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      Washing Hands according to the WHO Guideline since the COVID-19 Outbreak in the Context of Medical Undergraduates at a Tertiary Care Center: A Descriptive Cross-sectional Study


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          Hand washing is an important preventive measure to avoid transmission of Coronavirus Disease of 2019. Medical students should be acquainted with the World Health Organization's hand-washing guidelines and should follow them to break the chain of spread of the virus. This study aims to find the acquaintance of medical undergraduates with the guidelines and to find out if they have started implementing these guidelines since the corona-virus outbreak.


          This is a descriptive cross-sectional study, conducted among MBBS, BSc and PCL nursing students in first year to internship of a tertiary care hospital from May 2020 to August 2020, and ethical clearance was received from the Institutional Review Committee (ref no: IRC-LMC 11- D/020) of Lumbini Medical College and Teaching Hospital. Data collection was done through online questionnaires. Data analysis of the obtained information was done in Microsoft-excel. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.


          Of 462 respondents, 265 (57.4%) (52.9-61.9 at 95% Confidence Interval) respondents followed the World Health Organization hand-washing guidelines during every hand wash. Among them 172 (37.2%) participants had learned the guidelines through awareness programs. The majority of respondents belonged to 20-25 age groups, 275 (59.5%), and the majority were pursuing an MBBS degree, 360 (77.9%).


          We conclude that a notable number of medical undergraduates have been acquainted with standard hand-washing guidelines since the corona-virus outbreak, but some of them still do not follow the guidelines practically. Therefore, effective and impactful awareness programs need to be launched to improve hand hygiene practices.

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          Most cited references18

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          The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health — The latest 2019 novel coronavirus outbreak in Wuhan, China

