Publications by authors named "Sharon Welbel"

16 Publications

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Outbreak of COVID-19 and interventions in a large jail - Cook County, IL, United States, 2020.

Am J Infect Control 2021 Apr 2. Epub 2021 Apr 2.

Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address:

Background: Correctional and detention facilities are disproportionately affected by COVID-19 due to shared space, contact between staff and detained persons, and movement within facilities. On March 18, 2020, Cook County Jail, one of the United States' largest, identified its first suspected case of COVID-19 in a detained person.

Methods: This analysis includes SARS-CoV-2 cases confirmed by molecular detection among detained persons and Cook County Sheriff's Office staff. We examined occurrence of symptomatic cases in each building and proportions of asymptomatic detained persons testing positive, and timing of interventions including social distancing, mask use, and expanded testing and show outbreak trajectory in the jail compared to case counts in Chicago.

Results: During March 1-April 30, 907 symptomatic and asymptomatic cases of SARS-CoV-2 infection were detected among detained persons (n = 628) and staff (n = 279). Among asymptomatic detained persons in quarantine, 23.6% tested positive. Programmatic activity and visitation stopped March 9, cells were converted into single occupancy beginning March 26, and universal masking was implemented for staff (April 2) and detained persons (April 13). Cases at the jail declined while cases in Chicago increased.

Discussion/conclusions: Aggressive intervention strategies coupled with widespread diagnostic testing of detained and staff populations can limit introduction and mitigate transmission of SARS-CoV-2 infection in correctional and detention facilities.
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http://dx.doi.org/10.1016/j.ajic.2021.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016534PMC
April 2021

Identification of Presymptomatic and Asymptomatic Cases Using Cohort-Based Testing Approaches at a Large Correctional Facility-Chicago, Illinois, USA, May 2020.

Clin Infect Dis 2021 03;72(5):e128-e135

Cermak Health Services, Chicago, Illinois, USA.

Background: Coronavirus disease 2019 (COVID-19) continues to cause significant morbidity and mortality worldwide. Correctional and detention facilities are at high risk of experiencing outbreaks. We aimed to evaluate cohort-based testing among detained persons exposed to laboratory-confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to identify presymptomatic and asymptomatic cases.

Methods: During 1-19 May 2020, 2 testing strategies were implemented in 12 tiers or housing units of the Cook County Jail, Chicago, Illinois. Detained persons were approached to participate in serial testing (n = 137) and offered tests at 3 time points over 14 days (day 1, days 3-5, and days 13-14). The second group was offered a single test and interview at the end of a 14-day quarantine period (day 14 group) (n = 87).

Results: 224 detained persons were approached for participation and, of these, 194 (87%) participated in ≥1 interview and 172 (77%) had ≥1 test. Of the 172 tested, 19 were positive for SARS-CoV-2. In the serial testing group, 17 (89%) new cases were detected, 16 (84%) on day 1, 1 (5%) on days 3-5, and none on days 13-14; in the day 14 group, 2 (11%) cases were identified. More than half (12/19; 63%) of the newly identified cases were presymptomatic or asymptomatic.

Conclusions: Our findings highlight the utility of cohort-based testing promptly after initiating quarantine within a housing tier. Cohort-based testing efforts identified new SARS-CoV-2 asymptomatic and presymptomatic infections that may have been missed by symptom screening alone.
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http://dx.doi.org/10.1093/cid/ciaa1802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799274PMC
March 2021

Network Characteristics and Visualization of COVID-19 Outbreak in a Large Detention Facility in the United States - Cook County, Illinois, 2020.

MMWR Morb Mortal Wkly Rep 2020 Nov 6;69(44):1625-1630. Epub 2020 Nov 6.

