Hand Hygiene Fatigue

Coronavirus has provided the biggest ever media campaign for better hand-washing in hospitals. While the virus did produce a dramatic rise in hand-washing compliance in hospitals, the subsequent fall in performance has been equally dramatic, new study suggest. It confirms what infection control has failed to see for years: good hand-washing is not only a problem of hospital staff attention and habit, but of good leadership and organisational support structure.

The Natural Experiment: A Global Hand-Washing Media Campaign

For years, the infectious disease community has been asking for more public focus on hand hygiene performance. When Covid-19 hit, they got what they had asked for, and more. With every media outlet in the world focused on a virus, it became the biggest hand-washing media campaign ever.

With this much focus on hand-washing, it became possible to ask: โ€œIs it possible to achieve 100 percent hand hygiene compliance during the coronavirus pandemic?โ€ (source). Could we finally reach the goal that had eluded infection control for so many years?

Unprecedented hand-washing awareness

Initial studies were ecstatic. Pilot studies showed โ€œdramatically improved hand hygiene performance rates at time of coronavirus pandemicโ€ (source). But researchers knew, that this could not go on and pleaded that โ€œWe should find ways to maintain and still improve these rates once the COVID-19 pandemic abates.โ€ I donโ€™t know what these researchers were expecting, but the global scare did not last. Of course the media focus eventually faded, and fatigue set in.

Fast Rubbing Fatigue

Looking back at 2020, large-scale and longitudinal studies are now starting to come in, and the results are not encouraging. An unprecedentedly large study counted โ€œover 35 million hand hygiene opportunities (over a) 20-week periodโ€ with new detection technology (source). Basically, monitors were placed in doorways and rub-dispensers, detecting how staff moved through the ward and if they used hand rub or soap when entering and leaving rooms. The below figure is from that study and shows the discouraging result (with my annotation).

The impact of COVID-19 pandemic on hand hygiene performance in hospitals (source)

The figure shows how hand hygiene compliance initially exploded when Covid-19 hit (visualised as school closures), but compliance then fell dramatically again over the next 20 weeks. The figure is very interesting because it shows that in the best possible awareness scenario, with all media focusing on a virus 24/7, hand-washing performance max out at around 62%. That is what we can expect from universal, full focus on hand-washing, and it is not even that great a number.

There can be many explanations for why the compliance falls so dramatically, but the result is supported by research consensus that good hand hygiene compliance can only be sustained for a short time after a media campaign, unless it is also supported by focused leadership, timely evaluations and organisational changes (source). It is time to put to rest the idea that more media attention leads to better hand hygiene performance in hospitals. The ideal information campaign produced little more than a 20-week bump in compliance, and we have seen the same pattern over and over again with other large-scale hand-washing campaigns. Typically, hand-washing information campaigns largely affect the public. In hospitals, they mostly just bombard healthcare workers with information that they already know: it is important to wash your hands. If these campaigns are not followed by organisational action such as management focus, good feedback and evaluation of performance and better work conditions (including actual work time for hand rubbing), hand hygiene compliance will continue at its current mediocre level.


I wrote a masterโ€™s thesis on changing hand hygiene culture in hospitals back in 2015. You can find it here (written in danish, with an english abstract).

Malte Lebahn-Hadidi

Malte Lebahn-Hadidi