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WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009.

Cover of WHO Guidelines on Hand Hygiene in Health Care

WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.

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1Definition of terms

Hand hygiene. A general term referring to any action of hand cleansing (see below “Hand hygiene practices”).

Hand hygiene products

Alcohol-based (hand) rub

An alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one or more types of alcohol, other active ingredients with excipients, and humectants.

Antimicrobial (medicated) soap

Soap (detergent) containing an antiseptic agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth. The detergent activity of such soaps may also dislodge transient microorganisms or other contaminants from the skin to facilitate their subsequent removal by water.

Antiseptic agent

An antimicrobial substance that inactivates microorganisms or inhibits their growth on living tissues. Examples include alcohols, chlorhexidine gluconate (CHG), chlorine derivatives, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan.

Antiseptic hand wipe

A piece of fabric or paper pre-wetted with an antiseptic used for wiping hands to inactivate and/or remove microbial contamination. They may be considered as an alternative to washing hands with non-antimicrobial soap and water but, because they are not as effective at reducing bacterial counts on HCWs’ hands as alcohol-based handrubs or washing hands with an antimicrobial soap and water, they are not a substitute for using an alcohol-based handrub or antimicrobial soap.

Detergent (surfactant)

Compounds that possess a cleaning action. They are composed of a hydrophilic and a lipophilic part and can be divided into four groups: anionic, cationic, amphoteric, and non-ionic. Although products used for handwashing or antiseptic handwash in health care represent various types of detergents, the term “soap” will be used to refer to such detergents in these guidelines.

Plain soap

Detergents that contain no added antimicrobial agents, or may contain these solely as preservatives.

Waterless antiseptic agent

An antiseptic agent (liquid, gel or foam) that does not require the use of exogenous water. After application, the individual rubs the hands together until the skin feels dry.

Hand hygiene practices

Antiseptic handwashing

Washing hands with soap and water, or other detergents containing an antiseptic agent.

Antiseptic handrubbing (or handrubbing)

Applying an antiseptic handrub to reduce or inhibit the growth of microorganisms without the need for an exogenous source of water and requiring no rinsing or drying with towels or other devices.

Hand antisepsis/decontamination/degerming

Reducing or inhibiting the growth of microorganisms by the application of an antiseptic handrub or by performing an antiseptic handwash.

Hand care

Actions to reduce the risk of skin damage or irritation.


Washing hands with plain or antimicrobial soap and water.

Hand cleansing

Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material, and/or microorganisms.

Hand disinfection

is extensively used as a term in some parts of the world and can refer to antiseptic handwash, antiseptic handrubbing, hand antisepsis/decontamination/degerming, handwashing with an antimicrobial soap and water, hygienic hand antisepsis, or hygienic handrub. Since disinfection refers normally to the decontamination of inanimate surfaces and objects, this term is not used in these Guidelines.

Hygienic hand antisepsis

Treatment of hands with either an antiseptic handrub or antiseptic handwash to reduce the transient microbial flora without necessarily affecting the resident skin flora.

Hygienic handrub

Treatment of hands with an antiseptic handrub to reduce the transient flora without necessarily affecting the resident skin flora. These preparations are broad spectrum and fast-acting, and persistent activity is not necessary.

Hygienic handwash

Treatment of hands with an antiseptic handwash and water to reduce the transient flora without necessarily affecting the resident skin flora. It is broad spectrum, but is usually less efficacious and acts more slowly than the hygienic handrub.

Surgical hand antisepsis/surgical hand preparation/presurgical hand preparation

Antiseptic handwash or antiseptic handrub performed preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora. Such antiseptics often have persistent antimicrobial activity. Surgical handscrub(bing)/presurgical scrub refer to surgical hand preparation with antimicrobial soap and water. Surgical handrub(bing) refers to surgical hand preparation with a waterless, alcohol-based handrub.

Associated terms

Cumulative effect

Increasing antimicrobial effect with repeated applications of a given antiseptic.


The (possible) effect of the application of a hand hygiene formulation when tested in laboratory or in vivo situations.


The clinical conditions under which a hand hygiene product has been tested for its potential to reduce the spread of pathogens, e.g. field trials.


Inert substance included in a product formulation to serve as a vehicle for the active substance.

Health-care area

Concept related to the “geographical” visualization of key moments for hand hygiene. It contains all surfaces in the health-care setting outside the patient zone of patient X, i.e. other patients and their patient zones and the health-care facility environment.


Ingredient(s) added to hand hygiene products to moisturize the skin.

Medical gloves

Disposable gloves used during medical procedures; they include examination (sterile or non-sterile) gloves, surgical gloves, and medical gloves for handling chemotherapy agents (chemotherapy gloves).

Patient zone

Concept related to the “geographical” visualization of key moments for hand hygiene. It contains the patient X and his/her immediate surroundings. This typically includes the intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient such as the bed rails, bedside table, bed linen, infusion tubing and other medical equipment. It further contains surfaces frequently touched by HCWs while caring for the patient such as monitors, knobs and buttons, and other “high frequency” touch surfaces.

Persistent activity

The prolonged or extended antimicrobial activity that prevents the growth or survival of microorganisms after application of a given antiseptic; also called “residual”, “sustained” or “remnant” activity. Both substantive and non-substantive active ingredients can show a persistent effect significantly inhibiting the growth of microorganisms after application.

Point of care

The place where three elements come together: the patient, the HCW, and care or treatment involving contact with the patient or his/her surroundings (within the patient zone).1 The concept embraces the need to perform hand hygiene at recommended moments exactly where care delivery takes place. This requires that a hand hygiene product (e.g. alcohol-based handrub, if available) be easily accessible and as close as possible – within arm’s reach of where patient care or treatment is taking place. Point-of-care products should be accessible without having to leave the patient zone.

Resident flora (resident microbiota)

Microorganisms residing under the superficial cells of the stratum corneum and also found on the surface of the skin.


An attribute of some active ingredients that adhere to the stratum corneum and provide an inhibitory effect on the growth of bacteria by remaining on the skin after rinsing or drying.

Surrogate microorganism

A microorganism used to represent a given type or category of nosocomial pathogen when testing the antimicrobial activity of antiseptics. Surrogates are selected for their safety, ease of handling, and relative resistance to antimicrobials.

Transient flora (transient microbiota)

Microorganisms that colonize the superficial layers of the skin and are more amenable to removal by routine handwashing.

Visibly soiled hands

Hands on which dirt or body fluids are readily visible.

Copyright © 2009, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK144046


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