See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/329782823

Bioluminescence to Determine Contamination Differences in Hand Washing

According To Sex

Article  in  Transylvanian Review · November 2018

CITATIONS READS

0 52

5 authors, including:

Ma Fabiola Bustamante Pablo Navarro

Universidad de La Frontera Universidad de La Frontera
13 PUBLICATIONS   8 CITATIONS    71 PUBLICATIONS   218 CITATIONS   

SEE PROFILE SEE PROFILE

Javiera Nuñez Ramón Fuentes

Universidad de La Frontera Universidad de La Frontera
2 PUBLICATIONS   1 CITATION    215 PUBLICATIONS   689 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Clinical & Surgical Anatomy View project

Ortodoncia Preventiva e Interceptiva Infantil View project

All content following this page was uploaded by Ma Fabiola Bustamante on 02 January 2019.

The user has requested enhancement of the downloaded file.

Transylvanian
Review
Vol XXVI, No. 34, 2018

Transylvanian Review
Centrul de Studii Transilvane| str. Mihail Kogalniceanu nr. 12-14, et.5, Cluj-Napoca
Email: transylvanianreview@gmail.com
Online Submission System: http://transylvanianreviewjournal.org/
Fabiola et al. Transylvanian Review: Vol XXVI, No. 34, November 2018

Bioluminescence to Determine Contamination

Differences in Hand Washing According To Sex
1, 2
Bustamante Andrade, M. Fabiola, 1, 2, 3 Navarro Cáceres, Pablo, 4, 5 Núñez Contreras, Javiera, 2, 4, 5
Arellano Villalón, Manuel and 1, 2 Fuentes Fernández, Ramón E.
1
Departamento de Odontología Integral Adulto, Facultad de Odontología, Universidad de La Frontera, Temuco, Chile,
2
Centro de Investigación de Ciencias Odontológicas, Facultad de Odontología, Universidad de La Frontera, Temuco, Chile,
3
Universidad Autónoma de Chile, Chile, 4 Escuela de Odontología, Universidad de La Frontera, Temuco, Chile and 5
Programa de Magíster en Odontología, Facultad de Odontología, Universidad de La Frontera, Temuco, Chile

Abstract

Objective: Bioluminescence detects the amount of adenosine triphosphate (ATP) present on a surface, which is directly
related to biological dirt. This study sought to objectify the degree of hand contamination according to sex in our study
population of 40 dentistry students (63% female - 37% male) with a rapid quantitative measurement technique. Materials and
methods: This included measuring the contamination before and after clinical hand washing(CHW) in the interdigital and
hyponychium regions of both hands using a 3M™ Clean-Trace™ luminometer by reading relative light units(RLU) from a swab
considering pass <250 RLU and fail >251 RLU. Results: More contamination was found among the women prior to CHW, there
being greater contamination in the hyponychium and on the right hand, whereas this contamination was lower in the men and
the left hand was more contaminated in both regions. After CHW, it was found that the men presented greater contamination,
with the right hand being cleaner than the left in both regions, but better in the interdigital region, in the women the right hand
was cleaner, with both hands being cleaner in the interdigital region. Conclusion: We infer that before the CHW the women has
a higher level of contamination than the men (Cortizas & Rumbo 2015, Miranda et al, 2008). After CHW, clean skin was found,
but with greater contamination in the men than the women. There were presented improvements in contamination ranges,
identified and evaluated through bioluminescence, which is consistent with Boyce et al (2009) study.

Keywords: Clinical hand washing, bioluminescence, adenosine triphosphate, dentistry.


