Alimentacao Final 2 - Fronteiras XXI...Title Alimentacao_Final_2 Created Date 7/2/2019 12:16:22 PM
Japan Tsunami, 2011 Higienização das mãos: novas fronteiras
Transcript of Japan Tsunami, 2011 Higienização das mãos: novas fronteiras
![Page 1: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/1.jpg)
Japan Tsunami, 2011
Higienização das mãos: novas fronteiras Fernando Bellissimo Rodrigues
WHO Collaborating Centre on Patient Safety
Infection Control & Improving Practices
![Page 2: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/2.jpg)
De novo???
![Page 3: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/3.jpg)
Hand hygiene: a historical perspective
Trotula de Ruggiero, Medical School of Salerno, 12th century
J Matern Fetal Neonatal Med. 2015;28(14):1691-3.
![Page 4: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/4.jpg)
Hand hygiene: a historical perspective
Oliver Wendell Holmes, 1809 - 1894
New England Quarterly Journal of Medicine and Surgery, 1843
![Page 5: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/5.jpg)
Hand hygiene: a historical perspective
Ignaz Semmelweis, 1818 - 1865
Lancet 2011; 377:22-23
![Page 6: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/6.jpg)
Hospital Geral de Viena
(1847)
Hand hygiene: a historical perspective
![Page 7: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/7.jpg)
Hospital Geral de Viena (1847)
Hand hygiene: a historical perspective
![Page 8: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/8.jpg)
N Engl J Med 2012; 366:1-7, January 5, 2012
Hand hygiene: a historical perspective
![Page 9: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/9.jpg)
Hand Hygiene in the Infection Control Guidelines
Guidelines, year Infection(s) addressed Hand Hygiene
recommended? Level of
evidence
ATS/IDSA, 2005 SHEA/IDSA, 2008 Spanish Soc. of Intensive Care Medicine
Ventilator-associated pneumonia
Yes I Not ranked Moderate
SHEA/IDSA, 2008 Catheter-associated
urinary tract infection Yes A-III
CDC, 2011 SHEA/IDSA, 2014
Catheter-related blood stream infection
Yes IB II
SHEA/IDSA, 2014 Surgical site infections Yes II
![Page 10: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/10.jpg)
Hand Hygiene in the Infection Control Bundles
First author, year Infection(s) addressed Hand Hygiene
included?
Tolentino, 2007 Zaydfudim, 2009 Righi, 2014 Al-Thaqafy, 2014 Azab, 2015 Talbot, 2015
Ventilator-associated pneumonia
Yes No Yes No Yes No
Rosenthal, 2012 Navoa, 2013 Leblebicioglu, 2013 Kanj, 2013 Davis, 2014
Catheter-associated urinary tract infection
Yes Yes Yes Yes Yes
Venkatram, 2010 Apisarnthanarak, 2010 Resende, 2011
Catheter-related blood stream infection
Yes Yes
![Page 11: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/11.jpg)
Hand Hygiene in the Guidelines for controlling MDR pathogens
Guidelines, year Pathogen(s) addressed Hand Hygiene
recommended? Level of
evidence
SHEA, 2003 VRE Yes Not ranked
CDC, 2006 All MDR pathogens Yes IB
UK Hospital Infection Society, 2006 SHEA/IDSA, 2008
MRSA Yes 1b A-II
SHEA/IDSA, 2008 Clostridium difficile Yes A-II
CDC, 2012 Carbapenem-resistant
Enterobacteriaceae (CRE) Yes Not ranked
![Page 12: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/12.jpg)
Prevalence of health-care associated infections in
high-income countries
Range: 3.6-12.0%
![Page 13: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/13.jpg)
Range: 5.4-19.1%
Prevalence of health-care associated infections in
low- and middle-income countries
![Page 14: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/14.jpg)
Risk of death comparisons
1
10
100
1.000
10.000
100.000
1 10 100 1.000 10.000 100.000 1.000.000 10.000.000
To
tal
live
s l
os
t p
er
ye
ar
Number of encounters for each fatality
REGULATED DANGEROUS (>1/1000)
ULTRA-SAFE (<1/100K)
Health
Care
Mountain
Climbing
Driving
Chemical
Manufacturing
Chartered
Flights
Scheduled
Airlines
European
Railroads
Nuclear
Power
![Page 15: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/15.jpg)
Health-care associated infections:
clinical impact
![Page 16: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/16.jpg)
Health-care associated infections:
clinical impact
Clin Inf Dis 2001; 33 (suppl. 2):S84-S93
![Page 17: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/17.jpg)
Health-care associated infections:
clinical impact
Portilho online, 27.03.2014
“Uma paciente no Rio de Janeiro teve uma infecção
hospitalar e está com a barriga aberta”
![Page 18: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/18.jpg)
![Page 19: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/19.jpg)
19
Compliance with hand hygiene procedures
25 0
0
25
50
75
100
50 75 100
Opportunities for hand hygiene per hour of care
Com
plia
nce w
ith h
and
hygie
ne
(%
)
Pittet et al, Ann Intern Med 1999, 130:126
Time constraint is the main explanatory factor
![Page 20: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/20.jpg)
Shifting to a new paradigm: from hand washing to hand rubbing with alcohol
Pittet et al, Lancet 2000; 356: 1307–12
![Page 21: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/21.jpg)
70%
Duas décadas de promoção da higiene das mãos nos Hospitais Universitários de Genebra
0.0
20.0
40.0
60.0
0%
20%
40%
60%
80%
100%
44.6 l‰
HH compliance %
HH Campaign
The five moments
H1N1 National HH
campaign Swiss Noso
Hand rub solution consumption
l/‰ days of hospitalization
« Patient participation »
![Page 22: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/22.jpg)
Countries committed to addressing HAI
Countries committed in 2005-2006
Countries planning to commit in 2006
Launch of the
Clean Care is Safer Care campaign WHO HeadQuarters, 13 October 2005
![Page 23: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/23.jpg)
From modern health care settings
©
![Page 24: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/24.jpg)
To settings with limited resources
©
![Page 25: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/25.jpg)
Turmi, Ethiopia
![Page 26: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/26.jpg)
Local clinic in Turmi, Ethiopia
The Hamlin Fistula Hospital in Addis
![Page 27: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/27.jpg)
Bethesda Hospital
![Page 28: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/28.jpg)
PLoS One 9(9): e105866.