Correctional and detention facilities have been disproportionately affected by coronavirus disease 2019 (COVID-19) because of shared space and movement of staff members and detained persons within facilities (1,2). During March 1-April 30, 2020, at Cook County Jail in Chicago, Illinois, >900 COVID-19 cases were diagnosed across all 10 housing divisions, representing 13 unique buildings. Movement within the jail was examined through network analyses and visualization, a field that examines elements within a network and the connections between them. This methodology has been used to supplement contact tracing investigations for tuberculosis and to understand how social networks contribute to transmission of sexually transmitted infections (3-5). Movements and connections of 5,884 persons (3,843 [65%] detained persons and 2,041 [35%] staff members) at the jail during March 1-April 30 were analyzed. A total of 472 (12.3%) COVID-19 cases were identified among detained persons and 198 (9.7%) among staff members. Among 103,701 shared-shift connections among staff members, 1.4% occurred between persons with COVID-19, a percentage that is significantly higher than the expected 0.9% by random occurrence alone (p<0.001), suggesting that additional transmission occurred within this group. The observed connections among detained persons with COVID-19 were significantly lower than expected (1.0% versus 1.1%, p<0.001) when considering only the housing units in which initial transmission occurred, suggesting that the systematic isolation of persons with COVID-19 is effective at limiting transmission. A network-informed approach can identify likely points of high transmission, allowing for interventions to reduce transmission targeted at these groups or locations, such as by reducing convening of staff members, closing breakrooms, and cessation of contact sports.
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http://dx.doi.org/10.15585/mmwr.mm6944a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643900PMC
November 2020

Tuberculosis Mortality in the United States: Epidemiology and Prevention Opportunities.

Ann Am Thorac Soc 2018 06;15(6):683-692

California Department of Public Health, Tuberculosis Control Branch, Richmond, California.

More information on risk factors for death from tuberculosis in the United States could help reduce the tuberculosis mortality rate, which has remained steady for more than a decade. To identify risk factors for tuberculosis-related death in adults. We performed a retrospective study of 1,304 adults with tuberculosis who died before treatment completion and 1,039 frequency-matched control subjects who completed tuberculosis treatment in 2005 to 2006 in 13 states reporting 65% of U.S. tuberculosis cases. We used in-depth record abstractions and a standard algorithm to classify deaths in persons with tuberculosis as tuberculosis-related or not. We then compared these classifications to causes of death as coded in death certificates. We used multivariable logistic regression to calculate adjusted odds ratios for predictors of tuberculosis-related death among adults compared with those who completed tuberculosis treatment. Of 1,304 adult deaths, 942 (72%) were tuberculosis related, 272 (21%) were not, and 90 (7%) could not be classified. Of 847 tuberculosis-related deaths with death certificates available, 378 (45%) did not list tuberculosis as a cause of death. Adjusting for known risks, we identified new risks for tuberculosis-related death during treatment: absence of pyrazinamide in the initial regimen (adjusted odds ratio, 3.4; 95% confidence interval, 1.9-6.0); immunosuppressive medications (adjusted odds ratio, 2.5; 95% confidence interval, 1.1-5.6); incomplete tuberculosis diagnostic evaluation (adjusted odds ratio, 2.2; 95% confidence interval, 1.5-3.3), and an alternative nontuberculosis diagnosis before tuberculosis diagnosis (adjusted odds ratio, 1.6; 95% confidence interval, 1.2-2.2). Most persons who died with tuberculosis had a tuberculosis-related death. Intensive record review revealed tuberculosis as a cause of death more often than did death certificate diagnoses. New tools, such as a tuberculosis mortality risk score based on our study findings, may identify patients with tuberculosis for in-hospital interventions to prevent death.
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http://dx.doi.org/10.1513/AnnalsATS.201705-405OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531349PMC
June 2018

Pseudo-outbreak of Mycobacterium gordonae Following the Opening of a newly constructed hospital at a Chicago Medical Center.

Infect Control Hosp Epidemiol 2015 Feb;36(2):198-203

3Rush University Medical Center,Chicago,IL,USA.