Corresponding author: Departamento de Odontología Integral Adulto, Facultad de Odontología, Universidad de La Frontera,
Temuco, Chile.
8909
Fabiola et al.
Introduction
Hand washing (HW) is a vitally important procedure
to avoid the transmission of microorganisms. The main
vehicle of pathogen transmission in healthcare facilities is
via the hands. For this reason, the World Health
Organization (WHO) has carried out campaigns that show
clinical hand washing as a quality indicator that
safeguards the safety of patients and healthcare personnel
to increase awareness and knowledge among the
healthcare team, stimulating the practice of clinical hand
washing (CHW.), and thus avoiding infections, and making
it the most important measure to control healthcare-
associated infections (HAI), Boyce, J.M. & Pittet, D. (2002).
The importance of the CHW. technique, which is a very
simple action, continues to be the fundamental measure to
reduce the rate and propagation of microbial load, product
residues, organic waste, etc., which improves patient
safety in every area of healthcare (Bustamante et al 2018)
In the 21st century, the need to practice HW. Suitably and
with adequate frequency continues to be both a pending
problem in domestic environments and in healthcare
settings worldwide (Miranda et al 2008 & Correa 2011). In
a historical context, HW has not always been related to
patient care. Records published on patients and deceased
in hospitals in medieval Europe were alarming, and it is for
that reason they gained the nickname “pest houses”,
making reference to the plague epidemic that swept across
several countries in Europe and Asia, from which few
patients survived (Griffith, C.J. et al., 2007). An article
written in London in 1850 states that “Hospitals are the
doorway to death for the woman in labor”, alluding to the
high mortality rate for women giving birth in these
institutions. In France in 1870, a hospital was called “the
house of crime” due to the shocking number of women who
died of milk fever on the maternity wards (Grossman LI.
1981, Griffith, C.J. et al 2007). Ignorance of asepsis and
antisepsis measures is found in Dr. Louis I. Grossman’s
Endodontic Practice, where reference is made to it being
common in 1865 to see surgeons sharpening their scalpel
on their boots before entering the operating room, ensuring
the edge necessary to make the incisions, a typical
maneuver of barbers in those times. Such practices are
highly disturbing from the point of view of current
knowledge about infection, sterilization, asepsis and
antisepsis. It is worth noting that Dr. Samuel D. Gross told
his students that whatever was known about antisepsis, in
his opinion it had no value (Guh, A. et al., 2010, Padrón, E.R.
et al., 2015). And he was the most famous surgeon in the
US. In the 1860s. The association between the CHW
technique and the prevention of HAI was recognized more
than 170 years ago by Semmelweis, in 1861 he published
the results of these studies, 662 years after the writings of
Maimonides. However, poor compliance (50-60%)
continues to be a global problem as endorsed in a study by
Helder et al. (2012). Quite often, the only method used to
8910
Transylvanian Review: Vol XXVI, No. 34, November 2018
assess the CHW technique is visual inspection by means of
control test, which does not gauge the microbiological risk.
As a healthcare professional, the dentist is exposed to a
large number of microorganisms originating in the
patient’s blood, oral and respiratory secretions that can be
agents of infectious diseases (Bustamante et al., 2014 &
2018), which underscores the importance of adequate
CHW Thus, historic milestones contribute to the
assessment of HW in healthcare. In the US. in 1961, the
Public Health Service produced a film with
recommendations and techniques for HW (Padrón, E.R. et
al., 2015), recommended for healthcare workers in
hospitals with the common sense characteristic of
Maimonides, the logic of Holmes and the science of
Semmelweis. Between 1975 and 1985 formal guidelines for
CHW were produced for healthcare personnel in contact
with patients, HW with antiseptics, invasive procedures
and high-risk patients (Pittet, D., 2005). From 1988 to 1995
the Association for Professionals in Infection Control and
Epidemiology (APIC.) developed guidelines for HW and
antisepsis. In 1995 APIC produced publications and
standards on the use of alcohol solutions for HW and hand
hygiene (HH.). From 1995 to 1996 the WHO recommended
the use of antimicrobial soap by patients for hand washing
based on the current regulation (Boyce, J.M. & Pittet, D.
2002, Garth D., 2002, Griffith, C.J. et al., 2007 & Correa I.
2011). We know that to have an impact and to help improve
CHW compliance in daily practice, we must use techniques
that demonstrate of the correct use of this technique. This
is why in 1878 Louis Pasteur presented his report “Theory
of germs and their application in medicine and surgery”, in
the ensuing years scientists continued to identify bacteria
and their relation to diseases. In 2010, the Centers for
Disease Control and Prevention (CDC.) identified the main
tools and methods as direct observation from practice, the
use of hyssop and/or agar cultures in equipment,
fluorescent markers and bioluminescent adenosine
triphosphate, etc. to evaluate the cleanliness of surfaces
