gms | German Medical Science

GMS Hygiene and Infection Control

Deutsche Gesellschaft für Krankenhaushygiene (DGKH)

ISSN 2196-5226

Adoption of alcohol hand disinfection in the United States: a personal perspective

Alkoholische Händedesinfektion in den USA: ein persönlicher Kommentar dazu

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GMS Krankenhaushyg Interdiszip 2007;2(1):Doc24

The electronic version of this article is the complete one and can be found online at:

Published: September 13, 2007

© 2007 Boyce.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Even though alcohol-based hand disinfectants have been used for decades as a routine measure in Europe, in the USA until recently handwashing was the procedure of choice. Alcohol-based rub products were recommended only if no handwashing facility or running water was available. It was only during the late 80s and early 90s that the advantages of alcohol-based products began to elicit interest. In 1995 Larsen published new application guidelines for hand disinfection and in 1996 the CDC included alcohol-based hand disinfection in its “Isolation guideline”. However, these recommendations were rarely implemented in practice.

In 1996 Didier Pittet first gave me a demonstration of alcohol-based rub products at his Geneva hospital, and the following year experts at Lausanne University provided me with the products available at that time. In 1998 and 2000 I had the opportunity to exchange information and experiences with numerous European experts, including Dr. Molitor, who also gave me additional insights into the mechanism of action of such products. As a result of myriad scientific demonstrations, interest in these rub products now began to be expressed in the USA too. In 1999 an interdisciplinary working group for hand hygiene was set up, comprising representatives from CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and the Infectious Diseases Society of America, whose intention was to formulate new guidelines for hand hygiene in the healthcare sector. The insights that I gained from Dr. Molitor and from other European experts were of enormous value and helped to weigh up the pros and cons of alcohol-based hand disinfection, both in respect of the different products available and on comparing them with hand washing. The new CDC guideline for hand hygiene was published in 20002 and for the first time in the USA it featured the requirement that alcohol-based rub products be used as the method of choice provided that the hands were not visibly soiled or contaminated with protein-based material. Unfortunately, we have no reliable data, but it is estimated that today up to 95% of doctors and nurses in American hospitals preferentially use alcohol-based rub products – thus reflecting a situation that has long been common practice in Europe.


Auch wenn man in Europa schon seit Jahrzehnten alkoholische Händedesinfektionsmittel routinemäßig eingesetzt hat, blieb in den USA bis vor kurzem das Händewaschen die Methode der Wahl. Alkoholbasierte Einreibepräparate wurden nur dann empfohlen, wenn keine Wasserstelle, bzw. kein fließendes Wasser vorhanden waren. Erst in den späten 80ern und frühen 90ern begann man sich für die Vorteile der Alkohole zu interessieren. Larsen publizierte 1995 neue Anwendungsrichtlinien für die Händedesinfektion bzw. das CDC nahm 1996 die alkoholische Desinfektion der Hände in die „Isolierungsrichtlinie“ auf. Umgesetzt wurden die Empfehlungen in der Praxis allerdings kaum.

1996 demonstrierte mir Didier Pittet zum ersten Mal die alkoholischen Einreibepräparate an seinem Genfer Krankenhaus und im folgenden Jahr erhielt ich vom Fachpersonal des Krankenhauses der Universität Lausanne die gängigen Produkte zur Verfügung gestellt. 1998 und 2000 hatte ich die Chance zu einem Informations- und Erfahrungsaustausch mit zahlreichen europäischen Experten, darunter auch Dr. Molitor, der mir zusätzliche Erkenntnisse über die Wirkungsweise solcher Präparate vermitteln konnte. Als Folge zahlreicher wissenschaftlicher Darstellungen begann man sich nun auch in den USA für die Einreibepräparate zu interessieren. 1999 entstand eine interdisziplinäre Arbeitsgruppe für Händehygiene aus Vertretern des CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), der Society for Healthcare Epidemiology of America, der Association for Professionals in Infection Control und der Infectious Diseases Society of America, die neue Richtlinien erarbeiten sollte für die Händehygiene im Gesundheitswesen. Das Wissen, das ich von Dr. Molitor und anderen europäischen Experten bekommen hatte, war ein wertvoller Beitrag und half, die Vor- und Nachteile alkoholischer Händedesinfektion gegeneinander und gegenüber dem Händewaschen abzuwägen. Die neue CDC Richtlinie zur Händehygiene wurden 2002 publiziert und zum ersten Mal in USA enthielt sie die Aufforderung, alkoholische Einreibepräparate als Methode der Wahl einzusetzen, solange die Hände nicht sichtbar verschmutzt bzw. mit eiweißhaltigen Material verunreinigt sind. Leider liegen keine verbindlichen Daten vor. Schätzungen zufolge kann man aber davon ausgehen, dass heute bis zu 95% der amerikanischen Krankenhäuser Ärzten und Pflegepersonal den Gebrauch alkoholischer Einreibepräparate vorgeben – eine Situation also, wie sie in Europa schon lange üblich ist.