Quantidade x Qualidade
![Page 29: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/29.jpg)
Higiene das mãos:
Quando e Como
![Page 30: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/30.jpg)
Avaliação da qualidade da higiene das mãos
através de marcadores indiretos
![Page 31: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/31.jpg)
Volume de álcool?
Avaliação da qualidade da higiene das mãos
através de marcadores indiretos
![Page 32: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/32.jpg)
Should Alcohol-Based Handrub Use Be Customized to
Health-care Workers’ Hand Size?
![Page 33: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/33.jpg)
Should Alcohol-Based Handrub Use Be Customized to
Health-care Workers’ Hand Size?
• Objective: To evaluate the association between the volume of ABHR
taken by HCWs performing hand hygiene and the reduction of the
bacterial load in their hands, depending on their hands size.
• Design/setting: experimental, microbiological laboratory;
• Participants: 15 healthy HCWs with different hand sizes;
• Study protocol (EN 1500 standard):
Measurement of all health-care workers’ hand sizes;
Hand contamination with E. coli ATCC 10536;
Application of isopropanol 60%, from 0mL to 3mL, following the WHO
standard technique;
Fingertips culture.
Infect. Control Hosp. Epidemiol. 2016;37(2):219–221
![Page 34: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/34.jpg)
Infect. Control Hosp. Epidemiol. 2016;37(2):219–221
Should Alcohol-Based Handrub Use Be Customized to
Health-care Workers’ Hand Size?
![Page 35: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/35.jpg)
Infect. Control Hosp. Epidemiol. 2016;37(2):219–221
Should Alcohol-Based Handrub Use Be Customized to
Health-care Workers’ Hand Size?
![Page 36: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/36.jpg)
• There is a direct association between the volume of alcohol-based
handrub taken by healthcare workers performing hand hygiene and the
reduction of the concentration of bacteria in their hands.
• The healthcare workers’ hand size significantly affects that
association.
• These results suggest the need of customizing the volume of alcohol-
based handrub used for hand hygiene, according to the size of the
healthcare workers' hands, for ensure appropriate hand antisepsis and
patient safety.
Infect. Control Hosp. Epidemiol. 2016;37(2):219–221
Should Alcohol-Based Handrub Use Be
Customized to Health-care Workers’ Hand Size?
![Page 37: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/37.jpg)
Por quê pessoas com mãos grandes não conseguem descontaminar
suas mãos mesmo usando 3mL de solução alcóolica?
![Page 38: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/38.jpg)
Revisiting the WHO “How to handrub” standard
technique
ECCMID 2016, Amsterdam, submitted.
WHO fingertips first technique
![Page 39: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/39.jpg)
WHO “How to handrub”:
standard technique x fingertips first
• Objective: To evaluate whether modifying the sequence of the WHO “How to
handrub” standard technique to clean the fingertips first would lead to a
greater bacterial load reduction in hands;
• Design/setting: experimental, microbiological laboratory;
• Participants: 15 healthy HCWs with different hand sizes;
• Study protocol (EN 1500 standard):
Hand contamination with E. coli ATCC 10536;
Application of 3mL of isopropanol 60%, for 30 seconds, on a random order,
once using the WHO standard technique and once using the WHO fingertips-
first technique;
Fingertips culture.
ECCMID 2016, Amsterdam, submitted.
Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology
![Page 40: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/40.jpg)
WHO “How to handrub”:
standard technique x fingertips first
ECCMID 2016, Amsterdam, submitted.
