The CDC released guidance on use of personal protective equipment (PPE) to be used during care of patients with suspected or confirmed Ebola virus disease (EVD). In Australia, this guidance has been recommended in the CDNA National Guidelines for Public Health Units, which is endorsed by the Communicable Disease Network Australia (CDNA) and Australian Health Protection Primary Committee (AHPPC).

Amongst other recommendations, the CDC guidance includes disinfection of gloved hands. This has caused some concern in Australia given this practice is discouraged by the National Hand Hygiene Initiative and most previous international guidelines on hand hygiene in healthcare.

Hand Hygiene Australia generally advises against washing or decontamination of gloved hands. This is primarily because of a lack of information regarding the impact that this process may have on glove integrity. Additionally, such practices may result in inappropriate glove use which is associated with unnecessary resource consumption and sub-optimal hand hygiene performance.

Care for patients with suspect or confirmed Ebola virus disease represents an exceptional circumstance with a unique set of risks including high case fatality rate and incidental contamination associated with use of unfamiliar PPE. In this setting, the recent CDC guidance has recommended disinfection of gloved hands with alcohol-based handrub or disinfectant wipe when donning PPE, during patient care and when removing PPE. 

We note that this guidance is specifically for care of patients with suspected or confirmed Ebola virus disease and should not be applied outside of that setting. While we are unable to provide evidence-based guidance, we suggest considering the following issues regarding disinfection of gloved hands:

• Efficacy of ABHR against Ebola virus:
  We are not aware of data regarding the efficacy of alcohol-based handrubs against Ebola virus. Alcohol-based products are, however, generally considered active against enveloped viruses (Ebola virus is enveloped). Nevertheless, use of alcohol-based handrubs on gloved hands should be considered to be, at best, a process of disinfection rather than sterilisation. Alcohol-based handrubsshould be used only as an adjunct to PPE and not as a substitute. 

• Impact of alcohol-based handrubs on glove integrity:
  The impact of disinfection on glove integrity will vary depending on the type of glove. A general recommendation (made without firm evidence) is to use nitrile gloves when disinfection will be performed. Given that such gloves are suitable for use with cytotoxic agents it is presumed that they will be less affected by alcohol-based handrubs than other glove types.

• Indications for hand hygiene:
  The US does not have a national program using the ‘5 Moments for Hand Hygiene’. Australian readers should bear this in mind when reviewing documents originating from the US that may appear to differ from routine HHA recommendations regarding hand hygiene.

In summary, we suggest that if wearing nitrile gloves, use of alcohol-based handrubs is unlikely to be harmful and may reduce the risk of self-contamination by healthcare workers, but is also of unproven efficacy. Use of alcohol-based handrubs is not a substitute for appropriate PPE when caring for a patient with suspected or confirmed Ebola virus disease. Disinfection of gloved hands should be considered a practice applicable only to care for a patient with suspected or confirmed Ebola virus disease.

There is a clear need for research regarding the impact of standardised decontamination procedures on glove integrity and the effectiveness of various hand hygiene and disinfectant products in inactivating Ebola virus. Hand Hygiene Australia will update this commentary as further resources or evidence become available.

Hand Hygiene Australia recommends that healthcare facilities seek advice from their local jurisdictional authorities (see contact details below) regarding the infection control procedures to institute during the care of patients with suspected or confirmed Ebola virus disease.

Jurisdictional public health unit contact details