WHO: Ten threats to global health in 2019

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis.


The world is facing multiple health challenges. These range from outbreaks of vaccine-preventable diseases like measles and diphtheria, increasing reports of drug-resistant pathogens, growing rates of obesity and physical inactivity to the health impacts of environmental pollution and climate change and multiple humanitarian crises.

To address these and other threats, 2019 sees the start of the World Health Organization’s new 5-year strategic plan – the 13th General Programme of Work. This plan focuses on a triple billion target: ensuring 1 billion more people benefit from access to universal health coverage, 1 billion more people are protected from health emergencies and 1 billion more people enjoy better health and well-being. Reaching this goal will require addressing the threats to health from a variety of angles.

Here are 10 of the many issues that will demand attention from WHO and health partners in 2019.


Is our obsession with hand sanitisers doing us more harm than good?

Itʼs no secret that Donald Trump is a fan of Fox News, the American news channel whose hosts the President regularly sits down to do interviews with. However, one such host, Pete Hegseth, probably wonʼt be getting a handshake from the president any time soon.

“I donʼt really wash my hands ever,” Hegseth announced on air this week. “Germs are not a real thing. I canʼt see them, therefore theyʼre not real.”

Twitter erupted, while the president probably made a mental note to avoid shaking hands with Hegseth, one of his most vocal supporters, ever again. A self-confessed “germaphobe”, Trump has already admitted avoiding handshakes and is regularly caught on camera being handed small bottles of hand sanitiser by White House staff.
Robbie Williams was caught on camera doing the same (and looking quite squeamish) after performing Auld Lang Syne with audience members during a New Yearʼs Eve gig at Westminsterʼs Central Hall.

But Trump and Williams are far from alone. Sales of hand sanitisers have skyrocketed in the last ten years, along with antibacterial hand soaps and wipes, and recent data from Mintel found a third of us buy a bottle of hand sanitiser every month.

No longer the preserve of hospitals (the first hand sanitiser was invented by an American nurse in 1966 after discovering alcohol, when delivered through a gel, removed germs without soap and water), theyʼre now found in handbags, homes and on desks across the UK.

So, when did we become a nation of germ-fighters? And is it doing us any good?

“Of course you should wash your hands regularly,” says Tim Spector, a professor of genetic epidemiology at Kingʼs College London and author of The Diet Myth. “However, we seem to have developed an obsession with hygiene that, along with antibiotics, is decreasing our gut diversity and having an impact on our microbes and gut health.

“Children who grow up on farms have about a third less allergy risk. People who have pets, and those who come from large, poor families also have fewer allergies. The theory goes, if youʼre exposed to microbes from an early age, and have a healthy exposure to them in general, your immune system is exercised and trained to deal with harmful germs. Having friendly microbes on your skin and in your gut improves how your immune system responds to real threats.”

Speaking of threats, Professor Spector says headlines about SARS, Swine Flu and ebola have driven fears weʼre under siege from infection, when we should be more worried about the connection between overzealous clearning and poor gut health, which is linked to obesity and allergies.

“Of course, thereʼs a middle ground. If youʼre a chef, or work in a hospital, or youʼre on a cruise where thereʼs an outbreak of vomiting and diarrhoea, then it pays to be cautious. But the average person just needs to wash their hands with soap and hot water when required.”

“I find it scarcely believable that Pete Hegseth doesnʼt wash his hands,” says Professor John Oxford, a virologist at the Queen Mary School of Medicine. “Iʼve spent my life looking down microscopes and I can assure you that germs are very real.

“The first doctor who championed hand washing was a Hungarian called Ignaz Semmelweis, who in 1846 questioned why so many mothers on the maternity ward where he worked were dying. He realised doctors were performing autopsies and then delivering babies straight after. He ordered staff to wash their hands and death rates dropped. So hand washing is an important tool in public health.”

Though soap and hot water will do, thereʼs now a commercial edge to cleanliness too: “One hundred years ago, there werenʼt hundreds of cleaning products, bleaches, anti-bac sprays and hand sanitisers in our homes and lining supermarket shelves,” says Professor Spector. “Our kitchens didnʼt look like gleaming intensive care units. Our natural, friendly, healthy microbes are being washed, scrubbed and sanitised away so our immune systems have nothing to fight against.”

Indeed, so-called ‘clean-fluencersʼ (clean influencers) such as Mrs Hinch (1.8m followers and counting) are all over Instagram telling us how to keep our homes spotlessly clean, which, combined with the Marie Kondo effect means weʼre vulnerable to the idea we need to be as clean as possible – and never more so than when it comes to protecting our childrenʼs health. The child hand sanitiser market (unheard of 20 years ago) is rising, you can now buy antibacterial nappy sacks, and most mumsʼ nappy bags contain mini pots of hand sanitisers.

“Thereʼs been a huge rise in all types of allergies among children in the last 40 years,” says Professor Spector. “Somethingʼs going on. So while hand washing after nappy changing and going to the toilet should be encouraged, children should be allowed to play in the dirt, stroke pets and climb trees without worrying too much.
Otherwise, the danger is that we’re just ” replacing one problem – the risk of infection – for an altogether different one.”

By Maria Lally
February 12th 2019


Mind the Staph: London Is Crawling with Antibiotic-Resistant Microbes

The bacteria are not a major threat, but they could transfer their resistance to more dangerous pathogens

London is teeming with bacteria—some of which have developed resistance to antibiotics. These microbes are mostly harmless, but if they do cause an infection, it can be hard to treat. And there is a chance that they could transfer their resistance to more dangerous strains, experts warn.

In a new study, researchers in England and their colleagues found that frequently touched surfaces—such as elevator buttons, ATMs and bathroom-door handles—can be reservoirs of drug-resistant staphylococcus, or staph, bacteria.

The researchers collected 600 samples from locations throughout East and West London such as hospitals, public washrooms and ticket machines, finding 11 species of staphylococci. Nearly half of the samples—including 57 percent in East London and about 41 percent in less crowded West London—contained bacteria resistant to two or more frontline antibiotics. Just under half of the staph found in hospital public areas was drug resistant, compared with 41 percent in community settings, the team reported Thursday in Scientific Reports.