OBJECTIVE To identify the source of a pseudo-outbreak of Mycobacterium gordonae DESIGN Outbreak investigation. SETTING University Hospital in Chicago, Ilinois. PATIENTS Hospital patients with M. gordonae-positive clinical cultures. METHODS An increase in isolation of M. gordonae from clinical cultures was noted immediately following the opening of a newly constructed hospital in January 2012. We reviewed medical records of patients with M. gordonae-positive cultures collected between January and December 2012 and cultured potable water specimens in new and old hospitals quantitatively for mycobacteria. RESULTS Of 30 patients with M. gordonae-positive clinical cultures, 25 (83.3%) were housed in the new hospital; of 35 positive specimens (sputum, bronchoalveolar lavage, gastric aspirate), 32 (91.4%) had potential for water contamination. M. gordonae was more common in water collected from the new vs. the old hospital [147 of 157 (93.6%) vs. 91 of 113 (80.5%), P=.001]. Median concentration of M. gordonae was higher in the samples from the new vs. the old hospital (208 vs. 48 colony-forming units (CFU)/mL; P<.001). Prevalence and concentration of M. gordonae were lower in water samples from ice and water dispensers [13 of 28 (46.4%) and 0 CFU/mL] compared with water samples from patient rooms and common areas [225 of 242 (93%) and 146 CFU/mL, P<.001]. CONCLUSIONS M. gordonae was common in potable water. The pseudo-outbreak of M. gordonae was likely due to increased concentrations of M. gordonae in the potable water supply of the new hospital. A silver ion-impregnated 0.5-μm filter may have been responsible for lower concentrations of M. gordonae identified in ice/water dispenser samples. Hospitals should anticipate that construction activities may amplify the presence of waterborne nontuberculous mycobacterial contaminants.
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http://dx.doi.org/10.1017/ice.2014.28DOI Listing
February 2015

Examining the impact of patient characteristics and symptomatology on knowledge, attitudes, and beliefs among foreign-born tuberculosis cases in the US and Canada.

J Immigr Minor Health 2014 Feb;16(1):125-35

Charles P. Felton National Tuberculosis Center, ICAP, Mailman School of Public Health, Columbia University, 215 W. 125th St., 1st fl., Suite A, New York, NY, 10027, USA,

Foreign-born individuals represent the majority of TB cases in the US/Canada. Little is known about their TB knowledge, attitudes, and beliefs (KAB). Cross-sectional survey was conducted in 22 sites in the US/Canada among foreign-born adults with active TB. Multiple regression was used to examine KAB factors against covariates. Of 1,475 participants interviewed, most answered the six knowledge items correctly. Significant predictors of correct knowledge included region of origin, education, income, age, visa status, place of diagnosis, BCG vaccination, and TB symptoms. Significant predictors of higher perceived risk/stigma scores included region of origin, age, place of diagnosis, English fluency, time in the US/Canada, TB symptoms, and household rooms. This study examines associations between TB KAB and patient and disease characteristics in foreign-born individuals in the US/Canada. The findings call for improved health education, along with efforts to reduce stigma and enhance realistic risk assessments.
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http://dx.doi.org/10.1007/s10903-013-9787-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141606PMC
February 2014

Clinical outcomes of carbapenem-resistant Acinetobacter baumannii bloodstream infections: study of a 2-state monoclonal outbreak.

Infect Control Hosp Epidemiol 2010 Oct;31(10):1057-62

University of Miami, Miami, FL, USA.

Objective: To characterize the clinical outcomes of patients with bloodstream infection caused by carbapenem-resistant Acinetobacter baumannii during a 2-state monoclonal outbreak.

Design: Multicenter observational study. Setting. Four tertiary care hospitals and 1 long-term acute care hospital.

Methods: A retrospective medical chart review was conducted for all consecutive patients during the period January 1, 2005, through April 30, 2006, for whom 1 or more blood cultures yielded carbapenem-resistant A. baumannii.

Results: We identified 86 patients from the 16-month study period. Their mortality rate was 41%; of the 35 patients who died, one-third (13) had positive blood culture results for carbapenem-resistant A. baumannii at the time of death. Risk factors associated with mortality were intensive care unit stay, malignancy, and presence of fever and/or hypotension at the time blood sample for culture was obtained. Only 5 patients received adequate empirical antibiotic treatment, but the choice of treatment did not affect mortality. Fifty-seven patients (66.2%) had a single positive blood culture result for carbapenem-resistant A. baumannii; the only factor associated with a single positive blood culture result was the presence of decubitus ulcers. Interestingly, during the study period, a transition from single to multiple positive blood culture results was observed. Four patients, 3 of whom were in a burn intensive care unit, were bacteremic for more than 30 days (range, 36-86 days).

Conclusions: To our knowledge, this is the first time a study has described 2 patterns of bloodstream infection with A. baumannii: single versus multiple positive blood culture results, as well as a subset of patients with prolonged bacteremia.
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http://dx.doi.org/10.1086/656247DOI Listing
October 2010

Protecting health care workers from tuberculosis: a 10-year experience.

