PMA: Research on produce safety priorities

Bob Whitaker, Ph.D., chief science and technology officer for Produce Marketing Association (PMA), writes that because it provides inherently healthy, nutritious foods, the fresh produce industry is uniquely positioned to help solve the nation’s obesity epidemic. To do so, consumers must have confidence in the safety of the fresh fruits, vegetables, and nuts they eat and feed their families.

A green row celery field is watered and sprayed by irrigation equipment in the Salinas Valley, California USA

Following a large and deadly outbreak of foodborne illness linked to fresh spinach in 2006, the U.S. produce industry couldn’t wait for government or other direction. After finding significant knowledge gaps and a lack of data needed to build risk- and science-based produce safety programs, the industry created the Center for Produce Safety (CPS) in 2007.

CPS works to identify produce safety hazards, then funds research that develops that data as well as potential science-based solutions that the produce supply chain can use to manage those hazards. While two foodborne illness outbreaks in the first half of 2018 associated with leafy greens demonstrate the industry still has challenges to meet, CPS has grown into a unique public-private partnership that moves most of the research it funds from concept to real-world answers in about a year.

Each June, CPS hosts a symposium to report its latest research results to industry, policy makers, regulators, academia, and other produce safety stakeholders. Key learnings from the 2017 symposium have just been released on topics including water quality, cross-contamination, and prevention. A few highlights from those key learnings are summarized here, and for the full details, you can download the Key Learnings report from CPS’s website.

Know Your Water (we were doing that in 2002, long before youtube existed)
Irrigation water is a potentially significant contamination hazard for fresh produce while it is still in the field. While CPS research has revealed many learnings about agricultural water safety in its 10 years, many questions still remain. Meanwhile, the U.S. Food and Drug Administration (FDA)’s proposed Food Safety Modernization Act (FSMA) water testing requirements—which offers some challenges for producers in specific production regions—recently raised even more questions.

New CPS research illustrates the risks of irrigating with “tail water” from runoff collection ponds. With water becoming a precious resource in drought-stricken areas, the objective was to learn if tail water might be recovered and used for irrigation.  We learned that differences among pond sites—for example, water sources, climate, ag management practices—can strongly influence the chemistry and microbiology of the water. Further, water pH can influence disinfection treatment strategies.[1]

CPS research continues to investigate tools for irrigation water testing, looking specifically at sample volumes,[2] and searching for better water quality indicators and indexing organisms including harnessing next-generation DNA sequencing.[3] Following a CPS-organized colloquium on ag water testing in late 2017, FDA subsequently announced it would revisit FSMA’s ag water requirements, and postponed compliance.

Bottom line, CPS research demonstrates that growers must thoroughly understand their irrigation water before they can accurately assess cross-contamination risk. CPS’s findings clearly point to the need to take a systems approach, to understand and control the entire water system to help achieve produce safety. Long term, this may mean prioritizing research into ag water disinfection systems to better manage contamination hazards that can also operate at rates needed for field production.
Cross-Contamination Can Happen across the Supply Chain
While conceptually and anecdotally the fresh produce industry knows that food safety is a supply chain responsibility, research is needed that documents the role of the entire supply chain to keep fresh produce clean and safe from field to fork. At the 2017 CPS Research Symposium, research reports were presented focusing on cross-contamination risks from the packinghouse to retail store display.

In the packinghouse, CPS-funded research found that wash systems can effectively control cross-contamination on fruit, when proper system practices are implemented.[4] Post-wash, CPS research involving fresh-cut mangos also demonstrated that maintaining the cold chain is critical to controlling pathogen populations.[5] Across the cantaloupe supply chain, CPS studies show food contact surfaces—for example, foam padding—are potential points of cross-contamination.[6] See the full 2017 Key Learnings report for details, as these brief descriptions only scratch the surface of this research.