“Resistance genes and elements present in these bacteria can spread to human pathogens and result in the emergence of new [antimicrobial-resistant] clones,” says Hermine Mkrtchyan, a senior lecturer at the University of East London, who headed the team that conducted the research. “Although these bacteria are nonpathogenic, the increased levels of antibiotic resistance that we found in general public settings in the community and in hospitals pose a potential risk to public health.”

Should people be worried?

“So long as you wash your hands after going out into public areas, it should be fine,” says Richard Stabler, co-director of the Antimicrobial Resistance Center at the London School of Hygiene & Tropical Medicine, who was not involved in the work. “I certainly recommend washing your hands after being out in London.”

Despite the high ick factor of the idea of touching potentially dangerous bacteria in familiar settings, Stabler concedes that these species are commonly found on skin, so it is no surprise that they would be found in public places where people are constantly shedding skin and microbes.

These bacteria do not pose a real danger right now, Stabler says, because although some of them were resistant to two common antibiotics, they cannot evade the entire medical arsenal. “This is potentially a problem out there, but at the moment, it’s still quite containable,” he says.

Antimicrobial resistance is a major public health threat across the globe, Mkrtchyan notes. Every year, more than 700,000 people die because of it, and the toll is predicted to rise to 10 million by 2050. Resistance means patients will stay sick for longer, which increases the cost of health care, Mkrtchyan says. “Our research highlights that general public areas (part of our everyday life) can be reservoirs for multidrug-resistant bacteria and alerts us that concrete global efforts are required to tackle the problem.”

Mkrtchyan and her colleagues previously found similar drug-resistant bacteria in a study of London hotel rooms. They are now comparing the genes of the 11 species found in both studies to better understand how they evade drugs and the physical environments that support their development and transmission.

Knowing about the presence of antibiotic-resistant bugs is useful, Stabler adds, because public officials can utilize the information to prepare and guide treatment. “It’s okay that they’re out there,” he says. “We have to live with them rather than trying to exterminate them—because that doesn’t work.”

Antimicrobial resistance is a major public health threat across the globe, Mkrtchyan notes. Every year, more than 700,000 people die because of it, and the toll is predicted to rise to 10 million by 2050. Resistance means patients will stay sick for longer, which increases the cost of health care, Mkrtchyan says. “Our research highlights that general public areas (part of our everyday life) can be reservoirs for multidrug-resistant bacteria and alerts us that concrete global efforts are required to tackle the problem.”

Mkrtchyan and her colleagues previously found similar drug-resistant bacteria in a study of London hotel rooms. They are now comparing the genes of the 11 species found in both studies to better understand how they evade drugs and the physical environments that support their development and transmission.

Knowing about the presence of antibiotic-resistant bugs is useful, Stabler adds, because public officials can utilize the information to prepare and guide treatment. “It’s okay that they’re out there,” he says. “We have to live with them rather than trying to exterminate them—because that doesn’t work.”

Lipkin notes that some antibiotic resistance exists naturally. Researchers have found resistant microbes in isolated caves, he says, suggesting that some bacteria have evolved to tolerate natural antibiotics. But humans have dramatically increased the prevalence of these microbes by using antibiotics inappropriately.

The findings are concerning but not a reason to panic, Lipkin says. Similar drug resistance has been found in other places for years. “It’s just another call to be more sensible about how we use antibiotics,” he explains. Still, “the fact that they’re there at all means that they’re capable of moving into people.”


Article shared from: https://www.scientificamerican.com
By Karen Weintraub

Karen Weintraub is a freelance health and science journalist who writes regularly for the New York Times, STAT and USA Today, among others.

Hand hygiene helps reduce HCAIs (healthcare-associated infection)

Chris Wakefield, Vice President at GOJO Industries-Europe Ltd, highlights how hand hygiene systems reduce the spread of healthcare-associated infection (HCAI)

It is estimated that 300,000 patients a year in England acquire a healthcare associated infection (HCAI) as a result of care within the NHS. Such infections draw large attention from patients, regulatory bodies and the media. Not only because of the magnitude of the problem – after all, they are associated with morbidity, mortality and the financial cost of treatment – but, also, because most are preventable.

Despite being avoidable, HCAIs continue to present a major threat to our public health. They are particularly difficult to eliminate due to the speed and ease that they can be transmitted – and because of their long-life span. Did you know, for example, that MRSA can live up to nine weeks, whilst C.Diff spores can live up to five months? Or that they can be spread through both direct and indirect contact?

Studies have shown that contaminated hands can sequentially transfer some viruses to up to seven surfaces, and that fourteen people can be contaminated by touching the same object one after the other. Perhaps itʼs not surprising then, that research indicates that you have a 50/50 chance of picking up a dangerous pathogen anytime you touch anything or anyone in a hospital.

Such outbreaks can have serious repercussions; including the increased risk to the lives of vulnerable patients, disruption of services and reduced clinical activity, such as the enforced closure of hospital wards, cancelled admissions and delayed discharges. There is also the cost of treatment to factor.
Indeed, a report by the National Audit Office estimated that a reduction in the rates of MRSA bloodstream infections saved the NHS in England between £45 million-£59 million in treatment costs between 2003/4 and 2008/9. It also identified that by reducing the rate of C. difficile infections, between £97 million-£204 million was saved in treatment costs between 2006/7 and 2007/8.

Going back to basics

A great deal of scientific research has shown that, if properly implemented, hand hygiene is the single most important, easiest and cost-effective means of reducing the prevalence of HCAIs and the spread of antimicrobial resistance. In fact, research shows it can cut the number of HCAI cases by up to 50%. Several other studies have also demonstrated that handwashing virtually eradicates the carriage of MRSA which invariably occurs on the hands of healthcare professionals working in intensive care units. An increase in handwashing adherence has also been found to be accompanied by a fall in MRSA rates.
In order to reduce the spread of illness, everyone has to engage with hand hygiene practices – not only healthcare workers, who already make this a part of their daily lives, but visitors and patients too. As a founder member of the World Health Organization (WHO) Private Organizations for Patient Safety group, GOJO is a strong advocate of the ‘total solutionʼ approach to making hand hygiene second nature to everyone in a healthcare setting. We believe that, to successfully change behaviour, a triple-pronged approach is required.