on a more scientific basis (Guh et al., 2010). Despite there
being a variety of methods used to assess the effectiveness
of the cleaning, there are as yet no standards or guidelines
that provide a definition of what constitutes an
environmentally clean surface. Currently, visual inspection
is used to verify the effectiveness of cleaning protocols, but
it has been proven that this method is not effective.
Therefore, surfaces that appear to be visibly clean can still
harbor significantly high contamination levels (Boyce et al.,
2009). Bioluminescence is a rapid way to quantitatively
measure the organic residues on a surface by quantifying
the amount of ATP expressed in RLU corresponding to a
light emission directly proportional to the amount of ATP.
Present on the tested surface (Boyce et al., 2009). In the
presence of the enzyme luciferase, the ATP collected with
the 3M. ATP. Clean-Trace™ surface swab reacts with
oxygen and luciferin, which causes the emission of yellow-
greenish light photons. The ATP collected with the swab is
used to produce the light signal when using the previously
Fabiola et al.
described luciferin-luciferase system. In order to quantify
the measurement of the swabs, the 3M. Clean-Trace™
luminometer is used, which expresses its measurements
in RLU, with the amount of ATP being directly proportional
to the amount of light emitted, making it a good tool in
healthcare. These rays can be emitted by bacteria, fungi,
yeasts, and bio film and protein residues, among others.
The measurement of the ATP present in all cells as an
energy source (Cortizas Rey & Rumbo Prieto, 2015) makes
it possible to validate the cleaning and washing of different
surfaces. The test can be done in less than 30 seconds,
giving an immediate result, enabling the definition of an
immediate remedial action, as it can be cleaned and then
the surface re-evaluated. This determines the degree of
efficiency or inefficiency of the actions performed
compared with the standards known in other studies
(Cortizas Rey & Rumbo Prieto, 2015), which is of great
advantage from an educational point of view. Using this
tool, the aim of this study is to determine the
contamination before and after CHW in dentistry students
grouped by gender.
Materials and Methods
A simple random sampling, with a cross-sectional,
descriptive, observational-inferential design was
conducted on 2nd-year students in the dentistry program at
the Universidad de La Frontera, Temuco, Chile. The
students who agreed to participate in this study signed the
informed consent, approved by the Scientific Ethics
Committee of the Universidad de La Frontera, according to
resolution contained in file number 006/2015. The sample
was comprised of 40 students, who followed the
instructions required. Students with pathologies that
prevented the bioluminescence test from being performed
Figure 1: Plotting of swabbing of the hyponychium area, right and left hand.
Swab Nº 3 measured the right hand in the interdigital
region, from right to left, dragging the swab across the
entire surface in a rotating motion in the order described
for swab 1 (Bustamante et al., 2018) (Fig 2). Swab Nº 4
8911
Transylvanian Review: Vol XXVI, No. 34, November 2018
were excluded from the study. CHW training for the study
was developed and incorporated into the subject of
Semiology and Basic Nursing. Being used as educational
tools, there were a theoretical class and a practical step of
60 minutes each. The theoretical class included theoretical
and practical concepts of the CHW. technique proposed by
the WHO.: Rub hands palm against palm, rub the dorsum
against the palm of the opposite hand and vice versa, rub
the palms together with the fingers interlaced, rub the
back of the fingers of one hand with the opposite palm,
clasping the fingers, rub the thumbs in a circular motion,
rub the tips of the fingers against the opposite palm and
vice versa (Boyce et al., 2002, Pittet, 2005). The practical
workshop includes clinical activities so the students can
demonstrate that they have reached suitable competency
in CHW. Once they had passed the theoretical and
practical content, the 40 students were called to perform
the study. Two key points were determined for the
sampling: the interdigital area and the hyponychium,
which are defined as the area of the distal edge of the nails
where they join with the finger pads, according to the
description in studies by Boyle et al. The samples were
obtained by rotatory swabbing in each area (Fig 2). The
swabbing occurred before and after CHW in the areas
mentioned and according to the following protocol:
Swab Nº 1 measured the right hand in the hyponychium,
from right to left, dragging the swab across the entire
surface in a rotating motion. First thumb, then index finger,
middle finger, ring finger and little finger (Bustamante et
al., 2018) (Fig 1). Swab Nº 2 measured the left hand in the
hyponychium, from left to right, dragging the swab across
the entire surface in a rotating motion. First thumb, then
index finger, middle finger, ring finger and little finger
(Bustamante et al., 2018) (Fig 1).
measured the right hand in the interdigital region, from left
to right, dragging the swab across the entire surface in a
rotating motion in the order described for swab 2
(Bustamante et al., 2018) (Fig 2).
Fabiola et al. Transylvanian Review: Vol XXVI, No. 34, November 2018