          The city of Wuhan in China is the focus of global attention due to an outbreak of a febrile respiratory illness due to a coronavirus 2019-nCoV. In December 2019, there was an outbreak of pneumonia of unknown cause in Wuhan, Hubei province in China, with an epidemiological link to the Huanan Seafood Wholesale Market where there was also sale of live animals. Notification of the WHO on 31 Dec 2019 by the Chinese Health Authorities has prompted health authorities in Hong Kong, Macau, and Taiwan to step up border surveillance, and generated concern and fears that it could mark the emergence of a novel and serious threat to public health (WHO, 2020a, Parr, 2020). The Chinese health authorities have taken prompt public health measures including intensive surveillance, epidemiological investigations, and closure of the market on 1 Jan 2020. SARS-CoV, MERS-CoV, avian influenza, influenza and other common respiratory viruses were ruled out. The Chinese scientists were able to isolate a 2019-nCoV from a patient within a short time on 7 Jan 2020 and perform genome sequencing of the 2019-nCoV. The genetic sequence of the 2019-nCoV has become available to the WHO on 12 Jan 2020 and this has facilitated the laboratories in different countries to produce specific diagnostic PCR tests for detecting the novel infection (WHO, 2020b). The 2019-nCoV is a β CoV of group 2B with at least 70% similarity in genetic sequence to SARS-CoV and has been named 2019-nCoV by the WHO. SARS is a zoonosis caused by SARS-CoV, which first emerged in China in 2002 before spreading to 29 countries/regions in 2003 through a travel-related global outbreak with 8,098 cases with a case fatality rate of 9.6%. Nosocomial transmission of SARS-CoV was common while the primary reservoir was putatively bats, although unproven as the actual source and the intermediary source was civet cats in the wet markets in Guangdong (Hui and Zumla, 2019). MERS is a novel lethal zoonotic disease of humans endemic to the Middle East, caused by MERS-CoV. Humans are thought to acquire MERS-CoV infection though contact with camels or camel products with a case fatality rate close to 35% while nosocomial transmission is also a hallmark (Azhar et al., 2019). The recent outbreak of clusters of viral pneumonia due to a 2019-nCoV in the Wuhan market poses significant threats to international health and may be related to sale of bush meat derived from wild or captive sources at the seafood market. As of 10 Jan 2020, 41 patients have been diagnosed to have infection by the 2019-nCoV animals. The onset of illness of the 41 cases ranges from 8 December 2019 to 2 January 2020. Symptoms include fever (>90% cases), malaise, dry cough (80%), shortness of breath (20%) and respiratory distress (15%). The vital signs were stable in most of the cases while leucopenia and lymphopenia were common. Among the 41 cases, six patients have been discharged, seven patients are in critical care and one died, while the remaining patients are in stable condition. The fatal case involved a 61 year-old man with an abdominal tumour and cirrhosis who was admitted to a hospital due to respiratory failure and severe pneumonia. The diagnoses included severe pneumonia, acute respiratory distress syndrome, septic shock and multi-organ failure. The 2019-nCoV infection in Wuhan appears clinically milder than SARS or MERS overall in terms of severity, case fatality rate and transmissibility, which increases the risk of cases remaining undetected. There is currently no clear evidence of human to human transmission. At present, 739 close contacts including 419 healthcare workers are being quarantined and monitored for any development of symptoms (WHO, 2020b, Center for Health Protection and HKSAR, 2020). No new cases have been detected in Wuhan since 3 January 2020. However the first case outside China was reported on 13th January 2020 in a Chinese tourist in Thailand with no epidemiological linkage to the Huanan Seafood Wholesale Market. The Chinese Health Authorities have carried out very appropriate and prompt response measures including active case finding, and retrospective investigations of the current cluster of patients which have been completed; The Huanan Seafood Wholesale Market has been temporarily closed to carry out investigation, environmental sanitation and disinfection; Public risk communication activities have been carried out to improve public awareness and adoption of self-protection measures. Technical guidance on novel coronavirus has been developed and will continue to be updated as additional information becomes available. However, many questions about the new coronavirus remain. While it appears to be transmitted to humans via animals, the specific animals and other reservoirs need to be identified, the transmission route, the incubation period and characteristics of the susceptible population and survival rates. At present, there is however very limited clinical information of the 2019-nCoV infection and data are missing in regard to the age range, animal source of the virus, incubation period, epidemic curve, viral kinetics, transmission route, pathogenesis, autopsy findings and any treatment response to antivirals among the severe cases. Once there is any clue to the source of animals being responsible for this outbreak, global public health authorities should examine the trading route and source of movement of animals or products taken from the wild or captive conditions from other parts to Wuhan and consider appropriate trading restrictions or other control measures to limit. The rapid identification and containment of a novel coronavirus virus in a short period of time is a re-assuring and a commendable achievement by China’s public health authorities and reflects the increasing global capacity to detect, identify, define and contain new outbreaks. The latest analysis show that the Wuhan CoV cluster with the SARS CoV.10 (Novel coronavirus - China (01): (HU) WHO, phylogenetic tree Archive Number: 20200112.6885385). This outbreak brings back memories of the novel coronavirus outbreak in China, the severe acute respiratory syndrome (SARS) in China in 2003, caused by a novel SARS-CoV-coronavirus (World Health Organization, 2019a). SARS-CoV rapidly spread from southern China in 2003 and infected more than 3000 people, killing 774 by 2004, and then disappeared – never to be seen again. However, The Middle East Respiratory Syndrome (MERS) Coronavirus (MERS-CoV) (World Health Organization, 2019b), a lethal zoonotic pathogen that was first identified in humans in the Kingdom of Saudi Arabia (KSA) in 2012 continues to emerge and re-emerge through intermittent sporadic cases, community clusters and nosocomial outbreaks. Between 2012 and December 2019, a total of 2465 laboratory-confirmed cases of MERS-CoV infection, including 850 deaths (34.4% mortality) were reported from 27 countries to WHO, the majority of which were reported by KSA (2073 cases, 772 deaths. Whilst several important aspects of MERS-CoV epidemiology, virology, mode of transmission, pathogenesis, diagnosis, clinical features, have been defined, there remain many unanswered questions, including source, transmission and epidemic potential. The Wuhan outbreak is a stark reminder of the continuing threat of zoonotic diseases to global health security. More significant and better targeted investments are required for a more concerted and collaborative global effort, learning from experiences from all geographical regions, through a ‘ONE-HUMAN-ENIVRONMENTAL-ANIMAL-HEALTH’ global consortium to reduce the global threat of zoonotic diseases (Zumla et al., 2016). Sharing experience and learning from all geographical regions and across disciplines will be key to sustaining and further developing the progress being made. Author declarations All authors have a specialist interest in emerging and re-emerging pathogens. FN, RK, OD, GI, TDMc, CD and AZ are members of the Pan-African Network on Emerging and Re-emerging Infections (PANDORA-ID-NET) funded by the European and Developing Countries Clinical Trials Partnership the EU Horizon 2020 Framework Programme for Research and Innovation. AZ is a National Institutes of Health Research senior investigator. All authors declare no conflicts of interest.
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            Handwashing practice and the use of personal protective equipment among medical students after the SARS epidemic in Hong Kong