Firstly, handwashing facilities must be accessible and dispensers easy to use. The WHO recommends that an adequate number of appropriately positioned hand hygiene facilities should be readily available at the point of care.

Secondly, the high frequency with which healthcare workers clean their hands means that the formulations must be gentle yet effective against germs, complying with key hospital norms EN 1500, EN 14476 and EN 12791. Studies have also shown that using an alcohol-based handsanitising rub can improve hand hygiene practice, since it is quicker, is microbiologically more effective and is less irritating to skin than traditional hand washing with soap and water.
Finally, eye-catching signage is very effective as a prompt, especially at key germ hot-spots such as washrooms and waiting areas. Hand hygiene facilities must remain well-stocked and maintained at all times too.

Getting smart

Although evidence supports a ‘back to basicsʼ approach, digital innovation also has a role to play. GOJO has spent many years developing advanced formulations and high-tech dispensers, and has recently harnessed revolutionary smart technology to create its SMARTLINK™ Electronic Monitoring Solutions. These two mobile apps are a smarter way to help reduce the maintenance time spent on dispensers, and measure hand hygiene performance – ultimately helping to prevent the spread of germs.
Combining the latest technology with the simple act of hand hygiene, and working together to put effective systems in place, we can reduce the spread of HCAIs. GOJO, the leading global producer of skin health and hygiene solutions for away-from-home settings, is your specialist partner in healthcare hygiene.

For a tailored, effective, total solution for your setting, or for more information, please call +44 (0)1908 588444,
email infouk@GOJO.com or visit www.GOJO.com


By Kerrie Doughty
Trade Marketing & Communications Manager GOJO Industries-Europe
Tel: +44 (0)1908588457



1. https://www.nice.org.uk/guidance/qs61/chapter/introduction
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3. Barker J, Vipond IB, Bloomfield SF. J Hosp Infect 2004,58k42-494 Stiefel U et al. Infect Control Hosp Edipdemiol 2011; 32k185.
4. 2008 SDA Clean Hands Report Card® sponsored by the Soap and Detergent Association.
5. 24 &25 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/#ref1
6. 26 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/#ref1
7. 2,3 & 35

Ebola is back – can it be contained?

The current outbreak of the deadly virus in the DRC has been called the most complex public health emergency in history. Peter Beaumont describes his recent visit to the DRC and Sarah Boseley discusses how the 2014 outbreak was eventually contained. Plus: Helen Pidd on what has been achieved with the ‘northern powerhouse’

CLICK ON IMAGE to go to podcast

The latest outbreak of Ebola, with more than 2,200 cases and more than 1,500 confirmed deaths in just over a year, is the second largest in history, despite the recent availability of an effective experimental vaccine. Political, security and cultural complications – not least a refusal to believe that Ebola exists – have thwarted efforts to overcome the Democratic Republic of the Congo’s deadly outbreak.

Senior global development reporter Peter Beaumont tells Anushka Asthana about his recent trip to North Kivu, which is at the heart of the recent outbreak. He discusses why some health officials are calling it the most complicated public health emergency in history. Guardian health editor Sarah Boseley, who reported on the 2014 outbreak, looks at how that was contained – and why the situation is potentially far more frightening this time round.

And: the Guardian’s northern editor, Helen Pidd, looks at whether the “northern powerhouse” has been a success five years after its creation.


Publihed by the Guardian,

Presented by Anushka Asthana with Sarah Boseley, Peter Beaumont and Helen Pidd, produced by Nicola Kelly, Elizabeth Cassin, Iain Chambers and Axel Kacoutié; executive producers Nicole Jackson and Phil Maynard

The European Commission has awarded its Seal of Excellence to Resani’s Horizon 2020 Phase 2 proposal - describing Resani’s disruptive hand sanitizing and compliance technology.

The Seal of Excellence is a quality label awarded to a few project proposals submitted to Horizon 2020, the EU’s research and innovation funding programme.

Following evaluation by an international panel of independent experts, Resani’s proposal was scored as A HIGH-QUALITY PROJECT PROPOSAL IN A HIGHLY COMPETITIVE EVALUATION PROCESS *)

* ) This means passing all stringent Horizon 2020 assessment thresholds for the 3 award criteria (excellence, impact, quality and efficiency of implementation) required to receive funding from the EU budget Horizon 2020.

Hands are vehicles for transmission of Streptococcus pneumoniae

Hands can be vehicles for transmission of pneumococcus and lead to acquisition of nasopharyngeal colonization, according to research published in the European Respiratory Journal.

Streptococcus pneumoniae (pneumococcus) is a major cause of acute otitis media, sinusitis, pneumonia, and meningitis worldwide, with more than 1.2 million attributed deaths annually. Colonization of the nasopharynx with these bacteria is a prerequisite for infection and it is the primary reservoir for transmission. It is theorized that transmission of pneumococcus occurs primarily through indirect contact through inhalation of airborne droplets and is associated with living in higher-density populations. For upper respiratory tract infections in general, direct contact is implicated in disease transmission, which can be interrupted by hand washing. However, the relative contribution of direct and indirect transmission modes to pneumococcal colonization and disease are unknown. Therefore, this study sought to assess the potential for pneumococcal hand-to-nose transmission to cause nasopharyngeal colonization.

A total of 63 healthy adult participants were enrolled into a controlled Experimental Pneumococcal Challenge model that was modified to assess
“hand-to-nose” (ISRCTN identifier: 12909224). Participants were divided into 4 transmission groups and dministered pneumococcus (3.2X106 mid-log phase colony-forming units of S pneumoniae serotype 6B) onto their hand and asked to either sniff or make direct contact with the nasal mucosal surface with the bacterial residue either immediately after exposure (wet) or when visibly dry (1-2 minutes after exposure). The 4 groups were: (1) sniffing wet bacterial suspension (wet sniff), (2) sniffing bacterial suspension after air-drying (dry sniff), (3) pick/poke nose with finger exposed to wet bacterial suspension (wet poke), and (4) pick/poke nose with finger exposed to bacterial suspension after air-drying (dry poke). After 9 days of exposure, nasopharyngeal colonization was assessed through nasal washes and all samples were tested by quantitative polymerase chain reaction (qPCR) with primers for lytA and for S pneumoniae serotype 6A/b.