Figure 2: Plotting of swabbing of the interdigital area, right and left hand.

The result was obtained in RLU in 30 seconds after amount of ATP present in the sample of the swab surface.
introducing the swab into the luminometer (3M™ Clean- The results are categorized in Table 1. Pass was <250 RLU
Trace™) (Fig 3), this value is directly proportional to the and Fail >251 RLU.

Figure 3: 3M™ Clean-Trace™ luminometer with post-swabbing surface cultures when measuring the degree of
contamination in RLU.

To assess the results, the software used was 3M™ Clean-
Trace™ (Boyce, J. et al. 2009, Griffith, C. et al., 2007) (Table
1), which provides an advanced data analysis with follow-
up and full trending capability such as automatic report
generation.
standard deviation, a t-test for independent samples, and
Levene’s test of homogeneity of variance. A value of p<
0.05 was chosen as the threshold for significance.
Results

Statistical Analysis The participants, 40 students of both sexes: 25

The data were recorded on a Microsoft Excel® women (62.5%) and 15 men (37.5%). The results obtained
spreadsheet. The data analysis used the statistics with the swabbing prior to CHW revealed dirty skin (Table
program SPSS. Statistics® for Windows®, a descriptive 1), with a mean value of 597.5 RLU. (Fail), a minimum value
analysis to determine the mean and its respective of 248 RLU and a peak value of 4,187 RLU.

Table 1: Luminescence with values in standard RLU for the CHW technique.
RLU values Degree of chromatic acceptance RLU interpretation
<100 Very clean skin
101-250 Clean skin
251-500 Somewhat clean skin (remains of dirt, limited cleanliness)
501-750 Dirty skin
751-1000 Very dirty skin
>1000 Contaminated skin (intolerable level of dirt)

The left hand (mean of 623.91 RLU.) was dirtier than the (559.18 RLU.). In the women the right hand (649.86 RLU.)
right (mean of 571.08 RLU.). In the women the overall mean was more contaminated than the left (621.76 RLU.), no
contamination was greater (635.81 RLU.) than the men statistically significant differences were observed (Table 2).

8912
Fabiola et al. Transylvanian Review: Vol XXVI, No. 34, November 2018
Table 2: Distribution by sex according to mean value in RLU before CHW.
Location Sex Mean value Standard deviation Coefficient of variation p value
Right hand hyponychium Men 480.87 RLU 534.86 111.23 0.24
Women 784.64 RLU 1055.98 134.59
Left hand hyponychium Men 652.80 RLU 733.06 112.30 0.56
Women 824.60 RLU 964.80 117.00
Right hand interdigital Men 503.73 RLU 366.12 72.68 0.96
Women 515.08 RLU 826.32 160.43
Left hand interdigital Men 599.33 RLU 414.59 69.17 0.17
Women 418.92 RLU 385.64 92.07

