Thursday 18 June 2015

REVIEW OF LITERATURE

REVIEW OF LITERATURE

1.      Kelemua Gulilat. http://www.sciencepublishinggroup.com/journal/paperinfo.aspx?journalid=251&doi=10.11648/j.sjph.20140205.13 An observational study was conducted in April, 2012 in health facilities found in Bahirdar city administration. Data were collected using Pre tested questionnaire on 354 health care workers selected by simple random sampling technique. Overall knowledge score of respondents were 84.5% and about 55.6% had positive attitude and 54.2% of respondents had safe infection prevention practice. Result of multiple logistic regression analysis showed that working in hospital (AOR=2.54;95%  CI(1.12,5.75), working experience greater than 10 years. (AOR=3.79 (95% CI =2.33,6.17) and availability PPE (AOR=6.79 (95% CI=2.83,17.27) has positive association with infection prevention. Participants had better knowledge and positive attitude their practice of infection prevention was not optimum as per the national guideline. Improving institutional supplies like hand hygiene material, PPE, water supply & TST may improve safe infection prevention practice.

2.      Lt V. Anargh. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862659/ A cross sectional questionnaire and observation based study was carried out in a tertiary care health care facility in Pune to assess knowledge  and practices regarding hand hygiene among health care workers of a tertiary health care facility based on sample size calculations,100 HCWs working in medical and surgical wards were studied. Majority preferred hand washing with soap and water over hand washing with soap and water over hand rubbing with alcohol based solutions.21% of HCWs were missing in accessibility (9%) of hand hygiene facilities were the common reasons for non compliance. Inadequate compliance despite knowledge and false sense of security by alcohol based rubs was seen.
3.      AL-Naggar R A. http://iiumedic.net/imjm/v1/download/Volume%2012%20No%202/Vol12No2%20Page%2011-14.pdf A focus group discussion conducted in January-2010 among 40 medical science students from management and science university(MSU) Malaysia. Simple random sampling was used, the students divided into five focus groups .the number of each group ranged between 8-10 members .the majority of the participants mentioned that they frequently washed their hands using soap .some of the participants washed the hands only with plain water. Majority of the participants mentioned that the laziness was their main barrier of frequent hand washing followed by lack of nearby water supply and then the feeling that their hands are not dirty enough to be infected. medical  science students still have some misconceptions & negative attitude towards hand hygiene practice.
4.      SHANU S. J. http://dspace.sctimst.ac.in/jspui/bitstream/123456789/1601/1/475.pdf An observational study to assess the hand hygiene practices among HCWs to assess the reason for non compliance conducted in CSICU of SCTIMST, Trivandrum. 50 HCWs were taken for observation, 50 for assess the reported hand hygiene practices. Questionnaire and observation tool were used for data collection. The study revealed that there is a disparity between the opinion and the practices of hand hygiene among health care workers. The overall observed compliance rate67.08%(75 HCWs are included in observational study,111 no. of opportunities are given only 76 opportunities of hand hygiene being performed).the physiotherapist shows higher compliance rate(78%) the nurses& residents shows 68% and the technician and unit helpers shows low rate (60%).
5.      Anita Huis. http://www.implementationscience.com/content/7/1/92 Systematic searches of experimental and quasi-experimental a research on hand hygiene improvement strategy was conducted in Medline, Embase, CINAHL and Cochrane database from January 2000 to November 2009. We describe frequently used improvement strategy and related determinants of behavior change that promote good HH behavior to provide a better overview of the choice and content of such strategies. 41 studies are reviewed. Thirteen studies used a controlled design to measure the effect of HH improvement strategies on HH behavior. We found hidden and valuable components in HH hygiene improvement strategies. Addressing only determinants such as knowledge, awareness, action control and facilitation is not enough to change HH hygiene behavior.
6.      S. W. Aboelela. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0024262/ A Systematic review of Effectiveness of bundled behavioral interventions to control health care association infection. A total of 33 published studies met the inclusion criteria and were evaluated. Four of these earned a study quality score of >=80%.In All four significant reduction in HAIs or colonization rate were reported. Frequently used interventions included complaints monitoring (21.2% ) staff performance and /or compliance feedback (39.4%) and staff skills development and testing(36.4%).a vast majority of the studies(90.9%) reported either overall HAI rates or specific health care associated MDRO infection rates as the primary outcome.