Of the 40 participants, 20% were found by culture at follow up to be experimentally colonized with pneumococcus (6B), with the highest rates in the wet poke (40%) and wet sniff (30%) groups. In the dry sniff and dry poke groups, 10% and 0% of participants, respectively, were found to be experimentally colonized. When wet and dry groups were compared, colonization rates in the wet groups were significantly higher than in the dry groups (P =.04, Fisher exact test). Molecular detection via lytA qPCR identified higher colonization rates compared with culture (P <.0001). This was most apparent in the dry poke group, which had a colonization rate of 0% by culture and 70% using qPCR. Samples that were only positive with qPCR, such as the dry poke group, tended to have lower densities of carriage compared with samples that were positive with both methods, such as both of the wet groups.

Overall, the results provide a better understanding of the duration of survival of pneumococci in nasal secretions on the hands and the entire transmission process. The study authors concluded that, “This modification of the Experimental Pneumococcal Challenge model has several potential uses, including testing of current or new hand cleaning interventions to ensure reduction in transmission of this important bacterial pathogen.”

Connor V, German E, Pojar S, et al. Hands are vehicles for transmission of Streptococcus pneumoniae in novel controlled human infection study. Eur espir J. 2018;52(4):1800599.

Published by infectiousdiseaseadvisor.com , April 3rd 2019


Healthy and happy staff make businesses thrive

‘Nobody cares how much you know until they know how much you care.”

This quote, often attributed to Theodore Roosevelt, is one that more company bosses should consider, because those who look after their staff will reap the productivity benefits of a happier and more engaged workforce.

It also breeds loyalty, as the tale of one ex-Warburtons chairman tells. The story goes that he personally drove a delivery driver to the physio each week after the workerʼs legs were badly injured in an accident. He was treated until fit again and repaid the act by working for the family bakery until he retired as a senior director.

Another leader who believed that cared-for staff make for better and more successful organisations was John Spedan Lewis, founder of the John Lewis Partnership. He implemented pastoral care and employed a chief medical officer, GPs, physiotherapists and chiropodists to support department store colleagues. This was before and after the formation of the NHS.

I saw the benefits of this approach in the 2000s, when I was retail director of Waitrose. We had just taken over a number of competitor shops and I recall one poorly performing store having roughly one out of every 11 employees off sick at any one time.

By focusing on well-being and happiness, sick absence fell to below 3pc in less than six months. Staff turnover also decreased by two thirds. It not only brought immediate savings, but because experience was retained and improved, service standards and productivity increased. The shop went from being a loss-maker to generating a healthy profit.

In 2017, an estimated 131m working days were lost in the UK due to sickness. Absence will cost the economy £26bn by 2030. Something must be done to improve the situation. When I built my engaging.works website, which measures the workplace happiness of thousands of individuals, I wanted to find out how employees felt about their well-being at work.

Four questions of the overall 13 provide an answer. These are: do you rarely feel depressed or anxious at work; do you feel that the organisation cares for your well-being; do you feel that you have a good relationship with your line manager; and do you enjoy your job? Respondents answer on a scale of one (strongly disagree) to 10 (strongly agree).

The first two make up a “health hygiene” score, while the other two form a “job satisfaction” score. Plotted on an axis and ignoring those with no strong opinion either way, you can see several types of employee.

People who score low on health hygiene but high on satisfaction are what I call “stoics” (they endure personal problems due to their job being good enough). Oppositely, those who report high on health hygiene and low in encouragement are “discouraged”.

“Thriving” employees score more than seven out of 10 on both, while those who score low on both are “neglected”. Finally, there are
“prospering” workers, who donʼt score as highly as thriving colleagues, but still well.

Whatʼs striking is that almost one in four employees (24pc) scored themselves badly in terms of health hygiene, with one in 11 (9pc) falling into the “neglected” quadrant. That may sound like a decent score, but if 90 employees in a 1,000-strong organisation are suffering and have no job satisfaction, thatʼs a huge chunk of disengaged and unproductive staff.

Women make up the greatest numbers in the “neglected” camp, with 8pc of female managers in this group versus 5pc of male managers. For non-managers, itʼs 11pc versus 8pc, respectively – and for women and men over the age of 35, itʼs 10pc versus 7pc.

Women are also lacking when it comes to the “thriving” camp, with 31pc of male managers in this category compared to 28pc of their female counterparts. But there is one glimmer of hope at the non-management level; “thriving” women outscore men 29pc to 26pc.

What else? If youʼre in a non-management role, your health hygiene score is likely to be significantly worse than your manager (managers outperform non-managers in the “thriving” and “prospering” categories). Millennials are also more likely to be thriving than their older colleagues.

The results are clear that businesses must focus on improving the well-being of their female employees – managers in particular. Older colleagues and those on the front-line also need attention.

They could start by following Lewisʼs example and provide healthcare and mental health support. But importantly, employers should focus on the things that improve workplace happiness: fair reward, recognition, adequate and appropriate information to do a job well, trust, empowerment, career development and supportive line management.

Mark Price is a businessman, writer and was previously minister of state for trade and managing director of Waitrose. For a free copy of this report, email mark.price@engaging.works


By Mark Price

Published by Telegraph February 1st 2019


Stay healthy at the hospital

Protect yourself to ensure a speedy recovery and avoid infections and readmission.

Whether you go in for surgery, testing, or an outpatient procedure, your hospital stay can pose further health risks if you are not careful.

“Your potential risks depend in part on why you have to go into the hospital and the facility itself, but there are steps you can take to minimize your risk, especially when it comes to developing hospital-acquired infections that can lead to a longer hospital stay or readmission,” says Dr. Erica Shenoy, an infectious diseases specialist and associate chief of infection control at Harvard-affiliated Massachusetts General Hospital.

Here are some steps to take to ensure a safe hospital visit before, during, and after your stay.


Ask questions.

