Hand Hygiene Recommendations

Coronavirus Disease 2019 (COVID-19)

Guidance for Healthcare Providers about Hand Hygiene and COVID-19

This information complements the Infection Control Guidance and includes additional information about hand hygiene.

Background

Hand hygiene is an important part of the U.S. responseHand hygiene is an important part of the U.S. response to the international emergence of COVID-19.

Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet

eﬀective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations

reﬂect this important role.

The exact contribution of hand hygiene The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between

people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data

demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-

CoV-2.

ABHR eﬀectively reduces the number of pathogensABHR eﬀectively reduces the number of pathogens that may be present on the hands of healthcare providers

after brief interactions with patients or the care environment.

Hygiene

Methods

CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanolCDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings.

Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical

situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating

to hands and are eﬀective in the absence of a sink.

Hands should be washedHands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating,with soap and water for at least 20 seconds when visibly soiled, before eating,

and after using the restroomand after using the restroom. Learn more about hand hygiene in healthcare settings.

Impact to Operations

Healthcare organizations that encounter severe shortages of ABHRHealthcare organizations that encounter severe shortages of ABHR (and have exhausted supply chain

access to eﬃcacious products) may consider local production of formulations as described by the temporary FDA

Policy for Compounding of Certain Alcohol-Based Hand Sanitizer Products . Healthcare organizations should

return to using a commercially produced, FDA-approved product when supplies become available.

The FDA policy allows for ethanol or isopropyl to be used as the active ingredient in ABHR manufactured by

entities that are not currently registered with the FDA to manufacture drugs.

ABHR must be properly formulated with emollients to protect the health of the skin, reduce pathogens on the

hands, and avoid inadvertent exposure to organisms not killed by alcohol (e.g., spores).

[1,2]

[3]

Formulations included in the FDA guidance are consistent with World Health Organization Production Guidance
. These locally produced products are intended for routine healthcare personnel hand cleaning, must
not contain active ingredients other than those speciﬁed in the FDA guidance, and should not take the place of
other regulated skin antiseptics (e.g., surgical hand rub).
To avoid contamination with spore-forming organisms, WHO formulations require a 72-hour post-production
quarantine.
CDC does not have a recommended alternativeCDC does not have a recommended alternative to hand rub products with greater than 60% ethanol or 70%
isopropanol as active ingredients. Benzalkonium chloride, along with both ethanol and isopropanol, is deemed
eligible by FDA  for use in the formulation of healthcare personnel hand rubs.  However, available evidence
indicates benzalkonium chloride has less reliable activity against certain bacteria and viruses than either of the
alcohols. 
The The USP hand sanitizer toolkitUSP hand sanitizer toolkit  formulas formulas have ﬁnal concentrations of 80% ethanol or 75% isopropyl alcohol
concentrations. A ﬁnal concentration of 80% ethanol or 75% isopropyl alcohol recommended in the USP hand
sanitizer toolkit are aligned with World Health Organization (WHO) formulations .
These formulations have been deﬁned at a single concentration value that falls within the range recommended
by CDC.
WHO formulations have been manufactured in countries that do not have access to commercially available
ABHR, evaluated internationally, and are recommended by WHO for use in response to an emerging viral
pathogen, including viruses that are genetically related to, and with similar physical properties as, the SARS-
CoV-2.
References
1.  Kratzel A, Todt D, V’kovski P, Steiner S, Gultrom M, Thao TTN, et al. Inactivation of severe acute respiratory syndrome
coronavirus 2 by WHO-recommended hand rub formulations and alcohols. 
Emerg Infect Dis
. 2020 Jul [
date cited
].
https://doi.org/10.3201/eid2607.200915
2.  Siddharta A, Pfaender S, Vielle NJ, Dijkman R, et al. Virucidal activity of World Health Organization recommended
formulations against enveloped viruses include Zika, Ebola, and emerging Coronaviruses. 
J Infect Dis
. 2017
3.  CDC Core Practices for Infection Prevention in All Healthcare Settings (2017).
4.  Food and Drug Administration. Safety and eﬀectiveness for health care antiseptics: Topical antimicrobial drug
products for over-the-counter human use (ﬁnal rule) .
5.  Centers for Disease Control and Prevention. Guidelines for hand hygiene in healthcare settings (2002).
6.  Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation
with biocidal agents . 
J Hosp Infect
. 2020.
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Page last reviewed: May 17, 2020
Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases