University students' hand hygiene practice during a gastrointestinal outbreak in residence: what they say they do and what they actually do.

Introduction

The Centers for Disease Control and Prevention (CDC) estimate that 23 million cases of acute gastroenteritis are caused by norovirus infections annually. In 232 outbreaks of norovirus illness reported to CDC from July 1997 to June 2000, 57% were foodborne, 16% were due to person-to-person spread, and 3% were waterborne; in 23% of outbreaks, the cause of transmission was not determined (CDC, 2006).

Noroviruses are highly transmissible, and as few as 10 viral particles may be sufficient to infect an individual. Norovirus is primarily transferred through the fecal-oral route, though CDC (2006) also notes that environmental and fomite contamination may act as a source of infection. Evidence also exists for transmission due to aerosolization of vomitus that results in droplets contaminating surfaces or entering the oral mucosa and being swallowed. With norovirus possessing a low infectious dose and resistance to some sanitizers and environmental barriers (freezing, heat treatment), its prevention and management pose unique public health challenges.

Background: Outbreak Description

On February 1, 2006, the University of Guelph (located in Ontario, Canada) issued a media release (University of Guelph, 2006) that stated it was working with the Wellington-Dufferin-Guelph Public Health Unit to contain a viral outbreak in a single student residence (population 1,850+). On February 2, 2006, local news media reported that students experienced panic evoked by speculation that the illness outbreak may have been caused by contaminated drinking water, Salmonella spp., or the avian influenza (H5N1) virus. Although several ill students had eaten at one of the residence cafeterias, the outbreak was not believed to be food related (Konieczna, 2006). By February 5, 2006, the Guelph Mercury newspaper disclosed that although the University had provided hand sanitizer dispensers in residence washrooms, until the onset of the outbreak, it was the students' responsibility to provide their own hand soap and towels, potentially amplifying the problem. In total, between January 17, 2006 and February 15, 2006, when the outbreak was officially declared over, 340 cases of gastroenteritis were reported to public health officials, who interviewed 253 students and seven staff. Only four stool samples were collected. Neither the disease agent nor the specific source of the outbreak was definitively identified. Although norovirus was not isolated, it was suspected to be the causative agent (Clark, 2006).

Importance of Hand Hygiene

The World Health Organization (WHO, 2005) defines hand hygiene as any action of hand cleansing, which may include hand washing, antiseptic hand washing, or antiseptic hand rubbing. Several studies have shown the cross-transmission of organisms by hands. For example, Barker and co-authors (2004) suggested that fingers contaminated with norovirus could sequentially transfer virus to up to seven clean surfaces, and that during outbreaks of gastrointestinal illness, effective decontamination of hand and environmental surfaces is necessary to reduce the burden of cross-transmission. People living, traveling, and working in settings such as hospitals, nursing homes, summer camps, cruise ships, and university residences are predisposed to gastrointestinal illnesses based on their propinquity and frequent hand contact with commonly encountered public surfaces where viral contamination and risk of exposure may be greatest (Ho et al., 1989; Jiang et al., 1996; Marx et al., 1999).

Despite awareness of the rationale for hand hygiene--an established social norm (Monk-Turner et al., 2005)--previous research in health care settings has documented poor compliance among health care workers during routine patient care (Health Canada, 1998; Pittet, Mourouga, & Perenger, 1999; Pittet et al., 2000; Pittet et al., 2004). In 2003, a survey sponsored by the American Society of Microbiology (ASM, 2003) found that almost one-quarter (22.6%) of observed travelers (N = 7,541) passing through five major U.S. and one Canadian airport failed to wash their hands after using public washrooms. Specifically, average noncompliance with hand washing among travelers observed in U.S. airports was over one-quarter (26.3%), whereas in Toronto, Canada, a city that experienced a major SARS outbreak the same year, noncompliance was only 4.0%. In 2005, ASM conducted a similar observational study, but instead of the airport setting, individuals (N = 6,366) were observed engaging in hand washing at six public attractions (e.g., museum, aquarium, farmers market) in four major U.S. cities. Results indicated that 17.5% of those observed failed to engage in hand washing (ASM, 2005). Anderson and co-authors (2006), however, observed American college students at a single university in various campus restrooms in four different hand washing settings (soap and water present, hand sanitizer present, visual prompt to wash hands present, and both hand sanitizer and visual prompt present). The study revealed that overall, students practiced good hand hygiene (as defined by the authors with an 81% compliance rate) and that significant gender differences were noted, with a higher percentage of females practicing adequate hand washing than males.