It can be nerve-racking to ask questions, no matter how small they feel, but you need to muster up the courage and make the most of your interactions with medical staff and during consultation, says Dr. Shenoy. “Just like you, they want you to have a quick and uncomplicated recovery and are open to your inquiries — but you have to ask.”

What should you ask?
ere are some questions that can help you manage your own expectations and plan ahead for recovery:

How long will I be in the hospital?

What is the expected recovery time?

Am I likely to need rehab or at-home support? Do I have a choice between the two?

“If at all possible, bring your list of questions and a family member or friend with you during any question–and-answer session,” says Dr. Shenoy. “This will help you feel more confident, and your companion can take notes.”

Get screened for possible infections. Depending on your procedure, you could be at high risk of postoperative infections. For people undergoing knee or hip replacement, common bacteria they may have on their skin can increase the risk.

“About 30% of people carry the bacteria Staphylococcus aureus — or staph — on their skin, without it causing any problems or actual infection,” says Dr. Shenoy. “But this bacterium is implicated in many postoperative infections, which is why your doctor may ask you to get screened for staph colonization, which often involves using a cotton swab on the inside of your nose.”

If you do have staph on your skin, the doctor may prescribe several days of a special bath soap and nose ointment, which together have been shown to decrease — but not eliminate — the risk of developing this type of infection.

Review your medications.

Talk with your doctor about your medications— prescription and over-the-counter — to determine what you should stop taking before your procedure or whether you should change any dosages. “Some drugs, such as blood thinners, may require modifications,” says Dr. Shenoy. Your doctor may provide you with a pre-op checklist so you know what to take and what not to take.

Know the risks.

You may not be aware of all the potential risks. “Even the simplest of procedures has some risks, so it’s important to know what they are even if the odds are quite low,” says Dr. Shenoy. “Knowing the risks can help you make a more informed decision about whether or not to proceed, and also what signs of complications to look for during the recovery period.”


Practice good hygiene. Doorknobs, handrails, countertops — anything you can touch has the potential to harbor bacteria. Always wash your hands with water and soap before eating and after using the bathroom. Alcohol-based sanitizers are useful outside of those specific circumstances.

All doctors and nurses should wash their hands or use alcohol-base hand sanitizer before they examine you. If not, ask about it. “Many will perform hand hygiene in your presence, but don’t be afraid to ask if they’ve done so before they interact with you,” says Dr. Shenoy.

If your provider expects to encounter blood or body fluids when examining you, he or she may add other protective gear such as gloves and a gown. A clinician may also wear protective equipment if you have a history of harboring particular bacteria.

Know your contacts. Before you leave, get a list of contact information for anyone you need to call regarding your recovery. You’ll also need the dates, times, and locations of all follow-up appointments.

Look for warning signs.

When you return home, watch for red flags for when you should seek immediate care — for example, changes in pain, redness or swelling, or fever. “That’s where the list of contacts come in handy,” says Dr. Shenoy. “Reach out to your physicians if you experience symptoms that cause you concern. They can help determine the best next steps.”

Published: June, 2017


Estimated hospital costs associated with preventable health care-associated infections if health care antiseptic products were unavailable

Objectives: Health care-associated infections (HAIs) pose a significant health care and cost burden. This study estimates annual HAI hospital costs in the US avoided through use of health care antiseptics (health care personnel hand washes and rubs; surgical hand scrubs and rubs; patient preoperative and preinjection skin preparations).

Methods: A spreadsheet model was developed with base case inputs derived from the published literature, supplemented with assumptions when data were insufficient. Five HAIs of interest were identified: catheter-associated urinary tract infections, central line-associated bloodstream infections, gastrointestinal infections caused by Clostridium difficile, hospital- or ventilator-associated pneumonia, and surgical site infections. A national estimate of the annual potential lost benefits from elimination of these products is calculated based on the number of HAIs, the proportion of HAIs that are preventable, the proportion of preventable HAIs associated with health care antiseptics, and HAI hospital costs. The model is designed to be user friendly and to allow assumptions about prevention across all infections to vary or stay the same. Sensitivity analyses provide low- and high-end estimates of costs avoided.

Results: Low- and high-end estimates of national, annual HAIs in hospitals avoided through use of health care antiseptics are 12,100 and 223,000, respectively, with associated hospital costs avoided of US$142 million and US$4.25 billion, respectively.

Conclusion: The model presents a novel approach to estimating the economic impact of health care antiseptic use for HAI avoidance, with the ability to vary model parameters to reflect spe-cific scenarios. While not all HAIs are avoidable, removing or limiting access to an effective preventive tool would have a substantial impact on patient well-being and infection costs. HAI avoidance through use of health care antiseptics has a demonstrable and substantial impact on health care expenditures; the costs here are exclusive of administrative penalties or long-term outcomes for patients and caregivers such as lost productivity or indirect costs.

Keywords: anti-infective agents, topical, costs and cost analysis, hospital infections, antiseptic agents


