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  • Hand hygiene and cough etiquette

Hand hygiene and cough etiquette - Advice and information to the general public

Hand hygiene and good cough etiquette are important infection control measures that help to prevent transmission of infectious diseases.

Hand hygiene and good cough etiquette are important infection control measures that help to prevent transmission of infectious diseases.


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How to prevent transmission

Infectious diseases have different modes of transmission. For respiratory tract diseases such as COVID-19, infection from the respiratory tract by inhalation of droplets with infectious agents, as well as droplets with infectious substances settling directly on the mucous membranes of the eyes, mouth or nose, are common modes. In addition, contact infection plays a role, but it is a less common mode than inhalation and disposal. For other infectious diseases, such as gastroenteritis, direct and indirect contact infection is assumed to have a greater significance for transmission.

Read more about transmission of SARS-CoV-2 and influenza here:

There is still an ongoing pandemic and it is also peak season for many other infectious viruses that can have a major impact on health and the health service, such as influenza, RS virus and gastroenteritis.  It is still recommended to follow the general advice about good cough etiquette and good hand hygiene to prevent transmission:

  • People who are sick should stay at home
  • For symptoms consistent with COVID-19, have a low threshold for being tested. This also applies to people who are vaccinated and protected.
  • Keep a physical distance where possible
  • Good hand hygiene
  • Good cough etiquette

Hand hygiene

Hand hygiene prevents contact transmission. Contact transmission can occur either through direct contact with an infectious person (such as hugging and shaking hands) or indirectly by transmitting drops of infectious agent to contaminated surfaces and from there to the hands to entry points such as the mucous membranes of the nose, mouth and eyes. Properly performed hand hygiene will reduce both direct and indirect contact transmission.

When should you perform hand hygiene?

  • Before cooking and eating food
  • After using the toilet (including after changing nappies/diapers)
  • After contact with body fluids (e.g. after wiping the nose or coughing into the hand)
  • With visibly dirty hands
  • After contact with someone who is sick

It may also be appropriate to perform hand hygiene after touching contact points in busy places and on arrival at premises where food is sold (grocery stores, restaurants, cafes, etc.).

Soap and water are first choice, alcohol-based hand disinfection is a good alternative

Both hand washing and alcohol-based hand disinfection are good and effective hand hygiene methods.

Alcohol-based hand disinfection has a reduced effect in many situations where there is a need for hand hygiene, such as when the hands are wet, visibly dirty or soiled with organic material such as food residues and body fluids. There is also limited experience with widespread use of hand disinfection among children and adolescents. Hand washing with soap and water is therefore a recommended method outside the healthcare sector.

Alcohol-based hand disinfection can be a good alternative to hand washing when the hands are dry and not visibly soiled, and soap and water are unavailable.

For the best effect, follow the manufacturer's recommendations for how much to use and how long it takes to work.

There is no need to perform both hand washing and hand disinfection – one is sufficient.

Effective hand washing step by step: 

How to wash hands

Effective hand disinfection step by step:

illustrasjon hånddesinfeksjon

 

Choice of disinfectant

It is important that the products used are both effective, safe and skin friendly.

The Norwegian Institute of Public Health, like WHO and ECDC,  primarily recommends alcohol-based hand disinfection, based on ethanol or isopropanol. Ethanol is less irritating to skin, eyes and mucous membranes and may therefore be preferred as a main ingredient. The alcohol concentration should be between 70-90 per cent v/v.

Alcohol-based hand disinfectants have been used by the healthcare system in Norway for several decades. Even though some react with irritated skin, experience shows that alcohol-based disinfection is effective and is gentle to skin on the hands.

Hand disinfectants must comply with the requirements of the biocide regulations managed by the Norwegian Environment Agency. 

Hand disinfectants with active ingredients other than alcohol are also available. In order to be sold in  Norway, these products, like alcohol-based hand disinfectants, must comply with the requirements of the biocide regulations. They must show documented effect according to ES-NS-1500. There is limited experience with clinical use of these products.

How should you dry your hands after washing them?

You can dry your hands with disposable paper towels or warm air hand dryers. It is important that hand dryers are kept clean. They should be designed so that water does not collect at the bottom and then be blown out during use.

Hand towels can be used in private homes but should be changed regularly.

Warm air hand dryers should not be used in healthcare institutions. Read more about drying hands in the national hand hygiene guide in the health service.

How to prevent dry and sore hands?

Here is some advice to prevent dry and sore skin on the hands due to frequent hand hygiene:

  • Use skin-friendly soaps (perfume-free, pH <5.5) and use good quality paper towels to reduce drying out of the skin. At home, clean towels are a good option.
  • Wash your hands in lukewarm water, not hot water.
  • Wet your hands before applying soap.
  • Rinse your hands thoroughly after washing so that all soap suds are washed away.
  • Pat your hands with the paper towel / towel until they are completely dry, avoid rubbing hard.
  • Use hand cream to prevent dry and sore skin, as often as needed (e.g., after hand washing).
  • When using shared tubes (other than by people in the same household), it is important to ensure that the tube opening does not come into contact with skin or objects during use, to avoid contaminating the cream.

Film about skin-friendly handwashing in several languages

See these animated films in several languages from the Psoriasis and Eczema Association (PEF).

The film is intended to promote skin-friendly handwashing during the coronavirus pandemic.