Several researchers suggest that hand hygiene should be an educational priority, especially among healthcare workers (Boyce, 1999; Pittet et al., 2000; Stone, 2001). White and co-authors (2003), in a study documenting the effect of hand hygiene on illness rates among students in university residence halls, concluded that hand hygiene practices improved as awareness of the importance of hand hygiene in university dormitories increased. Nevertheless, Anderson and coauthors (2006) found that in general, visual prompts were ineffective in improving hand-washing practices among college students. Instead, some researchers believe intervention strategies must include the target audience's social context (Ramirez, Velez, Chalela, Grussendorf, & McAlister, 2006). Thus, the objective of this study was to observe student compliance to hand hygiene recommendations during a high-profile outbreak of gastrointestinal illness on a university campus and to examine beliefs and perceptions associated with hand hygiene and other infection control measures in this population following the outbreak.

Social desirability bias refers to the propensity that people have to present themselves in a manner that will be viewed positively by others (Fisher, 1993); to overreport the frequency with which they engage in socially desirable behaviors (e.g., voting, church attendance, hand hygiene); and to underreport the frequency with which they engage in socially undesirable behaviors (smoking, drinking, illicit drug use). When research participants provide socially desirable responses, results can significantly confound the information gained from self-reports (Curtis et al., 1993; Fisher, 1993). Redmond and Griffith (2003) and Medeiros and co-authors (2001) have advised that observational studies provide a more realistic indication of behaviors than what could be collected through an intermediary such as a survey.

Methods

Interventions Provided to Residents

The University of Guelph media release described the symptoms of the gastrointestinal illness, including severe nausea, vomiting, abdominal cramps, and diarrhea, and advised affected individuals to limit public interaction until symptom free for 48 hours. Hand hygiene, either by hand washing or hand disinfection, was stressed as the most important measure to prevent disease transmission; visits to all residence buildings were restricted to residents (University of Guelph, 2006).

During the outbreak of gastrointestinal illness, staff in student housing and student health services placed hand washing posters and outbreak notices in common areas of the residences. In addition to the visual cues, a temporary hand sanitation station located outside of the cafeteria in the residence of primary concern was created. The station included a plastic bottle of hand sanitizing gel (62.0% isopropyl alcohol) and a color poster that featured a message to refrain from entering the cafeteria if feeling unwell, or for those feeling well, to use the hand sanitizer prior to entering.

Observation

Two-hour observation periods took place outside of the cafeteria during dinner (4:30 p.m. to 6:30 p.m.) on February 9 and breakfast (7:30 a.m. to 9:30 a.m.) on February 10; the observer was not hidden but was as discreet as possible. Data on hand hygiene compliance was collected and recorded on a report form that included gender. Compliance with hand hygiene recommendations was defined as rubbing the hands with the hand sanitizing gel before entering the cafeteria. Data were analyzed with SPSS software (Version 13.0). Descriptive statistics were determined and tested for statistical association, using Pearson's Chi-square test.

Self-Report Survey

Two months after onset of the outbreak, a total of 100 students living in the residence most strongly associated with the outbreak were recruited to complete a self-report survey on cognitive factors related to hand hygiene and outbreak prevention and control measures. Participants were recruited before they entered the cafeteria and were selected as part of a convenience sample. Coupons for a cup of coffee or hot chocolate were used to increase participation.

The survey consisted of 25 questions that were a combination of multiple choice, true/ false, open-ended, and Likert scale items. The questions focused on characteristics of the student sample, outbreak reach and control measures, and hand hygiene knowledge. Cognitive factors were also assessed, including attitude toward hand hygiene, perception of difficulty of adhering to hand hygiene, and perception of social norms concerning hand hygiene. Survey construction followed the lead of other research in this area (Pittet et al., 2004) by applying concepts from social cognitive theories. The survey instrument was pretested for clarity and validity with students (N = 26) in a second-year food science course on campus. Questions were subsequently edited and written approval from the research ethics board at the University of Guelph was obtained. Data was analyzed with SPSS software (Version 13.0) for descriptive statistics.