Health care-associated infections (HAIs), which the Centers for Disease Control and Prevention (CDC) estimates occur in one of every 25 acute care hospitalizations,1 are of paramount interest in the US. HAIs in hospitals tracked by the CDC1 include central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP), and gastrointestinal infec-tions caused by Clostridium difficile. HAIs are an important metric for evaluating quality in health care institutions such that they are tracked by the Centers for Medicare and Medicaid Services (CMS) in its Hospital Compare program.2 High scores (poor per-formance) can lead to penalties, such as those associated with the Hospital-Acquired Condition Reduction Program established by the 2010 Patient Protection and Affordable Care Act; specifically, patients with certain infection types cannot have the diagnosis-related group for their hospital admission changed to a more complex code to obtain a greater reimbursement from CMS to cover the increased hospital costs associated with the infection. Consumer-focused hospital ratings may also consider HAI rates in their evaluations. With an increase in the prevalence of resistant organisms and incentives to discharge patients quickly while minimizing readmission rates, concerns about HAIs will likely continue to increase.
Despite an obvious public health mandate to minimize the occurrence and impact of HAIs, identifying the most cost-effective or even effective strategies to do so is a source of uncertainty. A number of strategies have been proposed, ranging from environmental controls and modifications, to changing physical contact (eg, avoiding handshaking), to educating patients and health care providers on hand hygiene techniques, to using biosensors to identify areas in need of disinfection. Invariably, hand hygiene is a part of any effort to control HAIs. Hand hygiene programs typically include multiple components, including the more obvious ones, like well-placed cleansers and sinks, and structural elements, such as compliance assessments and feedback mechanisms.3
Recently, in the US, there has been discussion about the merits of various over-the-counter antiseptics,4 including those used in health care settings, such as health care person-nel hand washes and rubs, surgical hand scrubs and rubs, and patient preoperative and preinjection skin preparations.
Introducing new interventions to decrease HAIs has inher-ent costs. For example, replacing surfaces with nonconductive copper has been shown to be effective5 but likely requires a substantial initial capital investment. Costs may be distrib-uted by replacing surfaces one floor or ward at a time, yet there is likely to be both cost and interruption to care. Other interventions, like adding reminders about hand washing and stronger messaging, may be less costly to implement but may require a steady stream of funding to maintain.
The research question underlying this paper is regarding the cost of not maintaining the status quo: what is the cost associated with removing an existing effective component of programs to avoid HAIs – the use of health care anti-septic products? The objective of this project is to estimate the incremental hospital costs associated with preventable illnesses that would no longer be prevented if certain health care antiseptics were to be eliminated. A total national esti-mate of the potential lost benefits from elimination of these products is based on a national number of cases of HAIs, assumptions about the proportion of all HAIs that are overall preventable, assumptions about the proportion of preventable HAIs that are associated with health care antiseptics, and the hospital costs for these illnesses (specific to each infection) obtained from the published literature. The end product of this effort is a spreadsheet model that incorporates various input parameters and can be used to test and explore potential outcomes of limiting health care antiseptic products. The model accounts for the sources of uncertainty in several ways – it provides a range of input values rather than a single base case and also allows the user to input alternative values should the available selections be inadequate.

The model is designed as a simple spreadsheet tool without a single set of default values; instead, a range of plausible input parameters based on the published literature is provided, from which a user can select preferred input values. Four basic types of information are required to populate the model: first, the number of cases of each type of HAI of interest; second, the proportion of all HAIs that are preventable; third, the proportion of preventable HAIs attributable to the use of health care antiseptics; and finally, the average hospital cost associated with each HAI. Essentially, the calculation starts with an estimate of the number of HAIs in the US in 2011 (the most recently published data), reduces that number to account for the proportion of infections that are considered unpreventable overall and those that are preventable through use of health care antiseptics, and then assigns corresponding hospital costs to each of the remaining HAI cases. The result-ing total infection count and cost equals the annual national estimate of potentially lost benefits that would be expected to occur if health care antiseptic products were eliminated.
Literature searches focusing on clinical efficacy and hospital costs were conducted to identify published values for model input parameters using the National Library of Medicine’s PubMed database. After PubMed searches, targeted searches of authors whose works are prominent in the field and government or quasi-government bodies that engage in documenting or improving the performance of health care systems (eg, Centers for Disease Control and Prevention, World Health Organization, and Agency for Healthcare Research and Quality) were also conducted.
Reviews and meta-analyses were examined for evidence of original data relevant to this analysis. For both the clinical and economic searches, reference lists of identified papers were also reviewed for relevant literature.
For the clinical efficacy component of the search, designed to identify papers that could provide information on the number of HAIs, preventability of HAIs, and the proportion of prevention attributable to the use of health care antiseptics, initial search terms (Medical Subject Headings [MeSH], keywords, and text fields) including “handwash”, “healthcare”, “hospital”, and “rate” were used to identify papers published in the previous 25 years in English with human subjects. Studies on the number of HAIs were limited to the US, but for identifying estimates of preventability and proportion attributable to health care antiseptic use, no country or region limitations were used, as it was determined that these should not be excluded a priori but rather reviewed on a case-by-case basis.
For the economic component of the search, search terms (MeSH, keywords, and text fields) included “healthcare”, “hospital”, “infection”, “costs and cost analysis”, and related subheadings suggested by PubMed; filters were applied to identify papers published in the previous 10 years in English with human subjects. A shorter time frame was selected than that for the clinical efficacy search to minimize variation in treatments and associated costs that could occur over a longer time frame. Papers on costs were limited to those providing estimates for the US. Studies were considered for this analysis if they presented hospital costs per case, rather than per household or total expenditures associated with an outbreak, and if they reported on a broad mix of patients. Costs were inflated to October 2015 US$ using the Consumer Price Index for medical care published by the Bureau of Labor Statistics (series ID CUUR0000SAM).
Abstraction of the cost estimates was a multistep process. Most papers provided a high and low estimate, rather than a single point estimate or average. To be consistent with the model’s approach of providing a range of estimates, an average of all the low estimates for each HAI and an aver-age of all the high estimates for each HAI were estimated.

In this manner, the estimates in the model not only inherently reflect uncertainty in the literature but also benefit from some aggregation of the estimates available.


Specification of input parameters

Number of HAIs
Three recent studies provide estimates of the number of HAIs annually observed in the US.1,6,7 The estimates from these papers are provided in Table 1. These studies estimate the number of cases of various infections but do not attempt to link infections to specific causal organisms. The model similarly makes the simplifying assumption that the distribu-tion of pathogens within and across HAIs is not relevant to the number of HAIs. This is necessary given the lack of data on the distribution of pathogens on a national level and the lack of detail on other input parameters (eg, prevention and costs) by pathogen. It is not unreasonable to think that there could be differences in the preventability of HAIs based on changes in the distribution of the causal organisms, if health care antiseptic products are more effective against some pathogens than others, and the costs of treating the same HAI caused by different pathogens could vary. However, none of these data are available and therefore the model does not allow for specification of pathogens.