Although alcohol-based hand rubs have been used routinely by healthcare workers in a number of northern European countries for several decades, washing hands between patients remained the principal method of hand hygiene in healthcare facilities in the United States until recently. A training film produced by the Centers for Disease Control and Prevention (CDC) in 1961 and written guidelines published in 1975 and 1985 recommended that healthcare workers wash their hands with either a non-antimicrobial soap and water or an antimicrobial soap and water before and after contact with patients [1], [2]. Alcohol-based hand rubs were recommended for use only in instances in which sinks or running water were not available. Potential adverse effects of alcohol hand rubs on the skin were listed as the major reason to avoid their routine use [1]. In the late 1980s and early 1990s, Larson and others began to point out the advantages of alcohol-based hand rubs, but few hospitals made them available to healthcare workers [3], [4]. Hand hygiene guidelines published by Larson in 1995 and isolation guidelines released by CDC in 1996 listed alcohol-based hand rubs as alternatives in several settings, but limited data suggest that relatively few health-care facilities adopted their use in the following years [5], [6].

In 1996, Professor Didier Pittet introduced me to the alcohol-based hand rub that was being promoted at University of Geneva Hospitals, and the following year, infection control personnel at University of Lausanne Hospital provided me with a sample of a commercially produced alcohol hand rub product that was in widespread use in their facility. Subsequent exchanges of views with European experts at conferences held in Europe in 1998 and 2000 provided me with further information regarding the advantages of disinfecting hands with alcohol-based hand rubs. At several of these meetings, I had the opportunity to discuss the use of alcohol-based hand rubs with Dr. Molitor, who provided me with additional insight into the beneficial characteristics of such products. In the United States, interest in the use of alcohol-based hand rubs in healthcare settings began to increase as a result of presentations made by a number of individuals at national infection control meetings held between 1999 and 2002. In 1999, a multidisciplinary Hand Hygiene Task Force, which was comprised of representatives from CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control, and the Infectious Diseases Society of America was charged with developing new guidelines for hand hygiene in healthcare settings. The interactions I had with Dr. Molitor and other European experts served as an impetus to carefully review the advantages and disadvantages of alcohol-based hand rubs as well as washing hands with non-antimicrobial or antimicrobial soap and water during the process of preparing the new Guideline for Hand Hygiene in Healthcare Settings, which I coauthored with Professor Pittet. Following input from members of the Hand Hygiene Task Force, the United States Food and Drug Administration and the public, and approval by HICPAC and the other supporting organizations, the final version of the Guideline for Hand Hygiene in Healthcare Settings was published in October 2002 [7]. For the first time in the United States, the guideline recommended that alcohol-based hand rubs should be used routinely by healthcare workers, as long as their hands are not visibly soiled or contaminated with proteinaceous material. In January 2003, the Joint Commission on Accreditation of Healthcare Organizations recommended that healthcare facilities in the United States comply with the new CDC Guideline for Hand Hygiene. Although official data are not available, it has been estimated that approximately 90% to 95% of hospitals in the United States now provide alcohol-based hand rubs to healthcare workers. As a result, alcohol-based hand rubs are now used nearly as frequently in hospitals the United States as they are in European countries where they have been popular for years.

Curriculum Vitae

Professor John M. Boyce, M.D.

Figure 1 [Fig. 1]

Clinical Professor of Medicine, Division of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut.

The international awards received by Professor Boyce would go far beyond the scope of this publication. Here writes one of the most renowned and worldwide acknowledged American infectologists.

Born in Boise/Idaho, John Boyce studies at the University of the Washington School of Medicine, where he graduates in 1970. His scientific career starts at the University of Mississippi Medical Center, Jackson, Mississippi, then he moves on to Brown University School of Medicine in Providence, Rhode Island and finally 2001 to Yale University, School of Medicine (Division of Infectious Diseases), New Haven, Connecticut.

Amongst others, Professor Boyce is a Board-Member of the Advisory Board of Infection Control and Hospital Epidemiology since 1997, has been Chairman of HICPAC/ SHEA/ APIC/ IDSA Hand Hygiene Task Force until 2002 and is Temporary Consultant to the World Health Organization, Geneva, Switzerland.


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