Hygiene in context with corona

Dr. Schumacher’s online portal is aimed at hygiene managers and specialists working in healthcare facilities. Contributions from research and practice are intended to provide well-founded information during the current COVID-19 pandemic – for better implementing hygiene and infection prevention measures.

Co-infections with COVID-19

Risk due to poor oral hygiene

22.07.2020Hygiene management // Oral hygiene

Risk due to poor oral hygiene

COVID-19 patients have an increased risk of contracting bacterial co-infections. Triggers of this may include oral bacteria that accumulate in the oral cavity. They can spread from there to other areas of the body and cause infections. Older people are particularly vulnerable. In order to guard against this, it is important to practice thorough oral hygiene.

Viral respiratory tract infections make patients more susceptible to bacterial co-infections. [1] The co-infections in turn lead to increased disease severity and mortality. A Chinese study demonstrates that during the coronavirus pandemic, 50% of deceased COVID-19 patients had concurrent, secondary bacterial infections. [2] Another Chinese study identified both bacterial and fungal co-infections. [3]

Oral bacteria as triggers of co-infections

The development of co-infections in COVID-19 patients is promoted by oral bacteria that spread throughout the body. Analyses of genomic material from patients with SARS-CoV-2 showed high values of cariogenic and periodontal pathogenic bacteria. This confirms the view that there is a link between the oral microbiome and COVID-19 complications. [4]

In addition, there is evidence that periodontal pathogenic bacteria are involved in the onset and development of respiratory diseases associated with COVID 19. Moreover, these bacteria are associated with chronic-inflammatory systemic diseases including type 2 diabetes, hypertension and cardiovascular diseases. These diseases are therefore often comorbidities, which increase the risk of severe complications and death in cases of COVID-19. [4]

Oral hygiene is particularly important for the elderly

In contrast, other studies demonstrate that the clinical outcomes considerably improve and the mortality decreases for patients suffering from pneumonia when they implement improved oral hygiene. [5] One in ten pneumonia-related deaths among elderly care home residents aged 65 years and older are deemed avoidable thanks to improved oral hygiene. [6]

Conclusion: These connections illustrate just how important thorough oral hygiene is for infection prevention. Good oral hygiene is particularly vital for older patients and residents in nursing facilities in order to reduce the germs in the oral cavity and to prevent the spread of oral bacteria to other parts of the body.


1. Cox M J et al. Co-infections: potentially lethal and unexplored in COVID-19, Correspondence.
www.thelancet.com/microbe Vol 1 May 2020.

2. Zhou F. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054–62.

3. Chen N et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507–13.

4. Patel J / Sampson V The role of oral bacteria in COVID 19, Correspondence. www.thelancet.com/microbe Vol 1 July 2020.

5. Manger D et al. Evidence summary: the relationship between oral health and pulmonary disease. Br Dent J 2017; 222: 527–33.

6. Sjögren P et al. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56: 2124–30.

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COVID-19 prevention

The main problems reported by nursing staff

22.07.2020Hygiene management // Personnel protection

The main problems reported by nursing staff

In order to prevent the spread of SARS-CoV-2, nursing staff must frequently disinfect their hands and in cases of presumed or actual contact with COVID-19, they must consistently wear respirator masks, goggles or visors. A study of 542 nurses in Hubei, China investigated the effect of preventive measures on skin health.

Work-related skin conditions are widespread among health professionals. Between 20 and 30 percent of all people working in patient and elderly care develop hand eczema [1]. The main cause of this is so-called 'wet work'. Wearing gloves for long periods of time and frequent contact with water and soap compromises the natural skin barrier and leads to skin damage on the hands. During this period of coronavirus, skin conditions seem to be increasing. It is not just the hands that are affected, but also parts of the face such as the bridge of the nose, cheeks and forehead.

The bridge of the nose is affected particularly often

A study at a tertiary care hospital in Hubei, China with over 500 nurses [2] came to the conclusion that wearing different respirator masks also left marks on the nurses' skin. According to a questionnaire evaluation, 97% of those asked, who were treating COVID-19 patients, had skin problems. The most common symptoms were a feeling of tightness, dryness, flaky skin and redness. Nearly 70% complained of damage to the skin on the bridge of their nose due to wearing a FFP2 mask. The number of nurses who observed damage to the skin on the bridge of their nose increased considerably when the FFP2 mask was worn for longer than 6 hours, rising to 81.1%.