Results

Observation

In two meal periods totaling four hours of observation, the observer recorded 357 opportunities for hand hygiene among students (68.3% female, 31.7% male). Compliance with hand hygiene was 17.4%. No significant (p < .05) differences were found by gender or between observation periods.

Self-Report Survey

Characteristics of Sample

A total of 100 students living in the residence associated with the outbreak completed the self-report survey. The median age of respondents was 19 years (range, 17-23 years). Three-quarters of the participants were female (n = 76). With respect to both age and gender, the profile of students in the study approximately matched that of the student population in the residence where observations were conducted.

Outbreak Reach and Control Measures

Among students surveyed, four-fifths (80.8%) indicated that either a roommate or someone on their floor was sickened during the outbreak. Nearly two-fifths (39.0%) of respondents became ill themselves; of these, just under half (48.7%) reported to Student Health Services, and roughly one-quarter continued to go to class (25.6%) and visit campus eateries while experiencing illness symptoms such as nausea, vomiting, and diarrhea (23.1%).

Respondents were asked to describe both how they first heard about the outbreak at hand and the most effective way to stop the spread of a gastrointestinal outbreak. A content analysis was performed on these open-ended questions. The most common first source of information was word of mouth (54.0%, e.g., "Friends talking about it"), followed by residence personnel (16.8%, e.g., "R.A. voicemail message") and university authorities (11.5%, e.g., "Via e-mail from Student Health Services"). Personal hygiene (47.6%, e.g., "Wash your hands frequently") was the most commonly prescribed method to stop the spread of a gastrointestinal outbreak. Over a quarter (25.9%) of respondents suggested that affected individuals should be kept in isolation or segregated to help limit the spread of illness (e.g., "Isolate those who are sick"). The term "quarantine," though not a control method discussed publicly by health authorities or residence officials, was cited in the responses of 11.0% of the respondents who wrote about isolation. The university's failure to provide proper hand hygiene tools was commented on by some (6.1%) of the respondents (e.g., "Have soap in the washrooms ALWAYS"). Respondents indicated recalling most of the overt communication or intervention strategies that were put in place by health authorities or residence personnel during the period of the outbreak; the most notable was the temporary placement of hand sanitizing stations (99.0% of cases), while the least prominent was public notices advising hand washing (78.8% of cases).

Knowledge and Perception of Hand Hygiene

A series of true/false questions reflecting generic (though debatable [Michaels et al., 2002]) recommendations as posted in residence halls were included to assess respondents' knowledge of hand hygiene protocols. Knowledge scores were calculated by assigning one point per correct answer. This generated scores that could range from 0 to 4 points. The mean knowledge ([+ or -] SD) score for respondents was 3.4 ([+ or -] 0.8) (range, 1-4).

On the backside of the survey, the recommended hand hygiene procedure (as posted in residence halls) was presented to respondents to read before continuing with the rest of the survey. A single item was used to measure perception of knowledge of the procedure using a 7-point scale for answers. The last two points of the scale closest to the positive perception evaluation were considered positive answers; all other points were considered negative answers. Less than three-quarters (69.0%) of students reported that they knew the recommended hand hygiene procedures.

Beliefs and Perceptions Toward Hand Hygiene

Most students reported a positive attitude toward hand hygiene before or after three types of behaviors that may have helped to spread the gastrointestinal illness: handling food or eating (85.0%), using the bathroom (98%), and nose blowing, sneezing, and coughing (87.0%). Few students reported that they were aware of a risk for cross-transmission posed with three common scenarios existing in residence: using tongs and serving spoons at the salad bar (40.0%), pushing the metal turnstile bar to enter the cafeteria (49.0%), and shaking/ holding hands (65.0%). Over three-quarters of students, however, recognized a risk for cross-contamination through the actions of serving or preparing food (77.0%).

A high proportion of students indicated that they adhered to hand hygiene during the outbreak (83.0%), but less than half indicated that their peers did the same (45.5%). Only 14.0% of students reported believing that their hand hygiene had an effect on that of their peers, and even fewer (10.0%) reported that the hand hygiene of peers had an effect on their own.

Despite the unrest caused by the outbreak, less than three-quarters of students (67.0%) reported that the outbreak had an effect on their hand hygiene (i.e., increased practice), and only 37.0% indicated that they were motivated to improve their adherence level.