Am J Infect Control 2009 Oct 28;37(8):668-73. Epub 2009 Apr 28.

Department of Medicine/Infectious Disease, Rush Medical College, and John H Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA.

Background: Cook County Hospital (CCH) is an inner-city, large public hospital. Twenty-five percent of Chicago's tuberculosis (TB) cases are diagnosed at CCH. We wanted to review and analyze interventions implemented over a 10-year period at CCH to prevent TB infection in health care workers.

Methods: We performed a retrospective review of interventions to prevent health care-associated tuberculosis. We collated and analyzed tuberculin skin test conversions in our employees for the same time period.

Results: From 1990 to 2002, we cared for over 1800 in-patients with tuberculosis. During 1992-1997, multiple interventions to eliminate health care-associated spread of tuberculosis were implemented. Tuberculin skin test conversions in our employees decreased markedly from January 1994 through December 2002. Two drops in tuberculin skin test conversion rates occurred: one after introduction of basic administrative and engineering controls and a second after we experienced a decrease in missed TB cases and the introduction of N-95 personal respirators with 1-time qualitative fit testing.

Conclusion: Our annual health care worker skin test conversion rate fell significantly when our primary interventions were relatively simple administrative and engineering controls. Educating health care workers to promptly recognize patients with TB and placing exhaust fans to create negative-pressure respiratory isolation rooms were probably our 2 most potent infection control measures.
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http://dx.doi.org/10.1016/j.ajic.2009.01.004DOI Listing
October 2009

Costs of management of occupational exposures to blood and body fluids.

Infect Control Hosp Epidemiol 2007 Jul 25;28(7):774-82. Epub 2007 May 25.

Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

Objective: To determine the cost of management of occupational exposures to blood and body fluids.

Design: A convenience sample of 4 healthcare facilities provided information on the cost of management of occupational exposures that varied in type, severity, and exposure source infection status. Detailed information was collected on time spent reporting, managing, and following up the exposures; salaries (including benefits) for representative staff who sustained and who managed exposures; and costs (not charges) for laboratory testing of exposure sources and exposed healthcare personnel, as well as any postexposure prophylaxis taken by the exposed personnel. Resources used were stratified by the phase of exposure management: exposure reporting, initial management, and follow-up. Data for 31 exposure scenarios were analyzed. Costs were given in 2003 US dollars.

Setting: The 4 facilities providing data were a 600-bed public hospital, a 244-bed Veterans Affairs medical center, a 437-bed rural tertiary care hospital, and a 3,500-bed healthcare system.

Results: The overall range of costs to manage reported exposures was $71-$4,838. Mean total costs varied greatly by the infection status of the source patient. The overall mean cost for exposures to human immunodeficiency virus (HIV)-infected source patients (n=19, including those coinfected with hepatitis B or C virus) was $2,456 (range, $907-$4,838), whereas the overall mean cost for exposures to source patients with unknown or negative infection status (n=8) was $376 (range, $71-$860). Lastly, the overall mean cost of management of reported exposures for source patients infected with hepatitis C virus (n=4) was $650 (range, $186-$856).

Conclusions: Management of occupational exposures to blood and body fluids is costly; the best way to avoid these costs is by prevention of exposures.
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http://dx.doi.org/10.1086/518729DOI Listing
July 2007

Effect of education on hand hygiene beliefs and practices: a 5-year program.

Infect Control Hosp Epidemiol 2007 Jan 15;28(1):88-91. Epub 2006 Dec 15.

John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA.

To evaluate infection control and hand hygiene understanding at 3 public hospitals, we surveyed 4,345 healthcare workers (HCWs) 3 times during a 5-year infection control intervention. The preference for the use of alcohol hand rub for hand hygiene increased dramatically; in nurses, it increased from 14% to 34%; in physicians, 4.3% to 51%; and in allied HCWs, 12% to 44%. Study year, infection control interactive education-session attendance, infection control knowledge, and being a physician or allied HCW independently predicted a preference for alcohol hand rub.
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http://dx.doi.org/10.1086/510792DOI Listing
January 2007

Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance.

Infect Control Hosp Epidemiol 2007 Jan 3;28(1):42-9. Epub 2007 Jan 3.