The film is available in these languages:

Use of disposable gloves

Transmission by hands wearing gloves happens in the same way as for hands without gloves. Therefore, we do not recommend the general use of disposable gloves, see Routine use of gloves for shop employees and customers is not recommended

Precautions with use of hand disinfectants

  • Alcohol-based hand disinfectants are flammable. Do not store or use at high temperatures or near open flames.
  • Hands must be dry after using hand disinfectant before activities that may involve contact with heat, sparks or open fire (normal drying time is 20-30 seconds). Cases have been reported where hands that are damp with alcohol-based hand disinfectant have been set alight after close contact with open flames, for example, when lighting a candle or lighting a fire in a stove.
  • Hands must also be dry before touching nearby objects because of the risk of static electricity. Sparks can arise. Cases have been reported where hands that are damp with alcohol-based hand disinfectant have touched metal objects, causing sparks. 
  • Alcohol-based hand disinfectants can be harmful if swallowed or if they come into contact with the eyes. Consider safe use and placement in areas where children, people with mental disorders or who are mentally impaired or other groups are at increased risk of accidental ingestion.

Read more about precautions when using hand disinfection in NIPH's national guide for hand hygiene (in Norwegian).

Cough etiquette

Good cough etiquette is crucial to limit respiratory tract transmission from someone who is infected with COVID-19.

  • Avoid coughing or sneezing directly on others.
  • Try covering your mouth and nose with a tissue (which you throw away afterwards) when coughing/sneezing, or cough/sneeze into your elbow if you do not have a tissue available.
  • Wash your hands after all contact with respiratory secretions or objects that may be contaminated.

Face masks

In situations with increased or high infection burden in society, local, regional or national advice or directive may be given about the use of face masks to reduce transmission.

References

  1. Marasinghe KM. A systematic review investigating the effectiveness of face mask use in limiting the spread of COVID-19 among medically not diagnosed individuals: shedding light on current recommendations provided to individuals not medically diagnosed with COVID-19, 27 March 2020, PREPRINT (Version 2) available at Research Square. DOI: 10.21203/rs.3.rs-16701/v2
  2. Feng S, Shen C, Xia N, Song W, Mengzhen F, Cowling BJ. Rational use of face masks in the COVID-19 pandemic, Lancet Resp Med. Published:March 20, 020. DOI: https://doi.org/10.1016/S2213-2600(20)30134-X
  3. Saunders-Hastings P, Crispo JAG, Sikora L, Krewski D. Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis. Epidemics, 2017, 1-20. DOI: https://doi.org/10.1016/j.epidem.2017.04.003
  4. Cowling BJ, Zhou Y, Ip DJM, Leung GM. Face masks to prevent transmission of influenza virus: a systematic review. Epidemiology & Infection 2010. DOI: https://doi.org/10.1017/S0950268809991658
  5. Facemasks for respiratory tract infections, systematic reviews
  6. Should individuals in the community without respiratory symptoms wear facemasks to reduce the spread of COVID-19? – a rapid review Iversen BG, Vestrheim DF, Flottorp S, Denison E, Oxman ad.; 2020.ISBN elektronisk: 978-82-8406-106-1: https://www.fhi.no/publ/2020/bor-personer-i-samfunnet-bruke-ansiktsmasker-for-a-redusere-spredningen-av-/
  7. Using face masks in the community - Reducing COVID-19 transmission from potentially asymptomatic or pre-symptomatic people through the use of face masks ECDC, report 8.4.2020: https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community-reducing-covid-19-transmission
  8. WHO: Advice on the use of masks in the context of COVID-19. Interim guidance 5. Juni 2020 . WHO/2019-nCov/IPC_Masks/2020.4: https://apps.who.int/iris/handle/10665/331693

History

07.12.2021: Changes in sections about how to prevent infection, when you should perform hand hygiene and the section that soap and water are the first choice.

26.11.2021: Minor linguistic changes

14.10.2021: REmoved section about cleaning and laundry. Minor language changes.

24.09.2021: 25.09.21: Reference to social distancing removed. Advice about hand hygiene and cough etiquette unchanged

04.08.2021: Shortened text, language edits. Added illustration "Effective hand disenfection step by step"

04.08.2021: Shortened text, language edits. Added illustration "Effective hand desinfection step by step".

04.03.2021: Removed sentence about temporary reduction in requirements for alcohol-based disinfectants.

18.12.2020: Moved section about precautions with hand disinfectants to own chapter.

10.12.2020: Added films about handwashing

29.10.2020 Moved information about face mask use to a separate article: Face mask use in the general public

27.10.2020 Minor changes in formulation of advice around use of hand disinfectants with other active ingredients than alcohol. 

10.10.2020 Updates to section about alcohol-based disinfectants, according to Norwegian version

25.09.2020 Updated section about face masks. Removed paragraph about cleaning.

27.08.2020 Added illustrations of how to use a face mask/cloth face covering. Added a sentence about wearing a mask with the coloured side facing out.

14.08.2020 Updated the paragraph about using face masks and cloth face coverings - added link to WHO's page about face masks. Updated the paragraph about recommendations and advice to people who use face masks and cloth face coverings.

11.08.2020
Adjusted definition of non-medical face mask to cloth face coverings. Added European standard for production of non-medical face masks. Updated knowledge base on use of face masks, with latest advice and recommendations from ECDC and WHO.

11.06.2020
New paragraph about drying hands.

29.05.2020 
Added illustration about effective hand hygiene.

27.05.2020
Updated advice about washing hands. Added paragraph about choosing disinfectants.

22.05.2020 
Updated information about Cleaning and laundry at home, as per Norwegian version.

22.04.2020
Updated information about use of non-medical face masks and updating of knowledge base, as per Norwegian version.