family to unnecessary chemicals. And some manufacturers have begun to revise these products to remove these ingredients.”

How do you tell if a product is antibacterial? For OTC drugs, antibacterial products generally have the word “antibacterial” on the label. Also, a Drug Facts label on a soap or body wash is a sign a product contains antibacterial ingredients.

Triclosan and Health Concerns

Triclosan can be found in many places today. It has been added to many consumer products—including clothing, kitchenware, furniture, and toys—to prevent bacterial contamination. Because of that, people’s long-term exposure to triclosan is higher than previously thought, raising concerns about the potential risks associated with the use of this ingredient over a lifetime.

In addition, laboratory studies have raised the possibility that triclosan contributes to making bacteria resistant to antibiotics. Some data shows this resistance may have a significant impact on the effectiveness of medical treatments, such as antibiotics.

The FDA and the Environmental Protection Agency (EPA) have been closely collaborating on scientific and regulatory issues related to triclosan. This joint effort will help to ensure government-wide consistency in the regulation of this chemical. The two agencies are reviewing the effects of triclosan from two different perspectives.

The EPA regulates the use of triclosan as a pesticide, and is in the process of updating its assessment of the effects of triclosan when it is used in pesticides. The FDA’s focus is on the effects of triclosan when it is used by consumers on a regular basis in hand soaps and body washes. By sharing information, the two agencies will be better able to measure the exposure and effects of triclosan and how these differing uses of triclosan may affect human health.

The EPA reevaluates each pesticide active ingredient every 15 years. The EPA’s Final Work Plan for the triclosan risk assessment can be found in docket EPA-HQ-OPP-2012-0811.

More on the FDA’s Rule

The FDA’s rule doesn’t yet apply to three chemicals (benzalkonium chloride, benzethonium chloride and chloroxylenol). Manufacturers are developing and planning to submit new safety and effectiveness data for these ingredients.

With the exception of those three ingredients that are still under study, all products that use the other 19 active ingredients will need to change their formulas or they will no longer be available to consumers. Manufacturers will have one year to comply with the rule.

This rule doesn’t apply to hand sanitizers. The FDA recently issued a final rule on OTC hand sanitizers and will continue to review the three active ingredients commonly used in hand sanitizers. To learn about the difference between consumer hand sanitizers and consumer antibacterial soaps, visit our consumer information page.

Consumers, Keep Washing with Plain Soap and Water

So what should consumers do? Wash your hands with plain soap and water. That’s still one of the most important steps you can take to avoid getting sick and to prevent spreading germs.

www.fda.gov/consumers


Hand Hygiene Day: It’s in your hands – prevent sepsis in health care

Sepsis is a life-threatening complication from infection that arises when an infection alters the body’s normal response, causing injury to tissues and organs. Each year, sepsis can cause up to 6 million deaths globally – most of which are preventable.

Sepsis is the most preventable cause of death and disability in Europe. According to the Global Sepsis Alliance, more than 3.4 million individuals develop sepsis every year in the WHO European Region, and 700 000 of these patients do not survive. An additional one third of survivors die within the following year, and many face lifelong consequences, such as physical, psychological and cognitive challenges.

The financial burden due to sepsis has been calculated to be more than US$ 24 billion, representing 6.2% of total hospital costs in 2013. Studies in Europe and Canada estimated the daily costs of hospital care of a septic patient to be between €710 and €1033 in 2000 (equivalent to about US$ 645 and US$ 939, respectively).

On Hand Hygiene Day, observed annually on 5 May, WHO calls on health facilities to prevent health care-associated sepsis through hand hygiene and infection prevention and control (IPC) action. By working together to each play our part, we can prevent sepsis and save millions of lives every year.

To stop sepsis, prevent infection

The first step to stopping sepsis is implementing measures that prevent infections from occurring. The second is preventing infections from evolving into sepsis. In both communities and health-care facilities, this requires early detection of sepsis signs and symptoms and appropriate antibiotic treatment.