7.      Roger Ulrich. https://smartech.gatech.edu/bitstream/handle/1853/25676/zimring_HERD_2008_researchlitreview.pdf?sequence=1 A scientific research on evidence based health care design and extracts its implications for designing better and safer hospitals in 2004.this review found a growing body of rigorous study to guide health care design, especially with respect to reducing the frequency of HAIs. Results are organized acc. To three general types of outcomes: patient safety, other patient outcome, and staff outcome. The finding further support and importance of improving outcome for a range of design characteristics or intervention and improving work settings.
8.      “Judy Tran” http://digitalcommons.library.tmc.edu/dissertations/AAI1467437/ A comparative study on hand hygiene to help determine the barrier to HH compliance and offer solution on improving these rates and to build on a hand hygiene evaluation. A total of eight HH studies are highlighted. At a children hospital Seattle, hand hygiene compliance rate increase from 62% to 81% after five period of intervention.
9.      In Thailand, http://digitalcommons.library.tmc.edu/dissertations/AAI1467437/ 26 nurses dramatically increase compliance from 6.3% to 81.2% after just 7 month of training. Automated alcohol based hand rub dispensers improved compliance rate in Chicago from 36.3% to 70.1%.using education and increased distribution of alcohol based hand rubs increased HH rates from 59% to 79%. All approaches were effective and increased compliance rates.
10.     Hixon S. http://ir.muhas.ac.tz:8080/jspui/bitstream/123456789/588/1/2012-11-05-CORRECTED%20ya%20mwisho.pdf A cross-section & observational study, was conducted among 118 ICU staff nurses at Muhimbili to identify Knowledge and practice on prevention of ventilator associated pneumonia.ICU nurses knowledge on VAP prevention was adequate but their practice was found to be poor. No significant association between ICU training, level of education, year of working experience and knowledge.
11.     Naikoba S. http://www.ncbi.nlm.nih.gov/pubmed/11247676 `A systemic literature review was conducted to establish the effectiveness of interventions aimed at increasing compliance with hand washing in healthcare workers. The result showed that multifaceted approaches which combine education with written material, reminders & combined feedback of performance can have an important effect on hand washing compliance &rates of HAIs.
12.     Aboelela S. W. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0024262/ A purpose of this systemic review was to evaluate studies testing the effectiveness of intervention aimed at changing health care workers behavior. A total of 33 published studies met the inclusion criteria and were evaluated four of these earned a study quality score of ≥ 80%. In all four significant reductions in HAI or colonization rates were reported.
13.     Michael White by. http://www.researchgate.net/profile/ML_Mclaws2/publication/7109639_Why_Healthcare_workers_don%27t_wash_their_hands_A_Behavioral_explanation/links/00b7d5280548ca32ca000000.pdf A study on focus group discussion to elucidate behavioral determinants of hand washing among nurses in the community and three tertiary care hospitals. 754 nurses were analyzed using backward, linear regression for hand washing intension. We reasoned that hand washing results in two distinct behavioral practices inherent hand washing (64%) and elective hand washing (76%). Intended elective in hospital hand washing behavior is further significantly predicted by nurses beliefs in the benefits of the activities (weighted β=3.12), peer pressure of senior physicians (weighted β=3.0) and administrators (weighted β=2.2) and role modeling (weighted β=3.0) but only to a minimal extent by reduction in effort (weighted β=1.13).
14.     John M Boyce. http://www.researchgate.net/profile/John_Boyce5/publication/51655480_Measuring_Healthcare_Worker_Hand_Hygiene_Activity_Current_Practices_and_Emerging_Technologies/links/541b34ff0cf2218008c05848.pdf  An observational study conducted by trained personnel monitoring hand hygiene compliances. Monitoring hand hygiene product consumption is less time consuming and can provide useful information regarding frequency of hand hygiene. Electronic hand hygiene monitoring system that utilized wireless system to monitor room entry and exit of health care workers and their use of hand hygiene product. The studies suggest that use of electronic monitoring system is associated with increased hand hygiene compliance rates and that such systems may be acceptable to care give us.
15.     Pittet d. A comprehensive study of essential aspects of hand hygiene in health care has been issued by WHO patient’s safety on 5th May, 2009 on the occasion of the launch of the save lives: clean your hand Initiative. The guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care and lesson learnt from testing their advanced draft and related implementation tools.