Most students perceived at least one barrier to following recommended hand hygiene procedures. The most notable was the lack of soap, paper towels, or hand sanitizer (90.6% of cases). Additional perceived barriers were the notion that hand washing causes irritation and dryness (28.1% of cases), laziness (24.0%), and forgetfulness (22.9%). Lack of knowledge of the recommended hand hygiene procedures was considered a low barrier (6.3% of cases).

Discussion

Results of the self-report survey indicated students followed recommended hand hygiene procedures. Thus, it is thought that those trying to control the suspected virus communicated risk effectively. Observed low hand washing rates, however, would suggest otherwise. The behavior changes that communicators hoped to achieve did not for the most part transpire, possibly helping to fuel the outbreak.

The effectiveness of prevention and health promotion messages depends heavily on the compelling nature of such messages. A common intervention error is to provide the tools that enable behavior change (e.g., soap, paper towels, hand sanitizer) and health education material, and then assume (alone or combined) that behavior will be positively changed. Careful evaluation to determine whether such efforts are effective must be included in crisis prevention and planning. Because communication materials also exist within a cultural context, crisis management stakeholders must understand how a given population relates to a health behavior and apply this knowledge in planning and activities (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2002). In this case, prevention and health promotion messages had to appeal to college students or the "MTV generation"--a demographic used to consuming mass quantities of fast-paced sound, graphics, and animation (Guzdial & Soloway, 2002), not a poster with a duck on it that plays down the risk.

The mediums for rapid dissemination of outbreak information and health care material are well documented, and today, technology forms the foundation of most college students' interactions. Although word-of-mouth appeared to be the primary source of outbreak notification and information in this study, college students are known to be voracious users of the Internet and social networking tools. Students are accustomed to using the Internet as a two-way information exchange (Thompson, 2007). In addition to word-of-mouth and traditional print material, instant messaging, text messaging, and social networking sites such as MySpace.com and Facebook.com need to be explored by crisis management personnel because of their strong influence in the lives of today's students (Powell, Surgeoner, Wilson, & Chapman, 2007).

Data collection through observation was completed without the knowledge and permission of students, so follow-up surveys could not be paired. Thus, while observed compliance with hand hygiene among students was less than 20.0%, even though more than 80.0% of surveyed students indicated adhering to recommended hand hygiene procedures during the outbreak, no definitive statement can be made about the relationship between actual and self-reported practices. These findings nevertheless agree with a review of studies of hand washing practices in the community conducted by Fung and Cairncross (2007) that showed recall bias and overreporting of socially desirable answers (e.g. "I always wash my hands").

In the cafeteria where students were observed entering, whole fruit and breads were displayed for sale and picked over in self-serve baskets and bags. Additional transmission pathways with significant hand contact were shared utensils at the self-serve salad bar, scoops for ice cream in reach-in freezer cases and bulk bins, and salt and pepper shakers in the main dining area. Although the initiating event is often the contamination of a common vehicle (food or water), person-to-person spread likely extends the duration of an outbreak (CDC, 2001). Hence, efforts to prevent both the initial contamination of the implicated vehicle and subsequent person-to-person transmission need to be explored.

No significant gender difference was noted in the compliance of the observed recommended hand hygiene procedure. Gender differences in the compliance of hand washing practices have been noted in at least eight past studies, including both of the ASM studies mentioned previously; women are more likely to practice hand hygiene (Fung & Cairncross, 2007).

One of the limitations of this study was that the researchers were unable to document student hand hygiene practices both before and after entering the observed area. It is possible that students washed their hands before leaving their rooms. Because of the building layout, all students entering the cafeteria came from outside (coming from classes) or from the dormitory rooms, which in both cases required opening at least two sets of double doors, the use of at least one handrail, and turning a steel turnstile to enter the cafeteria. These are all ample opportunities for cross-transmission and the self-report survey results indicated that few students were aware of this.

Although the researchers made an anecdotal note that students observed entering the cafeteria in groups were more likely to engage in the recommended hand hygiene procedure than those entering unaccompanied, self-report data obtained from the present study would suggest that social pressure is not a conscious-based predictor of compliance. Previous hand hygiene studies have shown, however, that having an observer present made it more likely that a person would wash his or her hands (Edwards, Monk-Turner, Poorman, & Rushing, 2002; Pittet et al., 2004). Therefore, hiring an individual--possibly someone who is indigenous to and influential among the population served (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2002) to assist in manning hand hygiene stations and common washrooms--might lead to desired behavioral changes.