            Background Hand hygiene is an important element of infection control. We conducted 2 surveys on hand hygiene practices and use of personal protective equipment among medical students during and after the outbreak of severe acute respiratory syndrome (SARS) to study its impact on their personal hygiene practice when they contacted patients. Methods Two cross-sectional surveys were conducted among medical students in their clinical training years (years 3-5) in a teaching hospital (at which the first and major SARS outbreak occurred) in March 2003 and August 2004, respectively. Results Prior to the recognition of the SARS outbreak in March 2003, 35.2% of the students washed their hands before and 72.5% after they physically examined patients in the wards. None of the students wore masks during history taking and physical examination. In the 2004 survey, the corresponding proportions were 60.3% and 100%, respectively, and 86.1% and 93.8% of students wore masks during history taking and physical examination, respectively. Attitudes to handwashing and perception of infection risk were not significantly associated with handwashing practice, whereas peer behavior might be a significant influencing factor. Conclusion A significant improvement in compliance with hand hygiene practice was found after the SARS outbreak.
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              Effects of an awareness raising campaign on intention and behavioural determinants for handwashing.

              This article assesses the effectiveness of The Great WASH Yatra handwashing awareness raising campaign in India on changing visitors' intention to wash hands with soap after using the toilet and the underlying behavioural determinants. Interviews based on the RANAS (Risk, Attitudes, Norms, Abilities, Self-regulation) model of behaviour change were conducted with 687 visitors before and after their visit to the campaign. Data showed that a campaign visit had little effect on the intention to wash hands with soap, even when comparing visitors who had actively participated in handwashing games with those who had not. After a campaign visit, knowledge about the benefits of washing hands had increased by almost half a standard deviation. A multiple linear regression analysis revealed that when considering all behavioural determinants change scores simultaneously, they were able to explain 57% of the variance in the intention change score. These findings suggest that substantively changing behaviour requires more than improving knowledge and emphasizing the importance of washing hands. Identifying the crucial behavioural determinants for handwashing may be an important first step in planning effective large-scale promotion programmes.

                Author and article information

                JNMA J Nepal Med Assoc
                JNMA J Nepal Med Assoc
                J Nepal Med Assoc
                JNMA: Journal of the Nepal Medical Association
                Journal of the Nepal Medical Association
                December 2020
                31 December 2020
                : 58
                : 232
                : 1018-1023
                [1 ]Lumbini Medical College and Teaching Hospital , Palpa, Nepal
                Author notes
                Correspondence: Ms. Anuska Khadka, Lumbini Medical College and Teaching Hospital, Palpa, Nepal. Email: misskhadka.anuska1@ 123456gmail.com , Phone: +977-9808847202.
                © The Author(s) 2018.

                This is an Open-Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Original Article

                covid-19 prevention,hand hygiene,medical students
                covid-19 prevention, hand hygiene, medical students


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