Collaborative Research Unit, Department of Medicine, Stroger Hospital of Cook County, Chicago, IL 60612, USA.

Objective: To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities.

Design: Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses.

Setting: Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).Intervention. At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub.

Results: We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance.

Conclusions: During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.
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http://dx.doi.org/10.1086/510809DOI Listing
January 2007

Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement.

Infect Control Hosp Epidemiol 2006 Feb 8;27(2):139-45. Epub 2006 Feb 8.

Chicago Department of Public Health, Chicago, IL 60612, USA.

Objective: In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation.

Design: Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices.

Setting: Level III NICUs at Chicago-area hospitals.

Participants: Neonates and healthcare workers associated with the level III NICUs.

Methods: From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS.

Results: Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs.

Conclusion: The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.
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http://dx.doi.org/10.1086/501216DOI Listing
February 2006

Computer algorithms to detect bloodstream infections.

Emerg Infect Dis 2004 Sep;10(9):1612-20

Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

We compared manual and computer-assisted bloodstream infection surveillance for adult inpatients at two hospitals. We identified hospital-acquired, primary, central-venous catheter (CVC)-associated bloodstream infections by using five methods: retrospective, manual record review by investigators; prospective, manual review by infection control professionals; positive blood culture plus manual CVC determination; computer algorithms; and computer algorithms and manual CVC determination. We calculated sensitivity, specificity, predictive values, plus the kappa statistic (kappa) between investigator review and other methods, and we correlated infection rates for seven units. The kappa value was 0.37 for infection control review, 0.48 for positive blood culture plus manual CVC determination, 0.49 for computer algorithm, and 0.73 for computer algorithm plus manual CVC determination. Unit-specific infection rates, per 1,000 patient days, were 1.0-12.5 by investigator review and 1.4-10.2 by computer algorithm (correlation r = 0.91, p = 0.004). Automated bloodstream infection surveillance with electronic data is an accurate alternative to surveillance with manually collected data.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320282PMC
http://dx.doi.org/10.3201/eid1009.030978DOI Listing
September 2004

Unnecessary use of central venous catheters: the need to look outside the intensive care unit.

Infect Control Hosp Epidemiol 2004 Mar;25(3):266-8

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

We developed criteria for justifiable CVC use and evaluated CVC use in a public hospital. Unjustified CVC-days were more common for non-ICU patients compared with ICU patients. Also, insertion-site dressings were less likely to be intact on non-ICU patients. Interventions to reduce CVC-associated bloodstream infections should include non-ICU patients.
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http://dx.doi.org/10.1086/502390DOI Listing
March 2004

Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital.

Clin Infect Dis 2003 Jun 22;36(11):1383-90. Epub 2003 May 22.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.

We determined risk factors for hand contamination and compared the efficacy of 3 randomly allocated hand hygiene agents in a group of surgical intensive care unit nurses. We cultured samples of one of the subjects' hands before and samples of the other hand after hand hygiene was performed. Ring wearing was associated with 10-fold higher median skin organism counts; contamination with Staphylococcus aureus, gram-negative bacilli, or Candida species; and a stepwise increased risk of contamination with any transient organism as the number of rings worn increased (odds ratio [OR] for 1 ring worn, 2.6; OR for >1 ring worn, 4.6). Compared with use of plain soap and water, hand contamination with any transient organism was significantly less likely after use of an alcohol-based hand rub (OR, 0.3; 95% confidence interval [CI], 0.1-0.8) but not after use of a medicated hand wipe (OR, 0.9; 95% CI, 0.5-1.6). Ring wearing increased the frequency of hand contamination with potential nosocomial pathogens. Use of an alcohol-based hand rub resulted in significantly less frequent hand contamination.
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http://dx.doi.org/10.1086/374852DOI Listing
June 2003

Adherence with hand hygiene: does number of sinks matter?

Infect Control Hosp Epidemiol 2003 Mar;24(3):224-5

Cook County Hospital, Chicago, Illinois, USA.

We observed adherence with hand hygiene in 14 units at 4 hospitals with varying sink-to-bed ratios (range, 1:1 to 1:6). Adherence was less than 50% in all units and there was no significant trend toward improved hand hygiene with increased sink-to-bed ratios.
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http://dx.doi.org/10.1086/502193DOI Listing
March 2003