Proportion of HAIs that are preventable
There are various estimates in the literature for the propor-tion of HAIs that are preventable;8–10 best practices, including hand hygiene and many other interventions, do not eliminate HAIs entirely. Cases that are not preventable are eliminated from this analysis at this stage of the calculations, as the use of health care antiseptics could not have an effect on these already-existing infections. For example, Umscheid et al10 estimate that only 65%–70% of CLABSIs and CAUTIs and 55% of cases of VAP and SSIs are preventable. In their comprehensive review of the impact of various interventions, Harbarth et al also found wide variation in the proportion of preventable infections across settings and patient types, but they suggest that 20% is a reasonable proportion of HAIs that are preventable.9 Based on the wide range of values in the literature, the model includes multiple options for the propor-tion of HAIs that are preventable (20%, 35%, 50%, and 70%). A prespecified common value can be applied to all infection types or prespecified individual values can be applied to each type of infection. Alternatively, the model can be customized by providing a common user-specified value to be applied to all infections or by providing individual user-specified values to be applied to each type of infection.

Number of prevented cases attributable to health care antiseptics
Multiple studies were considered in developing reasonable model inputs for attributable cases.11–16 The range of values provided in these studies was used in the model, rather than a point estimate (eg, the average of all values provided in the studies), for the reduction of cases associated with health care antiseptic use. As with other model inputs, the simplifying assumption that use of health care antiseptics would prevent cases of all types of HAIs equally, regardless of pathogen, was made. At this time, there are insufficient data to assign different patterns of prevention by pathogen. The model allows the user to choose between providing individual values for each HAI type in addition to the common value for all HAI types, and selecting from prespecified values. These prespecified values, 10%, 20%, and 30%, were not based on specific studies but are intended to reflect a conservative range of estimates in the literature.

Costs for each HAI
A number of reviews and summary papers were found during the clinical portion of the literature search that helped guide the search for primary data sources. For example, Scott7 pub-lished a national estimate of HAI counts that also estimated hospital costs in the US. To account for variation of cost estimates and methods in the reviewed literature, a range of costs for each type of HAI (inflated to October 2015 US$) was used in the model. Table 2 shows these ranges and the studies from which they were obtained. Several studies identified in the search were excluded, because they aggregated infections rather than presenting the infections of interest separately, or included a very specific population (eg, only pediatric or only elderly) or a small set of surgi-cal interventions or settings, or did not include the year in which costs were presented. After inflating cost values to October 2015 US$, estimates were aggregated by infection by taking the average of available low and high estimates for each infection type.

Based on the findings, the potential incremental hospital cost burden of hospital-acquired infections avoided by the use of health care antiseptics is between US$142 million and US$4.25 billion annually in the US. These results are presented in Table 5.
The results presented here provide a low and high estimate of the potential increase in cases and medical expenditures associated with elimination of health care antiseptic use. It is expected that actual potential increases would fall somewhere between these low and high estimates.
Given the uncertainty around many of the estimates in this model and our decision to use low and high estimates for model inputs rather than single values, traditional sensitivity analyses are not appropriate. Instead, we used values from Zimlichman et al’s 2013 meta-analysis17 as a comparison for hospital costs (number of cases prevented was not compared). The estimated avoided costs based on Zimlichman et al’s meta-analysis range from US$308 million to US$3.33 billion, which fall within the range of our model results. As with the low and high values discussed previously, the low end of this range is estimated using the number of current annual cases from Magill et al1 and the high end using the estimate from Scott.7

The purpose of this model is to help guide decision-making in the face of uncertainty. The model is a representation of the complex real-world relationships among changing rates of infections, hospital costs, and the potential impact of health care antiseptics. In the face of uncertainty about the continued availability of health care antiseptics, the model reflects the current state of knowledge while providing the opportunity to explore a variety of scenarios. The low and high scenarios presented in this paper can be used to understand the potential economic impact of a change in availability of health care antiseptics on human health and hospital costs in the US. Though the findings estimated here cover a broad range due to the breadth of existing data used in the model, they are indicative of the potential impact of changes in availability of health care antiseptics at the national level. The range of