In the men the contamination was greater in the left hand
(626.07 RLU.) than in the right (492.30 RLU.). The dirtiest
region for both sexes was the hyponychium (685.73URL.),
with the women having 804.62 RLU (very dirty skin) and
the men 566.84 RLU. (Dirty skin) (Table 1). The interdigital
area in the men was a mean of 551.53 RLU. (Dirty skin) and
in the women 467 RLU. (Somewhat clean skin) (Table 1). In
the women in decreasing order: the left hand hyponychium
824.6 RLU, the right hand hyponychium 784.6 RLU. (Very
dirty skin), right hand interdigital 515.1 RLU. (Dirty skin)
and left hand interdigital 418.9 RLU. (Somewhat clean skin)
(Table 1). In the men in decreasing order: the left hand
hyponychium 652.8 RLU., the left hand interdigital 599.3
RLU., right hand interdigital 503.7 RLU. (Dirty skin) and
right hand hyponychium 480.9 RLU. (Clean skin) (Table1).
After CHW, the mean results obtained were 134.76 RLU.
(Pass), which indicated clean skin, with a minimum value
of 14 RLU and a maximum value of 388 RLU. In the women,
the mean was 111.94 RLU and in the men 157.9 RLU both
with clean skin (Table 1). In the women we obtained clean
skin in the left and right hands, respectively (121.54/102.34
RLU.), with smaller ranges, approaching very clean in the
right hand (Table1), than in men with the same trend
(178.97/136.20 RLU.). The least clean region post-CHW in
both sexes was the hyponychium (146.11 RLU.). In the
women, however, in the hyponychium there were
significantly higher mean values (139.82 RLU.) than the
interdigital region (84.32 RLU). (Clean/very clean skin)
(Table 1). In the men the skin was clean with very similar
mean values (152.40/162.77 RLU). When comparing the
hyponychium/interdigital region. Statistically significant
differences were observed (p=0.041) only in the right hand
interdigital region according to the mean value in relation
to the RLU./sex, with a value of 142.73 RLU., in the clean
skin range for the men below the cutoff (<250 RLU.). The
mean value obtained in the women was 78.80 RLU. (very
clean skin), with a coefficient of variation of 48.60%, which
showed a moderate data spread with a standard deviation
of 38.30%, which confirms the tendency to homogeneity in
this group (Table 2 and Table 3). After CHW, approval
ranges were observed in both sexes in the sample. In the
women the interdigital region was less contaminated in
both hands, with a lower standard deviation (right=38.30%,
left=56.41%), which showed a smaller spread in the data,
thus in both swab areas, the spread was very high in the
hyponychium (right =109.49%, left=140.57%) (Table 3). No
statistically significant differences were observed, except
in the right hand interdigital zone with p=0.041. Therefore,
we inferred that there was greater cleanliness in the
women after the CHW technique was performed (Table 3).

Table 3: Distribution by sex according to mean value in RLU after CHW.

Location Sex Mean value Standard deviation Coefficient of variation. p value
Right hand hyponychium Men 129.67 RLU 155.00 119.53 0.93
Women 125.88 RLU 109.50 86.98
Left hand hyponychium Men 175.13 RLU 246.60 140.80 0.73
Women 153.76 RLU 140.57 91.42
Right hand interdigital Men 142.73 RLU 107.63 75.41 0.04
Women 78.80 RLU 38.30 48.60
Left hand interdigital Men 182.80 RLU 173.33 94.82 0.06
Women 89.32 RLU 56.41 63.16

After the CHW technique, the pass/fail cutoff range was
80-90% / 10-20%, both hands presented the highest ranges
of contamination in the hyponychium area with significant
heterogeneity, with a large data spread (Table 3).
Discussion
In terms of applying the CHW technique, according to
the steps proposed by the WHO, it was verified that the
pass/fail range improved significantly in the areas
sampled after its implementation. This study allows us to
infer that prior to CHW, the women have a higher level of
contamination than the men, results that agree with
studies published by Cortizas & Rumbo (2015). It has also
been observed that the left hand was more contaminated
than the right (Miranda et al., 2008). By sex we can
conclude that in women the right hand is dirtier than the
left. In men the dirtiest hand is the left, although the entire
study population is right-handed. The hyponychium zone
was the most contaminated in ranges of very dirty skin in
the women and dirty skin in the men. In the interdigital
area we found in the women less contamination than in the
men. After CHW, clean skin was found, but with greater
contamination in the men than the women. In the women