16.     Barnes Sl. A study to preventing the transmission of multi drugs resistant organisms: importance of hand hygiene and environmental cleaning interventions it developed and agent based model of patient to patient transmission via the hands of transiently colonized health care workers and incompletely terminally cleaned rooms – in a 20 patients Intensive care unit. Nurses and physician were modeled and had distinct hand hygiene compliance levels on entry and exit to patient rooms. A hand hygiene should remain a priority for infection control program.
17.     Sile A Creedon. A quasi experimental study of health care worker hand washing/ hand hygiene practices from a behavioral perspective the data were collected in 2001, health care worker hand washing practices and their predisposition and attitudes, beliefs and knowledge towards compliance with hand hygiene guidelines questionnaires n=62 were studied nurses, doctors, physiotherapist and cure assistants involved in direct patient care in the study unit participated in the study Implementation of the multifaceted intentional behavioral hand hygiene program resulted in an overall improvement in compliance with hand hygiene guidelines (51- 83%) p<0.001.
18.     T Rabie. A study to determine the effect of hand washing on the risk of respiratory infection in 2004 June studies were included in the review if they reported the impact of an intervention to promote hand cleansing or respiratory infection relating to hospital acquired infections, long term care facilities, immuno-compromised and elderly people were excluded list of 410 articles, 8 interventional studies met the eligibility criteria, all 8 eligible study reported that hand washing lowered risk of respiratory infection. 
19.     Sile A Creedon. An observational study examined difference in hand hygiene practice between 4 acute hospitals. To investigate health care workers compliances with hand hygiene guidelines in 4 acute care hospitals in Ireland. To examine factors that contributed to non compliance. Data collector observed health care workers in 4 hospitals.
20.     Stephan. harbarth@hcuge.ch Stephan Harbarth. the purpose of this review is to examine studies that have assessed the association between hand hygiene enhancement and MRSA(methicillin resistant staphylococcus aureus)rates and to explore controvercies surrounding this association many studies have been published .these studies have also shown the cost beneficial nature of these programmes .enhancement of hand hygiene compliance has been shown to reduce MRSA rates .
21.     M Malliarou-2013www.internationaljournal of caringsciences.org. A study to  point out the importance of nurses hand hygiene of articles with key words”hand,hygiene,hard,contamination,guideline.infectious disease are a particular risk to the very young,the elderly those with a preexisting disease, and people with a comprised immune system,nurses washing their hands not only prevent them from getting sick but it also reduces the risk of infecting others
22.     Suvarna  Sande. A study to assess the effect of hand washing among nursing staffs in Tertiary care Hospital. swabs were collected from 150 nursing staffs working in various wards and intensive care units(ICUs),from hands before & after Hand washing with antimicrobial soap. swabs were inoculated on blood agar and Mac-Conkey’s agar. Microorganisms were identified by standard methods. out of total 150 samples collected before hand washing, growth was observed in 107(71.3%)samples and no growth in 43(28.7%) samples Methicillin resistant staphylococcus aureus (MRSA) strains were also isolated from hand swabs collected before hand washing, no growth was obtained in 128(85.3%) samples and growth were observed in 22(14.7%)samples after hand washing.
23.     Z Abbas. Z.abbasnejad@ymail.com. study to investigate Knowledge, Attitude or beliefs and performance related to hand hygiene in health care staffs. the result of reviewing 14 articles showed that seven investigations  have been carried out as descriptive, five experimentals  & two by interventional methods. the result of limited studies were indicating poor hand hygiene in health care setting.
24.     www.hindawi.com /journals/ipid/2012/679129/ Azzam al Kadi and Sajad Ahmad Salati. A cross sectional study was undertaken from January to March 2012 in the dept. of surgery of college of medicine ,Qassim University ,Saudi Arabia on hand hygiene practice among medical students. On the basis of WHO’s concept of “five movements for hand hygiene”.activities commonly undertaken by medical students during cilinical phase ( 4th year of MBBS course )were selected, and a questionnaire .a purpose of the study was explained as per the ethical guideline of Helsinki, the student were requested to fill the questionnaires .60 student agreed to participate and subsequently were enrolled in the study.the average awareness regarding positive indication of hand hygiene was 51.7% for male student and 62.5% for female student .only 29% of student were able to identify all the five indication.