Conclusion

University residences present unique challenges for crisis management teams to mitigate the spread of an infectious agent like norovirus (Clark, 2006). In addition to providing the tools for hand hygiene (running water, soap, and paper towels), even in the absence of an outbreak, a well-conceived, current, and thorough crisis communication and management plan must be present in every residence that

* provides a multifaceted approach to rapid dissemination of outbreak information;

* provides compelling messages that are culturally appropriate and emphasize the need for proper hygiene measures after attacks of diarrhea and vomiting;

* identifies individuals who can act as "insiders" and advise on what is and is not culturally appropriate for the target audience, and who can be used in the communication campaign to influence desirable behaviors; and

* identifies potential sources for spread of infection in common eating areas.

REFERENCES

American Society for Microbiology. (2003, September 15). American Society for Microbiology Survey reveals that as many as 30 percent of travelers don't wash hands after using public restrooms at airports. [Press Release]. Retrieved October 3, 2007, from http://www.asm. org/Media/index.asp?bid=21773

American Society for Microbiology. (2005, September 21). Women better at hand hygiene habits, hands down. [Press Release]. Retrieved October 3, 2007, from http://www.asm.org/Media/index. asp?bid=38075

Anderson, J.L., Cole, M., Reggie, I.L., Perez, E., Phillips, S., Warren, C.A., Wheeler, J., & Misra. (2006, November). Is hand hygiene a social norm with a college population? Paper presented at APHA 134th Annual Meeting and Exposition, Boston, MA.

Barker, J., Vipond, I.B., & Bloomfield, S.F. (2004). Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. Journal of Hospital Infection, 58(1), 42-49.

Boyce, J.M. (1999). It is time for action: Improving hand hygiene in hospitals. Annals of Internal Medicine, 130(2), 153-155.

Centers for Disease Control and Prevention. (2001). Norwalk-like viruses: Public health consequences and outbreak management. Morbidity and Mortality Weekly Report, 50(RR-9), 1-24.

Centers for Disease Control and Prevention. (2006, August 3). Norovirus: Technical fact sheet. Retrieved October 3, 2007, from http:// www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm

Clark, C. (2006, September). The unique culture of a university in terms of norovirus outbreak. Paper presented at the 67th Annual Ontario Branch (Canadian Institute of Public Health Inspectors) Educational Conference, Niagra Falls, Ontario, Canada.

Curtis, V., Cousens, S., Mertens, T., Traore, E., Kanki, B., & Diallo, I. (1993). Structured observations of hygiene behaviors in Burkina Faso: Validity, variability, and utility. Bulletin of the World Health Organization, 71(1), 23-32.

Edwards, D., Monk-Turner, E., Poorman, S., & Rushing, M. (2002). Predictors of hand-washing behavior. Social Behavior and Personality, 30(8), 751-756.

Fisher, R.J. (1993). Social desirability bias and the validity of indirect questioning. Journal of Consumer Research, 20(2), 303-315.

Fung, I.C-H., & Cairncross, S. (2007). How often do you wash your hands? A review of studies of hand-washing practices in the community during and after SARS outbreak in 2003. International Journal of Environmental Health Research, 17(3), 161-183.

Guzdial, M., & Soloway, E. (2002). Teaching the Nintendo generation to program. Communication of the ACM, 45(4), 17-21.

Health Canada. (1998). Hand washing, cleaning, disinfection and sterilization in health care. Canada Communicable Disease Report, 24(S8), 1-66.

Ho, M.S., Glass, R.I., Monroe, S.S., Madore, H.P., Stine, S., Pinsky, P.F., Cubitt, D., Ashley, C., & Caul, E.O. (1989). Viral gastroenteritis aboard a cruise ship. The Lancet, 2(8669), 961-965.

Jiang, X., Turf, E., Hu, J., Barrett, E., Dai, X.M., Monroe, S., Humphrey, C., Pickering, L.K., & Matson, D.O. (1996). Outbreaks of gastroenteritis in elderly nursing homes and retirement facilities associated with human caliciviruses. Journal of Medical Virology, 50(4), 335-341.