CPS studies clearly demonstrate that food safety is a supply chain responsibility—a message that must be internalized from growers and packers to transporters, storages, and retailers to commercial, institutional, and home kitchens. While translating this research into reality will present engineering and operational challenges, our new understanding of produce safety demands it.
Verifying Preventive Controls
The produce industry must know that its preventive controls are in fact effective. That said, validation can be tricky. If validation research doesn’t mimic the real world, industry ends up fooling itself about whether its food safety processes work—and the human consequences are real.

Numerous scientists presented research at the 2017 CPS Research Symposium that validates various preventive controls, from heat treating poultry litter[7] to pasteurizing pistachios[8] to validating chlorine levels in wash water systems.[9] Some researchers effectively used nonpathogenic bacteria as a surrogate in their validation studies, while another is working to develop an avirulent salmonella surrogate, and another. Wang used actual Escherichia coliO157:H7 (albeit in a laboratory).

Importantly, CPS research finds that the physiological state of a pathogen or surrogate, and pathogen growth conditions themselves, are critically important to validation studies.[10] Meanwhile, suitable surrogates have been identified for some applications, the search continues for many others.

The research findings described here are just some of the real world-applicable results to emerge from CPS’s research program. To learn more, download the 2017 and other annual Key Learnings reports from the CPS website > Resources > Key Learnings page at www.centerforproducesafety.org.

We were doing these videos in the early 2000s, long before youtube.com existed, and weren’t quite sure what to do with them. But we had fun.

 

Proper handwashing requires proper tools

Apparently, that’s just a throw-a-way tag line, at the end of an abstract for a paper, but my observations say it’s the most important. Have paper towels, not bacterial blow dryers; have soap; and have vigorous running water, not a trickle-down (as effective in economics as in handwashing).

Each year millions of children are enrolled in center-based childcare. Childcare employees are tasked with handling over half the children’s weekly meals. Proper food handling practices are crucial in mitigating this high-risk population’s risk of foodborne illness. The purpose of this study was to identify childcare food handling employees’ (n = 278) perceived barriers and motivators to follow recommended food safety practices. Six important barriers and 14 key motivators to following recommended food safety practices were identified. Important barriers pertained to time restraints, workloads, and lack of understanding of the importance of following proper food safety practices. Key motivators were focused on children’s safety, available supplies, communication, and food safety training/information. Employee and facility characteristics were shown to influence perceived importance of barriers and motivators to following food safety practices. Childcare directors should review scheduling and job duties of employees as the majority of identified barriers focused on “work pace” and “time restraints.” Directors should also attempt to increase food safety communication through practical situational training, written food safety policies, and use of food safety signage to increase understanding of the importance of proper food safety practices. Ensuring proper supplies are available is necessary.

Childcare food handling employees’ perceived barriers and motivators to follow food safety practices

Early Childhood Education Journal, pp 1-9, 24 October 2017, Joel Reynolds, Lakshman Rajagopal

https://link.springer.com/article/10.1007/s10643-017-0885-3

NZ school’s removal of soap from children’s toilets labeled ‘appalling’

Whenever someone tells me of an outbreak at a school, day care, university residence, whatever, the first place I go, or someone more geographically-centered should go, is check out the bathrooms.

It’s easy to preach proper handwashing as a way to reduce the spread of infectious disease.

But proper handwashing requires access to proper tools.

So I check out the bathroom and usually find the tools, uh, missing.

Proper handwashing requires vigorous water flow (temperature doesn’t matter), a vigorous rub with soap, and drying with paper towel.

Garth Bray of TVNZ reports an Auckland primary school has dumped a policy that saw soap and hand towels removed from all children’s toilets.

The school felt the children were wasting those basic items, but failed to follow some of the most basic health advice with its policy.

“I think it’s appalling”, said Dr Michael Baker, who is the University of Otago Professor of Public Health.

“We’ve got good evidence in big trials showing that having handwashing can actually reduce risk of gut infections by about 30 per cent and respiratory infections by about 20 per cent so I think all of our schools need to be part of this,” Dr Baker told Fair Go.