estimates can be narrowed as new data become available for the model. In addition, the uncertainty in the model may be substantially minimized when applied to local, institution- or system-specific situations, since input data are generally better understood at the local level. Ideally, the model could be applied to explore the local impact of antiseptic avail-ability to aid in decision-making, in addition to projecting values nationally.
There are multiple sources of uncertainty associated with the estimates used as model input parameters. We address how the model incorporates and manages this uncertainty across each of the four main model inputs in turn. First, there are challenges in identifying the total number of HAIs nationally. The studies selected for use in this model are based on reported infections as part of surveillance programs rather than administrative claims data to identify events. A recent review and meta-analysis of the accuracy of using administrative data to identify HAIs18 found inconsistencies across types of infections in terms of sensitivity and specific-ity. This, as well as earlier work that suggests “traditional” surveillance reporting is superior to other approaches for identifying HAIs,19 supports our avoidance of administrative claims data in the base case estimates but points to difficul-ties in quantifying the number of HAIs. The same surveil-lance reports suggest that rates of HAIs are higher among patient populations who are younger, older, or otherwise compromised,20 which both validates our decision not to include data from these studies and suggests that once these more severe patients are included, their higher hospital costs might mean our general population approach underestimates infections and costs. Additionally, the process of attribution on the part of the hospital is complex; determining whether an infection is health care-associated can be challenging, particularly for patients who have had multiple health care encounters prior to the hospital admission. The model is limited to infections that are treated in a hospital setting, but the problem of infections acquired in long-term care is known to be substantial.21 If it were possible to quantify the number and treatment costs for health care-associated infections in other settings, estimates of the national impact of HAIs would increase. Lastly, also related to the count of HAIs included in this model, the analysis was limited to bacterial infections only. However, health care antiseptics, particularly alcohol-based hand rubs and gels, may have a role in preventing viral conditions.22 Thus, the findings of this study could be considered to be conservative and benefits would increase if viral conditions were included in the model. At this point, there are insufficient data to add the estimates for viral infections to the model but future studies may permit it.
A second source of uncertainty is related to estimating the proportion of cases prevented by the use of health care antiseptics. This aspect of uncertainty is challenging because, in accordance with the World Health Organization guide-lines,23 the use of health care antiseptics is only one com-ponent of typical multipart strategies to address hygiene. In their meta-analysis, Schweizer et al point out that more than three-fourths of interventions included bundles with multiple components rather than the single-intervention studies that have been observed in previous reviews (see Schweizer et al for a full listing of the studies reviewed).24 Rarely do studies report on a comparison between similar cohorts in which the use of health care antiseptics is the only difference. The effect of introduction or elimination of antiseptics alone is not addressed sufficiently in the literature for each of the infection types of interest. The model acknowledges this and is conservative in eliminating a number of infections that are deemed to be not preventable by any means and by assuming, in our high scenario, that no more than 30% of preventable infections could be prevented based on health care antiseptic use. The structure and form of the model are designed with the assumption that there is some effect of health care antiseptic use on the rate of HAIs, consistent with real-world findings,25,26 but it accepts the user’s input about what fraction of HAIs can be prevented rather than endorsing a particular value. It would have been possible to split the prevention component of the model into two separate pieces, one of which would apply values for the potential preventive effect of the antiseptics, and the second of which would allow the user to assume the level of performance to moderate the potential effect. Given the uncertainty in these inputs as well as the fact that they would simply be multiplied, we chose to handle this issue as a single model input. Further, the model only estimates incremental hospital costs for infections that can reasonably be attributed to the use of hand hygiene rather than a more comprehensive set of benefits. Thus, the estimates here are likely to be conservative.
Third, there is uncertainty about the financial impact of HAIs, although a variety of methods and approaches have been used to develop estimates. The health care facilities and sites that were used for the estimates in the model may have had an older/younger or sicker/healthier population than an average hospital. In most cases, the model used an aver-age of available cost estimates, which should minimize the influence of particular factors associated with an individual study or site on the final estimate used. Even if the cost for each type of HAI were known, it is important to recognize the difference between reimbursements, herein referred to as costs, and the actual costs that a hospital requires to treat a patient. Although insurers may not directly bear the costs for HAIs in the future given the trend toward not reimburs-ing hospitals for a growing list of preventable infections, hospitals will still need to provide the additional resources required to treat the infections.
The scope of this model includes only initial hospital costs associated with HAIs in the US. As such, the model inputs that required use of US data included the counts of HAIs and hospital costs. The model integrated data on pre-ventive potential and attributability to antiseptics from any study worldwide, with the assumption that the preventive effect of any agent would be similar regardless of the region in which it was used. There are a number of additional costs relevant to calculating the full impact of removing antiseptic products from the market not captured here. These costs include but are not limited to hospital readmission, short-term rehabilitation, long-term follow-up care, co-pays and out-of-pocket fees, lost wages, caregiver assistance, lost productivity, and transportation. General estimates for these elements are available in the published literature and could be combined with the HAI-specific inputs to this model to produce a more comprehensive evaluation of costs.27,28 As the costs of long-term morbidity and mortality are not cur-rently included in this analysis, the model’s estimates are conservative.
In addition to these sources of uncertainty, there is also a layer of regional variation that should be considered in applying these findings. Various hospitals, regions, and pay-ers may have different input assumptions than those used in this model based on the pathogens present in their facilities. Certain pathogens, resistance patterns, and infection types are more prevalent at some facilities and in particular regions than others, and thus while this model is designed to reflect the US as a whole, results cannot directly be scaled down to reflect a smaller region or population.
Not only are there differences in terms of HAIs and causes across sites but there may also be differences in populations. HAIs may cause disproportionate burden in certain racial and ethnic groups. Findings from an analysis of the Medicare Patient Safety Monitoring System suggest that the rate of HAIs is significantly higher among Asian and Hispanic patients.29 Because there are insufficient data to add patient characteristics to the model, it has not been included; however, the inclination to scale these estimates to subpopulations should be resisted for this reason, also.

It is important to recognize that this analysis does not challenge the idea that some hospital-acquired infections are not preventable. Even in the low scenario (which uses the most conservative estimates), the model assumes that some HAIs cannot be prevented. However, the reported number of HAIs may be influenced by lack of reimbursement. In their efforts to minimize rates of HAIs, hospitals may conduct more screening at admission to understand whether patients are already colonized at admission to determine whether infec-tions should be considered hospital-acquired,8 which could result in a decrease in infections determined to be hospital-acquired. Further, lack of reimbursement for some of these infections may encourage proactive antibiotic treatment and the unintended negative consequence of contributing to develop ment of resistance, making HAIs more expensive to treat. Regardless of these uncertainties, the underlying frame-work of this model assumes that there is some proportion of HAIs that are currently avoided as a result of the use of health care antiseptics, and that limiting availability of these types of products would be associated with an increase in the rate of these types of infections and associated hospital costs.

Although multiple sources of uncertainty exist, this model uses a range of estimates to effectively identify the plausible effect of health care antiseptic use on the number of HAIs and associated hospital costs in the US. Low- and high-end estimates of the number of national, annual HAI cases avoided through use of health care antiseptics are 12,100 and 223,000, respectively, with associated avoided hospital costs of US$142 million and US$4.25 billion, respectively.


Author contributions
JKS and CKH took primary responsibility for review of literature, JKS and SS took responsibility for model design and construction, and JAK, PCD, RS, and PAC provided inputs and interpretations. All authors contributed toward data analysis, drafting and revising the paper and agree to be accountable for all aspects of the work.

JK Schmier, CK Hulme-Lowe, S Semenova, and JA Klenk are employees of Exponent, a consulting company that has received a grant from the American Cleaning Institute for this research. PC DeLeo and R Sedlak are employees of the American Cleaning Institute. PA Carlson is an employee of Ecolab. The authors report no other conflicts of interest in this work.


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Jordana K Schmier1
Carolyn K Hulme-Lowe1
Svetlana Semenova2
Juergen A Klenk3
Paul C DeLeo4
Richard Sedlak5
Pete A Carlson6
1Health Sciences, Exponent, Inc., Alexandria, VA, 2EcoSciences, Exponent, Inc., Maynard, MA, 3Health Sciences, Exponent, Inc., Alexandria, VA, 4Environmental Safety, 5Technical and International Affairs, American Cleaning Institute, Washington, DC, 6Regulatory Affairs, Ecolab, Saint Paul, MN, USA