Konieczna, M. (2006, February 2). Norwalk outbreak has students spooked: University administrators advising visitors to stay away from all campus residences. Guelph Mercury, p. A4.

Kreuter, M.W., Lukwago, S.N., Bucholtz, D.C., Clark, E.M., & Sanders-Thompson, V. (2002). Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Education and Behavior, 30(2), 133-146.

Marx, A., Shay, D.K., Noel, J.S., Brage, C., Bresee, J.S., Lipsky, S., Monroe, S.S., Ando, T., Humphrey, C.D., Alexander, E.R., & Glass, R.I. (1999). An outbreak of acute gastroenteritis in a geriatric longtermcare facility: Combined application of epidemiological and molecular diagnostic methods. Infection Control and Hospital Epidemiology, 20(5), 306-311.

Medeiros, L.C., Kendall, P., Hillers, V., Chen, G., & Dimascola, S. (2001). Identification and classification of consumer food handling behaviors for food safety. Journal of the American Dietetic Association, 101(11), 1326-1339.

Michaels, B., Gangar, V., Schultz, A., Arenas, M., Curiale, M., Ayers, T., & Paulson, D. (2002). Water temperature as a factor in hand-washing efficacy. Food Service Technology, 2, 139-149.

Monk-Turner, E., Edwards, D. Broadstone, J., Hummel, R., Lewis, S., & Wilson, D. (2005). Another look at hand-washing behavior. Social Behavior and Personality, 33(7), 629-634.

Pittet, D., Mourouga, P., & Perenger, T.V. (1999). Compliance with handwashing in a teaching hospital. Annals of Internal Medicine, 130(2), 126-130.

Pittet, D., Hugonnet, S., Harbath, S., Mourouga, P., Sauvan, V., Touveneau, S., & Perneger, T. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 356(9238), 1307-1312.

Pittet, D., Simon, A., Hugonnet, S., Pessoa-Silva, C.L., Sauvan, V., & Perneger, T.V. (2004). Hand hygiene among physicians: Performance, beliefs, and perceptions. Annals of Internal Medicine, 141(1), 1-8.

Powell, D.A., Surgeoner, B.V., Wilson, S.W., & Chapman, B.J. (2007). The media and the message: Risk analysis and compelling food safety information from farm-to-fork. Australian Journal of Dairy Technology, 62(2), 55-59.

Ramirez, A.G., Velez, L.F., Chalela, P., Grussendorf, J., & McAlister, A.L. (2006). Tobacco control policy advocacy attitudes and self-efficacy among ethnically diverse high school students. Health Education and Behavior, 33(4), 502-514.

Redmond, E.C., & Griffith, C.J. (2003). Consumer food handling in the home: A review of food safety studies. Journal of Food Protection, 66(1), 130-161.

Stone, S.P. (2001). Hand hygiene--The case for evidence-based education. Journal of the Royal Society of Medicine, 94(6), 278-281.

Thompson, J. (2007). Is education 1.0 ready for web 2.0 students? Innovate, 3(4). Retrieved May 15, 2009, from http://74.125.47.132/ search?q=cache:0tNxcomd4VwJ:csdtechpd.org/file.php/1/moddata/ glossary/4/26/Is_Education_1.0_Ready_for_Web_2.0_Students-. pdf+Is+education+1.0+ready+for+web+2.0+students%3F &cd=3&hl=en&ct=clnk&gl=us&client

University of Guelph. (2006, February 1). Viral outbreak on campus (Campus Bulletin). Retrieved October 2, 2007, from http://www. uoguelph.ca/news/2006/02/viral_outbreak.html

White, C. Kolble, R., Carlson, R., Lipson, N., Dolan, M., Ali, Y., & Cline, M. (2003). The effect of hand hygiene on illness rate among students in university residence halls. American Journal of Infectious Control, 31(6), 364-370.

World Health Organization. (2005). WHO guidelines on hand hygiene in health care (advanced draft). Retrieved June 22, 2007, from http://www.who.int/patientsafety/information_centre/ ghhad_download/en/index.html

Brae V. Surgeoner, MS

Benjamin J. Chapman, PhD

Douglas A. Powell, PhD

Corresponding Author: Douglas A. Powell, Associate Professor, Scientific Director, International Food Safety Network, Kansas State University, Department of Diagnostic Medicine/ Pathobiology, Manhattan, KS 66506. E-mail: [e-mail].