In health-care settings, sepsis may result from health care-associated infections. This makes it all the more important for health workers to practise good IPC measures, including effective hand hygiene. Washing hands properly prevents infections and, in turn, reduces the risk of sepsis in health-care facilities.

This year’s Hand Hygiene Day campaign follows a resolution, adopted in May 2017 by the Seventieth World Health Assembly, recognizing sepsis as a global health priority and calling for improved prevention, diagnosis and clinical management of sepsis. It emphasizes 5 calls to action for 5 target audiences:

• health workers: “Take 5 moments to clean your hands to prevent sepsis in health care”;
• IPC leaders: “Be a champion in promoting hand hygiene to prevent sepsis in health care”;
• health facility leaders: “Prevent sepsis in health care, make hand hygiene a quality indicator in your hospital”;
• ministries of health: “Implement the 2017 WHA sepsis resolution. Make hand hygiene a national marker of health care quality”; and
• patient advocacy groups: “Ask for 5 moments of clean hands to prevent sepsis in health care”.

It is also vital to ensure that health workers can recognize, diagnose and rapidly treat sepsis. Despite its tragic impact, sepsis is frequently underdiagnosed at an early stage when it is still potentially reversible.

The evolution of an infection to sepsis can be prevented through early detection of the signs and symptoms, followed by prompt medical care and especially treatment with appropriate antimicrobials. This is crucial to increasing the chances of surviving sepsis. In the case of antimicrobial-resistant infections, which are becoming increasingly common, a patient’s condition can deteriorate rapidly, further underscoring the need for early diagnosis.

Working towards a sepsis-free world

It is possible to envision a world free from sepsis, but this vision will only become a reality through concerted action taken by a range of actors. On Hand Hygiene Day, it is time to collectively commit to raising awareness about the proven approaches to preventing infection, and to encourage everyone – particularly health workers – to recognize that stopping sepsis is in their hands.

WHO/Europe


Hand hygiene is key to preventing the flu, but researchers say it’s going to take more than just hand sanitizer

Colder months on the way, there will be more chances for infections to spread. Before flu season is fully underway, it’s a great time to think about what we all can do to prevent the highly contagious virus.

A new study has revealed that hand sanitizer alone isn’t completely effective in killing the bacteria that spreads the flu from person-to-person. Researchers say more drastic measures need to be taken to help stop the infection.

“The physical properties of mucus protect the virus from inactivation,” said researcher Dr. Ryohei Hirose. “Until the mucus has completely dried, infectious [influenza A virus] can remain on the hands and fingers, even after appropriate antiseptic hand rubbing.”

Keeping hands clean

Based on previous studies, the researchers learned that ethanol-based disinfectants (EBDs) like hand sanitizer aren’t the most effective in stopping the spread of the flu virus. With that in mind, they set out to discover how consumers can do their best to keep the infection to a minimum.

Dr. Hirose and his team ran various tests with infected mucus and EBDs. One of their primary goals was to be able to minimize the spread of the flu at doctors’ offices, as germs are easily transmitted among sick patients.

The researchers learned that EBDs tend to struggle to deactivate the flu virus when infected mucus is wet, mainly due to its thickness. In one trial, they discovered that it took at least four minutes of exposure to the EBD for it to do the trick, as anything under the four-minute mark didn’t kill the germs of the flu virus.

Ultimately, what this means for consumers is that when they use hand sanitizer to stay virus-free, the product doesn’t work instantly, and so the risk of developing the flu remains.

Preventing flu outbreaks

However, the researchers did explain that EBDs tend to work differently if a consumer came into contact with infected mucus that was wet versus dry. Hand sanitizer can more easily attack the virus when the mucus is dry, killing the germs in up to 30 seconds.

The researchers encourage consumers not to underestimate the power of simply washing their hands with antibacterial soap, as doing so can also kill the flu germs in under one minute.

“These findings will greatly contribute not only to the development of a more effective method of preventing [influenza A virus] outbreaks, but also to the advancement of current hand hygiene and contact infection prevention strategies,” the researchers wrote.

By Kristen Dalli
Published 09/19/2019 | ConsumerAffairs
www.consumeraffairs.com