Fair Go was contacted by four parents of children at the school who objected to the school withdrawing soap but had been told by teachers this was the policy.

Some had simply accepted this and started sending their children to school with little bottles of liquid hand soap to use.

However, one took her concerns to the principal and to a school board member.

Fair Go has seen written messages between the board member and the parent which say: “There are no legal requirements from the Ministry of Health and the students were wasting the soap and hand towels so they were taken out but every class has hand sanitiser that they encourage their kids to use regularly.”

That’ll work until the kids start drinking the stuff.

Fair Go spoke with the principal, who disclosed that classrooms were sometimes locked at lunchtimes, meaning children had no access to anything but water for washing before meals and after using toilets.

The principal told Fair Go that the same week our programme had made contact, the school board had decided to reverse the policy and will now stock toilets with soap and hand towels again.

On that basis, Fair Go has decided for now not to name the school publicly as it takes steps to make good its commitment to provide hygienic hand washing facilities for children.

“New Zealand’s got an appalling record of having very high rates of a lot of major childhood diseases – respiratory infections, skin infections and gut infections and these are exactly the things that hand washing can protect our children against,” Dr Baker said.

Fair Go’s advice is for parents to take a look at their own school’s facilities and reassure themselves their children have the essentials on hand at school.

I do.

And the school knows I check.

Microbiological failure? UK school forces teachers to shake hands with pupils to help kids feel respected

Trevor Noah of The Daily Show rarely shakes hands with guests or correspondants.

He’s big into the fist-bump.

Maybe Schaffner can design a study to figure out which is microbiologically safer.

It’d be another pop-culture hit.

Maybe someone has done it.

Whatever, the  handshaking policy introduced by a new principal has led to panic among staff and parents.

Some teachers at Tunbridge Wells Grammar School for Boys, southeast of London, are now arming themselves with hand sanitiser amid fears that shaking hands up to 150 times a day may cause them to pick up germs.

Principal Amanda Simpson is standing by her decision, which sees teachers shaking hands with every member of their class before each lesson.

One parent told local news website Kent Live that she was worried about the consequences of the mandatory handshaking.

“It will be interesting to see what happens if there’s an outbreak of Norovirus,” she said.

“I assume it was introduced because the new head wanted to introduce some element of respect – but I wouldn’t think that sort of thing would make any difference.”

Ms Simpson believes that starting every lesson “with a handshake and a smile” makes children feel welcome and appreciated.

She confirmed that hand sanitiser was available throughout the school for anyone worried about the spread of germs.

Shigella in Kansas: Proper handwashing requires proper tools

There was this one time, when I was in Kansas, and there was an outbreak of something at the local high school.

Stalker alert: I went to the boys’ bathroom.

No paper towel. No soap.

Proper handwashing requires access to proper tools.

The Shawnee County Health Department and KDHE are checking several shigellosis cases in children.

USD 501 confirms it centers on Highland Park Central Elementary, saying the district sent information to those parents.

Shigellosis is a gastro intestinal illness caused by a bacteria.

It is treatable and most people quickly recover from symptoms including diarrhea, fever, nausea, vomiting, and stomach cramps.

Shigella is found in the feces of an infected person. It’s spread by close contact, and by eating and drinking contaminated food or water.

To stop the spread, always wash your hands thoroughly with soap and water before eating. Do not share food, drinks, spoons and or straws.

No paper towel. No soap.

Proper handwashing requires access to proper tools.

Those are the kinds of questions that get full professors fired.

Handwashing is never enough, bureaucrats have no spine: E. coli O157 from animals at Ekka edition

The EKKA, Queensland’s agricultural showpiece, concluded last week in Brisbane, about the same time an uncomfortable memory was finally published in the peer-reviewed cyber-sphere.

In Aug. 2013, 56 people became sick with E. coli O157 after contact with animals, or hanging out in the animal facility at the EKKA.

No child, or family, should have to go through grief and anguish because they took the kids to a petting zoo at the local fair.