25.     hub.hku.hk/handle/10722/179923.jsessionid=DAD 4CEA55464F91375FD3AD4015EAAB82  A systemic study on effectiveness of hand hygiene programs that improve compliance rate among health care worker .it conducted in 2012. HH the most effective & economical way to prevent the transmission of many bacteria and virus in health care setting yet. The objective of this review were to identify the effectiveness of these HH intervention program. Results showed that 8 HH program were effective while 1 program was in effective in improving HH compliance rate.
26.     infectioncontrolplus.com.au/research/ Allegranzi,B and D. Pittet(2009). A study on role of HH  in healthcare –associated infection prevention “ in journal of hospital infection 73(4):305-315.” Hand hygiene  is the leading measure for preventing  the spread of microbial resistance and reducing health care –associated infection. The main objective of the first global Patient safety Challenge, launched by the WHO is to achieve an improvement in HH practice worldwide with the ultimate gole of promoting a strong patient safety culture.
27.     Alsubaie , S, A. Maither, et al (2013) An observational  study on determinants  of HH noncompliance  in intensive care units .This study estimate HH compliance among health care worker  and examined  factors associated with noncompliance .This study was carried out in 5 intensive care unit (ICUs) at the university  Hospital in Riyadh , Saudi Arabia. Among 242 HCWs A total of 3,940 HH opportunity were observe by 6 trained medical interns and student .The WHO “ five moments of hh ” procedure was used as a basis for the obesvation.overall HH noncompliance was high in ICUs of this hospital. HH compliance was highest among therapists and technician becoce of fewer patient interaction and thus fewer HH noncompliance opportunity per person .
28.     By  Nura Muhammed Abdella, Mekuriaw www.biomedcentral.com/1471-2458/14/96 A Tefera cross section study on HH compliance and associated factor among health care provider in Gonder University Hospital .This study sough to determine HH  compliance and associated factor among health care providers. This study conducted  from April to may,2013 in GUH. Stratified sampling technique was used to select 405health care providers. A total of 405 study particpants were interviewed and observed with a response rate of 96.4% Good HH compliance of health care providers was found to be 16.5%. It is better to give training on HH compliance and provide alcohol based hand rub individual towel or tissue paper for HH compliance.
29.     By Michael Langston Phd, RN H. MARILYN OERMANN Phd, RN ,FAAN www.nursingcenter.com/lnc/jouranalartical?Artical_ID=1143139  A systemic study on effects of  peer feedback on HH in surgical intensive care unit and step- down units The goal of this research was to increase compliance through  both nonpersonal and personal feedback to staff. for the purpose of this study ,personal feedback was defined as any feedback state directly and verbally from one person to another about the individual behavior. A total of 263 preintervention  observation were made by observers .Of these observations, 110 observations of the hh compliance were made after direct patient contact  and 152 were after nonpatient contact.
30.     By Taylor ,J kyie Basco, Roselyne www.freepatentsonline.com/article/Clinical-Laboratory-science/231310602.html An observational study was conducted to evaluate hygiene habits of students with field of stud, gender ,and understanding  of hygiene at a university in Alabama. One hundred student were chosen to participate in this study. Participants  were divided by gender and college major(50 science and 50 nonscience ) .females had a tendency to wash their hands more often than male while visiting the bathroom. Science majors were more likely to wash their hands then nonscience major.   
31.     www.ukessays.com/essays/nursing/hand-htgiene-practices-amng-health-care-workers-nursing-essay.php A descriptive study on HH practice among 30 health care workers in NICU at Hospital Raja Perempuan Zainab ll kota Baharu Kelantan. The researcher  find out that 15 out of 30 respondents wash their hands before handling the infant which is 50% of totals respondent. This technique is widely implemented by the Specialist as 6 out of 15 respondents (40%). It is followed by the Medical officer with 26.6 % which is 4 respondents.
32.     By Juliet Ferrelli and Marge Hardt Dicuccio www.eurekaselect.com/115888/article A study on sustainable HH efforts; a review of successful campaning. The aim of this paper is to provide a review of the hand hygiene literature and to give an example of the use of this literature to create a multimodal sustainable hand hygiene program .The literature offers strategies that have led to successful program in the past .The multimodal use of these strategies was demonstrated in the creation of a successful HH program at one academic medical center.