Baseline
(n=16)
Standard technique
(n=16)
Fingertips first
(n=16) P-value
Globally (log10) 6.2 (±0.9) 3.5 (±1.4) 2.7 (±1.3) <0.001a
By hand size
Small (log10) 5.3 (±0.8) 1.9 (±1.3) 1.3 (±1.1) <0.001b
Medium (log10) 6.2 (±0.8) 3.6 (±1.0) 3.1 (±1.2) <0.001b
Large (log10) 6.7 (±0.4) 4.4 (±1.1) 3.3 (±0.8) 0.001b
aFrom a mixed linear model with a random effect on the intercept; bFrom a mixed linear model with a random effect on the intercept and an interaction between the sequence and category of hand size.
0.6
0.5
1.1
Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology
![Page 41: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/41.jpg)
WHO “How to handrub”:
standard technique x fingertips first
In conclusion, WHO fingertips-first technique proved to be significantly more
efficient in cleaning hands than the WHO standard technique.
ECCMID 2016, Amsterdam, submitted.
Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology
![Page 42: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/42.jpg)
What about the duration of handrubbing?
![Page 43: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/43.jpg)
Duration of handrubbing
ECCMID 2016, Amsterdam, submitted.
• Objective: To evaluate the association between the duration of handrubbing by
HCWs and the reduction of the bacterial load in their hands;
• Design/setting: experimental, microbiological laboratory;
• Participants: 15 healthy HCWs with different hand sizes;
• Study protocol (EN 1500 standard):
Hand contamination with E. coli ATCC 10536;
Application of 3mL of isopropanol 60% following the WHO standard
technique, each one with a different duration of handrubbing, from 10 to 60
seconds;
Fingertips culture.
Presented as an oral session at the ECCMID 2016
![Page 44: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/44.jpg)
Duration of handrubbing
ECCMID 2016, Amsterdam, submitted.
0
.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
Ba
cte
ria
l cou
nt m
easu
red
(lo
g10
UF
C)
Baseline 10sec 15sec 20sec 30sec 45sec 60sec
Duration of hand hygiene
Presented as an oral session at the ECCMID 2016
![Page 45: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/45.jpg)
But after all, what is the minimum bacterial reduction to be
accomplished with the hand hygiene procedure to avoid
bacterial transmission?
![Page 46: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/46.jpg)
The transmission study
Presented as an oral session in the ASM - Microbe 2016
![Page 47: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/47.jpg)
The transmission study
• Objective: To evaluate what is the minimum bacterial load in hands to efficiently
accomplish cross transmission skin-to-skin;
• Design/setting: experimental, microbiological laboratory;
• Participants: 6 healthy HCWs with different hand sizes (2 in each category of
small, medium and large);
• Study protocol:
Hand contamination with E. coli ATCC 10536, in growing concentrations;
Hand holding with another HCW whose hands are clean, for 1 minute;
Fingertips culture of both.
Presented as an oral session in the ASM - Microbe 2016
![Page 48: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/48.jpg)
The transmission study
Presented as an oral session in the ASM - Microbe 2016
![Page 49: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/49.jpg)
The transmission study
Presented as an oral session in the ASM - Microbe 2016
![Page 50: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/50.jpg)
The transmission study
• The idea was to evaluate what was the minimum bacterial load in
hands to accomplish cross-transmission skin-to-skin (1 log10);
• Then to compare that number with the average contamination
burden on HCWs hands in clinical practice (± 1-3 log10);
• Then, realize what is the minimum bacterial reduction (2 log10) to be
accomplished with the hand hygiene procedure to avoid bacterial
transmission (“microbiological concept of safe hands”).
• Then, suggest the revision of the norms EN 1500 and ASTM E2755-10.
Presented as an oral session in the ASM - Microbe 2016
![Page 51: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/51.jpg)
Impact of using a device providing individual feedback on health-care
workers hand hygiene behavior: a cluster-randomized clinical trial
On going study, funded by the Swiss National Research Foundation
![Page 52: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/52.jpg)
Impact of using a device providing individual feedback on health-care
workers hand hygiene behavior: a cluster-randomized clinical trial
On going study, funded by the Swiss National Research Foundation
![Page 53: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/53.jpg)
It could be you in this bed...
...so, give the patients the same care you would like to have, perform hand hygiene before touching them!
![Page 54: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/54.jpg)
Em síntese...
• A higienização das mãos ainda é a medida mais simples, segura e efetiva para
a prevenção de todas as infecções hospitalares;
• Enquanto a adesão à higienização das mãos têm aumentado, a qualidade do
gesto ainda têm muito a melhorar;
• Para uma adequada descontaminação de suas mãos:
Use 2-4 mL de solução alcóolica de acordo com o tamanho da sua mão
Friccione todas as partes de suas mãos, mas, sobretudo, não se esqueça das
pontas dos dedos
Friccione suas mãos por pelo menos 15 segundos
Em cada um dos 5 momentos, como você gostaria que fosse feito com você!
![Page 55: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/55.jpg)
![Page 56: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/56.jpg)
![Page 57: Japan Tsunami, 2011 Higienização das mãos: novas fronteiras](https://reader031.fdocuments.us/reader031/viewer/2022012515/618eb2923ad75e592f304035/html5/thumbnails/57.jpg)
Proteja seus pacientes como a quem você quer bem... Use álcool gel antes de tocá-los!