Being repeatedly told they failed because they didn’t wash their hands is condescending. And ignores the science.

Handwashing is never enough.

At the time, a Biosecurity Australia dude said, “This highlights the importance of people practising sound hygiene measures following all contact with animals, their body fluids and excretions.”

How many want bureaucrats talking about body secretions?

As Anderson and Weese found in 2011 at a temporary petting zoo in Guelph (that’s in Canada) using video observation, 58 per cent of visitors performed some form of hand hygiene (either using water, soap and water, or hand sanitizer), and two interventions (improved signage while offering hand sanitizer, and verbal hand hygiene reminders by venue staff) were associated with increased hand hygiene compliance. U.K. health officials currently recommend handwashing stations with soap and water only (no wipes or sanitizers).

And while some studies suggest inadequate handwashing facilities may have contributed to enteric disease outbreaks or washing hands was protective against illness, others suggest relevant infectious agents may be aerosolized and inhaled.

In the fall of 2009, an E. coli O157:H7 outbreak at Godstone Petting Farm in the U.K resulted in 93 illnesses – primarily little kids.

The investigation into the Godstone outbreak identified evidence of environmental contamination outside the main barn, indicating acquisition of illness through both direct animal or fecal contact, and indirect environmental contact (e.g. contacting railings or soiled footwear).

Aerosolization of potential pathogens is also possible, as suggested in an E. coli O157:H7 outbreak at a county fair in Oregon, in which 60 people fell ill.

As part of the response to the Godstone outbreak, U.K. health types recommended handwashing stations with soap and water only (no wipes or sanitizers, because they don’t work that well under certain conditions).

Ihekweazu et al. subsequently concluded that in the Godstone outbreak, “handwashing conferred no demonstrable protective effect. …

“Moreover, from the findings of many previous published studies, it must be assumed that all petting or open farms are potentially high-risk environments for the acquisition of VTEC O157 infection (an STEC).”

This is what the Ekka folks had to say about the 2013 outbreak (which no one in Brisbane seems to know about).

The 2013 Ekka agricultural show displayed >10,000 animals and included sections where direct contact between visitors and animals could occur. The animal boulevard included a large animal nursery where visitors could pat and feed farm animals, including goats, lambs, calves, piglets, chicks, ducklings, donkeys, and turkeys. A milking demonstration took place in an area adjacent to the animal nursery and visitors were invited to milk a cow. Unpasteurized milk was not served. Visitors could also view the birth of lambs that took place in an enclosed booth. The birthed lambs were available for supervised petting after >24 h after veterinary clearance. Other animals displayed in the animal boulevard and other pavilions were less accessible to the public for direct contact. 

The number of visitors in the animal nursery was not restricted. Limited unsupervised handwashing facilities were available opposite the exit of the animal nursery. Hand sanitizers were available in other areas. Signs in animal contact areas encouraged visitors to wash their hands. Staff at the agricultural show regularly removed animal waste from animal contact areas. 

Stool samples from 56 of 57 case-patients showed identical virulence gene profiles, consisting of stx1, stx2, eaeA, and ehxA . The virulence gene profile of the remaining probable primary case-patient was only stx2 and ehxA. Twenty bovine, 4 ovine, and 2 caprine fecal samples were tested from animals traced to other properties after the show had ended. Serotype O157:H- was confirmed from 51 of the human cases, and also from ovine, caprine, and bovine feces, and the animal bedding sample. All O157:H- isolated from animal and environmental sources displayed the same MLVA profiles (6_8_2_9_4_7_8_2_3_8 and 11–7-13–4-5–6-4–9) (Technical Appendix Table 2), stx1a and stx2c subtypes, and sequence type ST11, and 2/51 of human isolates differed by 1 allele in 1 of the MLVA profiles. Although E. coli O157 has frequently been reported to belong to sequence type 11 (13), the MLVA profiles were novel to the Queensland collection of previously typed STEC isolates (n = 112). 

A table of petting zoo outbreaks is available at http://www.barfblog.com/wp-content/uploads/2017/08/Petting-Zoo-Outbreaks-Table-7-26-17.xlsx

Mild illness during outbreak of shiga toxin-producing Escherichia coli O157 infections associated with agricultural show, Australia

Emerging Infectious Diseases, vol. 23, no 10, October 2017, Bhakti R. Vasant, Russell J. Stafford, Amy V. Jennison, Sonya M. Bennett, Robert J. Bell, Christine J. Doyle, Jeannette R. Young, Susan A. Vlack, Paul Titmus, Debra El Saadi, Kari A.J. Jarvinen, Patricia Coward, Janine Barrett, Megan Staples, Rikki M.A. Graham, Helen V. Smith, and Stephen B. Lambert

https://wwwnc.cdc.gov/eid/article/23/10/16-1836_article

During a large outbreak of Shiga toxin−producing Escherichia coli illness associated with an agricultural show in Australia, we used whole-genome sequencing to detect an IS1203v insertion in the Shiga toxin 2c subunit A gene of Shiga toxin−producing E. coli. Our study showed that clinical illness was mild, and hemolytic uremic syndrome was not detected.

Erdozain G, Kukanich K, Chapman B, Powell D. 2012. Observation of public health risk behaviours, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011. Zoonoses Public Health. 2012

Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. This paper details an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas (9) and Missouri (4), U.S., petting zoos. Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors were 4.8x more likely to wash their hands when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; p<0.001, OR=4.863, 95% C.I.=3.380-6.998). Visitors at zoos with a fence as a partial barrier to human-animal contact were 2.3x more likely to wash their hands (188/460, 40.9%) than visitors allowed to enter the animals’ yard for contact (26/114, 22.8%; p<0.001, OR= 2.339, 95% CI= 1.454-3.763). Inconsistencies existed in tool availability, signage, and supervision of animal-contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks.

4 sick with campy linked to raw milk served at Royal Welsh Show

In 2013, at least 50 people, mainly children, became ill with E coli O157 at the Ekka, Queensland, Australia’s version of the state fair.

It starts again on Friday, and because organizers have done little except to encourage people to wash their hands, we won’t be going.

Handwashing is never enough.

Manure from ruminants is easily aerosolized in these environments, and I’ve been to many human-animal interaction events for research, and there is shit everywhere.

Although ostensibly designed to promote understanding of food production, these agricultural celebrations rarely discuss risk – until an outbreak happens.

The motto seems to be: It’d be better for us if you don’t understand.

Now, four people have been sickened with Campylobacter linked to unpasteurised or raw cow’s milk from Penlan y Môr farm near New Quay, Ceredigion and sold at the Royal Welsh Show.

Public Health Wales says the four cases all consumed or bought the milk at Aberystwyth Farmer’s Market after June 1.

But visitors to the Royal Welsh Show in Builth Wells may also have sampled or bought the milk which was available there on Wednesday, 26 July.

A table of animal-human-interaction outbreaks is available at http://www.barfblog.com/wp-content/uploads/2017/08/Petting-Zoo-Outbreaks-Table-7-26-17.xlsx

Erdozain G, Kukanich K, Chapman B, Powell D. 2012. Observation of public health risk behaviours, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011. Zoonoses Public Health. 2012 Jul 30. doi: 10.1111/j.1863-2378.2012.01531.x. [Epub ahead of print]

Observation of public health risk behaviors, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. This paper details an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas (9) and Missouri (4), U.S., petting zoos. Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors were 4.8x more likely to wash their hands when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; p<0.001, OR=4.863, 95% C.I.=3.380-6.998). Visitors at zoos with a fence as a partial barrier to human-animal contact were 2.3x more likely to wash their hands (188/460, 40.9%) than visitors allowed to enter the animals’ yard for contact (26/114, 22.8%; p<0.001, OR= 2.339, 95% CI= 1.454-3.763). Inconsistencies existed in tool availability, signage, and supervision of animal-contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks.