8913
 View publication stats
Fabiola et al.
both hands presented higher levels of contamination in the
hyponychium. With a statistically significant heterogeneily
and with a very high standard deviation in both sexes. It is
worth noting that the technique incorporates an emphasis
on both locations. However, in the hyponychium area
better access and contact with soap/water is achieved and,
due to the position of the hands, this drains proximally
from the extremity. Only in men this emphasis was
achieved, in the women less contamination was found in
both areas this being significantly less in the interdigital
area, underscoring that this area seems to be more
difficult to access and dry, which would lead us to
conclude that in the women there is greater cleanliness in
CHW, in agreement with studies by Cortizas & Rumbo,
2015. The results obtained after CHW presented
improvements in the contamination ranges, identified and
evaluated through bioluminescence, which is consistent
with a study by Boyce et al. 2009. Bioluminescence has
proven to be a useful and fast tool for healthcare personnel,
making it possible to improve quality processes in
healthcare centers (Boyce et al., 2009).
Acknowledgements
Project DI15-0066 financed by the Dirección de
Investigación, Universidad de La Frontera Temuco, Chile.
References
Boyce, J.M., Havill, N.L., Dumigan, D.G., Golebiewski, M.,
Balogun, O. & Rizvani, R. Monitoring the effectiveness
of hospital cleaning practices by use of an adenosine
triphosphate bioluminescence assay. Infect. Control
Hosp. Epidemiol., 30 (7): 678-84, 2009.
Boyce, J.M., Havill, N.L., Dumigan, D.G., Golebiewski, M.,
Balogun, O. & Rizvani, R. Monitoring the effectiveness
of hospital cleaning practices by use of an adenosine
triphosphate bioluminescence assay. Infect. Control
Hosp. Epidemiol., 30 (7): 678-84, 2009.
Boyce, J.M., Pittet, D., Healthcare Infection Control
Practices Advisory Committee & saves lives. Rev Chil Infectol. 25 (1): 54-7.2008.
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
Guideline for Hand Hygiene in Health-Care Settings.
Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
Society for Healthcare Epidemiology of
America/Association for Professionals in Infection
Control/Infectious Diseases Society of America. M.M.
W.R. Recomm. Rep., 51 (RR-16): 1-45, 2002.
Bustamante, A.M.F., Herrera, M.J, Ferreira, A.R. &
Riquelme, S.D. Analysis of bacterial contamination
produced by aerosols in dental clinic environments.
Int. J. Odontostomatol., 8 (1): 99-105, 2014.
Bustamante F., Núñez J., Crot W., Arellano M, Navarro P. y
Fuentes R, Bioluminiscencia: herramienta de
medición y análisis en lavado de manos clínico
8914
Transylvanian Review: Vol XXVI, No. 34, November 2018
aplicado a la Odontología. Int. J. of Odontostomatol.,
vol. 12 (2): 99-105, 2018.
Cortizas Rey, J. S. & Rumbo Prieto, J.M. Nivel de
contaminación-descontaminación de la epidermis de
las manos medida por luminiscencia. Enferm.
Dermatol., 9 (24): 34-45, 2015.
Correa I., Manuel I.M. Higienización de las manos. El
cotidiano del profesional de la salud en una unidad de
internación pediátrica. Rev Invest Educ. Enferm. 2011,
29 (1): 54-60.
Garth D. Sources of Surgical Infection. Surgery (Oxford).
2002, 20 (1): 179-85.
Griffith, C.J., Obee, P., Cooper, R.A., Burton, N.F. & Lewis,
M. The effectiveness of existing and modified cleaning
regimens in a Welsh hospital. J. Hosp. Infect., 66 (4):
352-9, 2007.
Grossman L.I. Endodontic Practice. 10 ed. Philadelphia:
Lea & Febiger, 1981. p. 228.
Guh, A., Carling, P. & Environmental Evaluation
Workgroup. Options for evaluating environmental
cleaning. Atlanta, Centers for Disease Control and
Prevention, 2010. Available from:
https://www.cdc.gov/hai/toolkits/evaluating-
environmental-cleaning.html
Helder, O.K., Brug, J., Looman, C.W., van Goudoever, J.B. &
Kornelisse, R.F. The impact of an education program
on hand hygiene compliance and nosocomial infection
incidence in an urban neonatal intensive care unit: an
intervention study with before and after comparison.
Int. J. Nurs. Stud., 47 (10): 1245-52, 2010.
Laval E. Apuntes históricos sobre el manejo de la infección
en el desarrollo de la cirugía. Rev. Chil. Infect. 2010,
27 (3): 228-32.
McElroy. WD, Proc Natl Acad Sci, USA 33: 342-5, 1947 /
McCapra F. The chemistry of bioluminoscence. En:
Bioluminiscence in action. Peter J. Herring
Academi.Press London. New York-San Francisco.
1978.
Miranda M., Navarrete L., Semmelweis and his
outstanding contribution to Medicine: Washing hands
Organización Mundial de Salud. Una atención limpia es
una atención más segura. OMS 2015. Disponible en:
http://www.who.int/gpsc/5may/background/es/
Pittet, D., Clean hands reduce the burden of disease.
Lancet, 366 (9481): 185-7, 2005.
Padrón, E.R., Companioni Landín, F.A. & Rosales R.S.A.,
Revista Cubana de Estomatol 2015, 52 (2) abr.-jun.
2015.: versión On-line ISSN 1561-297X, HISTORIA Y
PEDAGOGÍA, Apuntes históricos sobre el lavado de
las manos.