33.     By freeman, MC, Stocks, ME, Cumming, www.bristol.ac.uk/social-community-medicine/people/julian-p-higgins/pub/32391562 A systemic study on hygiene and health: systematic review of hand washing practice worldwide and update of health effects. Studies with data on observe rates of hand washing with soap published between 1990 and august 2013 were identified from a systematic search of pubmed, Embase and ISI Web of knowledge. From the 42 studies reporting hand washing prevalence we estimate that approximately 19% of the world population washes hands with soap after contact with excreta. Results show that hand washing after contact with excreta is poorly practiced globally, despite the likely positive health benefits
34.     By Lesley T Bourne, N Pilime, M Sambo , A Behr sajcn.co.za/index.php/SAJCN/article/view/760 A study on V. food hygiene and sanitation in infants and young childrens: a paediatric food based dietary guideline. This review utilizes sourced references in both global and local evidence based study by conducting repeated literature searches via PubMed, the Cochrane Collaboration , Google Scholar, EBSCO information Services and United Nations’ agency documents, as well as the “grey” literature . on this basis of the lieterature review, it is proposed that the following message is tested for inclusion in the food based dietary guideline for infants and young children. “hands should be washed with clean water and soap before pertaining, feeding or eating, and after going to the toilet”.
35.     By Juliet Ferrelli and Hardt DiCuccio www.eurekaselect.com/115888/article A study on sustainable hand hygiene efforts; a review of a successful campaign.  
36.     B y Paulson ,Daryl S .Fendler, Eleanor J. www.gojo.com/united-kingdom/proven-results.aspx A  study on a close look at alcohol gel as an antimicrobial sanitizing agent in August 1999. In this study  the healthcare personnel hand wash data showed that the mean log reduction from base line were greatest for the lotion soap with alcohol gel sanitizer , less for alcohol alone and the antimicrobial soap alone and least for the bland soap alone .In term of both microorganism reduction and skin irritation , the most effective production regimen were the use of alcohol gel sanitizer  in combination with either an antimicrobial or a bland soap.
37.     By  Fendler,E. J. Ali., Y.Hammond,B.S.,M.B. CRRN. www.gojo.com/united-kingdom/proven-result.aspx A study on the impact of alcohol hand  sanitiser use on infection rates infection rates in an extend care facility  in june 2002.In this study the primary infection type found were urinary tract with foley catheter, respiratory tract,and wound infection . comparison  of the infection types  and rates for the units where hand sanitiser was used with those for the control units where the hand sanitiser was not used showed a 30.4% decreased in infection rates for the 34-month period in the units where hand sanitizer was used. This study indicates that  use of an alcohol gel hand sanitizer can decease infection rates and provide an additional tool for an effective infection  control programme.  
38.     By  C.A. Kolly, J.W.Arbogast, D.R. Macinga www.gojo.com/united-kingdom/proven-results.aspx  A study on the bacterial shedding and desquamation from the hands of healthcare workers correlates with skin condition in june 2006.in this study bacterial dispersal and quantitative skin measurement were obtained from 86 health care workers over a 3 day period .The results of this hospital study demonstrate that the level of bacteria shed from the hands of health care workers are influenced by the health of the individuals skin ;I .e. dry skin shed more bacteria .This increased bacteria dispersal from dry skin may increase the infection transfer risk for healthcare worker with poor skin condition in the acute care setting.   
39.     By Military Medicine, volume 172 www.gojo.com/united-kingdom/proven-result.aspx A cohort  study on alcohol based instant hand sanitizer use in military settings –a prospective cohort study of  army basic trainees in November 2007.when compared to the control group ,intervention group experienced 40% less respiratory  illness 44% less lost training time ,48% less gastrointestinal illness and 31% fewer health care encounters. These finding suggest that this intervention is capable of significantally reducing illness in this setting has the potential to help reduce absentees in the military work force as a whole.
40.     By  Fendler , E. J. , Dolan,M. J.,Williams.,R.A. www.gojo.com/united-kingdom/proven-result.aspx A  study on hand washing and gloving for food protection :examination of the evidence .This paper presents a review on published literature (medical, microbiology, and food industry) related to all aspects of hand washing and gloving .This review of demonstrates that there is insufficient scientific evidence to support the premise that the use of gloves on transfer of pathogens to food and , consequently ,to support the requirement for no-hand contact with ready –to-eat food.
