No soap? No water? What can we use as alternative hand hygiene agents in extreme situations?

Dr Peta-Anne Zimmerman1,2,3,4, Dr Sophie Dennis5, Dr  Jocelyne Basseal6

1School of Nursing and Midwifery, Griffith University, Southport, Australia, 2Gold Coast Hospital and Health Service, Southport, Australia, 3Collaborative for the Advancement of Infection Prevention and Control, , Australia, 4Menzies Health Institute, QLD, Southport, Australia, 5University of Bristol, Bristol, United Kingdom, 6Discipline of Infectious Diseases and Immunology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia

Introduction: Hand hygiene is regarded as one the most crucial measures to control and limit the spread of disease. Yet access to clean water and soap or alcohol-based hand rub (ABHR) may be scarce or unattainable in some situations.  This integrative review aims to identify alternative hand hygiene (HH) agents and water sources that have demonstrated some efficacy in extreme resource limited settings.

Methods: A framework of Whittemore and Knafl along with a quality assessment performed in-line with the Mixed Methods Assessment Tool guided this review.  The Population, Intervention, Comparison, Outcome and Context (PICOC) framework was used to assist with structing the clinical question.   An electronic database search was conducted via the Cumulative Index for Nursing and Allied Health Literature (CINAHL), Embase, and National Library of Medicine (Medline) using specific search terms pertaining to HH and water sources that have shown some efficacy to reduce microbial load.

Results: Of the 125 titles identified, a total of four were included in the final review that specifically related to the use of alternative HH agents with no soap or ABHR.

Conclusion: This study summarises friction generating agents that are successful in reduction of microbial load on hands in comparison to the use of soap and water as the hand hygiene strategy.  In addition, alternative water sources are suggested for hand hygiene in limited resource situations where clean water is lacking.  Long term effects on skin integrity, compliance and sustainability of suggested strategies must also be considered.


Dr Peta-Anne Zimmerman (RN, DPH, CICP-E, SFHEA) is an internationally respected clinician, educator, and researcher in infection prevention and control (IPC). Dr Zimmerman’s experience in IPC spans over 20 years and her domestic clinical experience, research, and expertise has led her to work extensively in China, South East Asia and throughout both the South and North Pacific, directly on outbreak response, the development of comprehensive infection prevention and control programs, and integration of public health and acute care response in infectious disease emergencies in low and middle income country settings.

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