Best practices for planning events encouraging human-animal interactions

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

Shock and shame: Science behind getting people to wash their hands

Gimmie shelter from the ravages of time.

I’d largely forgotten about my lab’s handwashing phase, probably because I was leaving the safety (shurley not) of Kansas and heading to Australia.

But was reminded from this excerpt in The New Yorker from Nate Dern’s “Not Quite a Genius,” to be published by Simon & Schuster:

Employees must wash hands.

Employees must wash their own hands.

Employees must wash their own hands after they use the restroom.

Employees of this restaurant must wash their own hands after they use the restroom.

Employees of this restaurant must wash their own hands (literally, not metaphorically) after they use the restroom.

Employees of this restaurant must wash their own hands (literally, not metaphorically) after they use the restroom, or else they are in violation of the health code.

Employees of this restaurant must wash their own hands (literally, not metaphorically) after they use the restroom, or else they are in violation of the health code, and, no, there is no practical way to regulate or enforce this rule.

Employees of this restaurant must wash their own hands (literally, not metaphorically) after they use the restroom, or else they are in violation of the health code, and, no, there is no practical way to regulate or enforce this rule, but, yes, we still ask, and trust that you will comply.

Employees of this restaurant must wash their own hands (literally, not metaphorically) after they use the restroom, or else they are in violation of the health code, and, no, there is no practical way to regulate or enforce this rule, but, yes, we still ask, and trust that you will comply, and, O.K., we apologize for the condescending tone of the posting of this rule, which seems to imply that without such a sign we would assume that our employees are disgusting children with no regard for their own hygiene.

Employees must wash hands. Greg has been fired.

Filion, K., KuKanich, K.S., Chapman, B., Hardigree, M.K., and Powell, D.A. 2011. Observation-based evaluation of hand hygiene practices and the effects of an intervention at a public hospital cafeteria. American Journal of Infection Control 39(6): 464-470.

Background

Hand hygiene is important before meals, especially in a hospital cafeteria where patrons may have had recent contact with infectious agents. Few interventions to improve hand hygiene have had measureable success. This study was designed to use a poster intervention to encourage hand hygiene among health care workers (HCWs) and hospital visitors (HVs) upon entry to a hospital cafeteria.

Methods

Over a 5-week period, a poster intervention with an accessible hand sanitizer unit was deployed to improve hand hygiene in a hospital cafeteria. The dependent variable observed was hand hygiene attempts. Study phases included a baseline, intervention, and follow-up phase, with each consisting of 3 randomized days of observation for 3 hours during lunch.

Results

During the 27 hours of observation, 5,551 participants were observed, and overall hand hygiene frequency was 4.79%. Hygiene attempts occurred more frequently by HCWs than HVs (P = .0008) and females than males (P = .0281). Hygiene attempts occurred more frequently after poster introduction than baseline (P = .0050), and this improvement was because of an increase in frequency of HV hand hygiene rather than HCW hand hygiene.

Conclusion

The poster intervention tool with easily accessible hand sanitizer can improve overall hand hygiene performance in a US hospital cafeteria.

Wilson, S.M., Jacob, C.J. and Powell, D.A. 2011. Behavior-change interventions to improve hand hygiene practice: A review. Critical Public Health 21: 119-127.

http://www.informaworld.com/smpp/content~content=a934338802~db=all~jumptype=rss

Despite the role of hand hygiene in preventing infectious disease, compliance remains low. Education and training are often cited as essential to developing and maintaining hand-hygiene compliance, but generally have not produced sustained improvements. Consequently, this literature review was conducted to identify alternative interventions for compelling change in hand-hygiene behavior. Of those, interventions employing social pressures have demonstrated varying influence on an individual’s behavior, while interventions that focus on organizational culture have demonstrated positive results. However, recent research indicates that handwashing is a ritualized behavior mainly performed for self-protection. Therefore, interventions that provoke emotive sensations (e.g., discomfort, disgust) or use social marketing may be the most effective.