41.     BY Fendeler,E.J.,Dolan,M.J.,Williams, R.A.,Paulson, D.S. www.gojo.com/united-kingdom/proven-result.aspx A study on hand washing and gloving for food protection: effectiveness. This paper presents a 2-phase study which evaluate the effectiveness of hand washing compare to gloving, under stimulated food service condition. The first phase evaluated the ability of hand contaminant  bacteria to penetrate compromised vinyl glove barrier. The second phase evaluate the microbial contamination level picked up on the hands from handling contaminated hamburger.
42.     By Paulson ,Daryl S,Fendler,Eleanor J,Dolan,Michael J.BS http://portal.ub.tu-berlin.de/primo_library/libweb/action/search.do;jsessionid=6A21428D94F5033A4A158D00A5C6C87A?mode=Basic&vid=TUB&vl%28freeText0%29=Fendler%2C+E&fn=search&tab=tub_all&  A study on close look at alcohol gel as an antimicrobial sanitizing agent in August 1999.the health care personnel hand wash data showed that the  mean log reduction from baseline were greatest for the lotion soap with alcohol gel sanitizer, less for the alcohol alone and the antimicrobial soap alone, and least for the bland soap alone. all of the product regimens showed a low potential for skin irritation. In  term of both microorganism reduction and skin irritation, the most effective product regimen were the use of alcohol gel sanitizer in combination with either an antimicrobial or  a bland soap. 
43.     By Hammond,Brian a;Ali,Yusuf https://www.gojo.com/en/United-Kingdom/About-GOJO/News/Resources/Cold-and-Flu/Research-Studies-HH.aspx A study on effect of hand sanitizer use on elementary school absenteesism in October 2000.The overall reduction in absenteeism due to infection in the school included in this study was  19.8% for schools that used an alcohol gel hand sanitizer compared with the control schools. Elementary school absenteeism due to infection is significantly reduce when an alcohol gel hand sanitizer is used in the classroom as part of a hand hygiene program.
44.     Arbogast JW http://www.gojo.com/international/proven-results.aspx?sc_lang=en A study on effectiveness of a hand care regimen with moisturizer in manufacturing facilities where workers are prone to occupational irritant dermatitis in March 2004.comparison of the change in the skin condition of workers using the full hand care regimen with moisturizer versus a control group using a regimen without moisturizer demonstrated significant(p <.05)improvements in multiple measures  after 1 to 2 weeks. Corneometer readings consistently showed significant improvement for employees using moisturiser, regardless of their work location. Improved skin condition  resulted from the regular use of an effective skin conditioning  hand  moisturizer as part of a skin care regimen in work environments in which workers were prone to experiencing occupational irritant contact dermatitis.
45.     By White Cindy,Kolble,Robin BSN a, Carlson http://www.gojo.com/australia/proven-results.aspx?sc_lang=en A study  the effect of hand hygiene on illness rate among students in university residence halls in October 2003. The overall increase in hand hygiene  behavior and reduction in symptoms illness rates, and absenteeism between the product group and control group was statistically significant. Reduction in upper respiratory illness symptoms ranged from 14.8% to 39.9%. total improvement in illness rate was 20% . the product group had 43% less missed school/work days. Hand hygiene practice were improved with increased frequency of  hand washing through increasing awareness of the importance of hand hygiene, and the use of alcohol gel hand sanitizer in university dormitories. This resulted in fewer upper respiratory- illness symptoms, lower illness rate and lower absenteeism.    

46.     Guinan, Maryellen ,McGu http://www.ncbi.nlm.nih.gov/pubmed/12032496 The  effect of a comprehensive hand washing program on absenteeism in elementary school in June 2002.two hundred ninety students from five independent schools were enrolled in the study.each test classroom ahad a control classroom, and only the test classroom received the intervention (education program and hand sanitizer ).the number of absence was 50.6% lower in the test group.the data strongly suggest that  a hand hygiene program that combines education the use of a hand sanitizer in the classroom can lower absenteeism and be cost effective.
REFERENCES:
1.      Kelemua Guli
2.       Lt V. Anargh.
3.      AL-Naggar R A.
4.      SHANU S. J.
5.      Anita Huis.
6.      S. W. Aboelela.
7.      Roger Ulrich.
8.      “Judy Tran
9.      THIALAND

10.  Hixon S

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