Wearing time of less than 6 hours recommended

Over half of the study participants complained of skin irritation on their forehead caused by wearing a protective visor. The number of people affected increased by 10% when the protective visors were worn for longer than 6 hours. Only gloves did not show any difference between the extent of the skin irritation and the duration of wear: even after 6 hours, the skin irritation caused by gloves was not significantly worse than after a shorter duration of wear, but it was at an overall high level of 76%.

Preventing skin damage

Hand hygiene was named as the cause of the skin irritation by 60% of the nurses who availed of up to 10 opportunities for hand hygiene. More than 10 hand hygiene opportunities led to skin irritation in almost 80% of the nurses. The study did not mention which products were used for hand hygiene. For the prevention of skin irritation on the bridge of the nose, the authors refer to another study that had positive results through the preventive use of hydrocolloid dressings.


Barrier nursing with respirator masks, protective visors (if applicable) and consistent hand hygiene is essential to prevent the transmission of SARS-CoV-2 when caring for COVID-19 patients. If possible, the nursing staff should not wear the masks for longer than 6 hours. The protective effect of FFP2 masks lasts for a maximum of 8 hours. This duration of wear (link to ) for FFP2 masks should only be fully utilized in case of a shortage of masks and in emergency situations.

The Robert Koch Institute [3] and the AKTION Saubere Hände [4] recommend focusing in particular on the skin compatibility of hand disinfectants. This is usually the case with comprehensively examined products, e.g. by means of VAH certification. However, on the basis of the general ruling (link ) according to the Federal Institute for Occupational Safety and Health (Bundesanstalt für Arbeitsschutz und Arbeitsmedizin, BAuA), not all hand disinfectants have sufficient care properties and thus sufficient skin compatibility.


1. Skudlik C, Dulon M, Wendeler D, John SM, Nienhaus A.
Hand Eczema in Geriatric Nurses in Germany – Prevalence and Risk Factors.
Contact Dermatitis, accepted 22. Oct. 2008

2. Juan Tao. Skin damage among health care workers managing coronavirus disease-2019. Research Letter. J AM ACAD DERMATOL, Mai 2020, Volume 82, No. 5.

3. Robert Koch-Institut. Händehygiene in Einrichtungen des Gesund­heits­wesens (2016). www.rki.de. (Letzter Zugriff 21.07.2020)

4. Wissenschaftlicher Beirat der AKTION Saubere Hände. Positionspapier Verträglichkeit von Händedesinfektionsmitteln. November 2010. Letzter Zugriff 21.07.2020)

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Surface hygiene during the COVID-19 pandemic

Disinfect several times daily

28.05.2020Hygiene Management // Surface Disinfection

Disinfect several times daily

With its new interim guidance regarding surface hygiene in connection with COVID-19, the World Health Organization (WHO) wants to “reduce any role that contaminated surfaces may play in the transmission of SARS-CoV-2”. Surfaces in rooms where a patient with a suspected or confirmed COVID-19 infection is present must, according to the experts, be cleaned and disinfected several times. In this regard, the sequence of cleaning or disinfection is also important.

The role that surfaces which have been contaminated with SARS-Cov-2 play in the transmission of the novel pulmonary disease is not yet fully understood. Previous studies that investigated the survival of the novel coronaviruses were based on experimental studies and laboratory experiments. Now, studies on the real contamination of surfaces in Chinese COVID-19 hospitals and laboratories prove that frequently touched surfaces in particular pose a transmission risk.

Increased frequency of cleaning

With this in mind, the World Health Organization (WHO) has published new interim guidance on surface cleaning and disinfection in connection with COVID-19. Surfaces in facilities associated with the care of suspected or confirmed COVID-19 patients should be cleaned or disinfected up to three times daily. In the guidance published, the WHO goes beyond the daily wipe disinfection recommended by the Robert Koch Institute (RKI).

PDF Download the overview table

PDF Download graphics for individual areas


World Health Organization (WHO). Cleaning and disinfection of environmental surfaces in the context of COVID-19. Interim guidance
15 May 2020

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Expert Hotline:
Disinfection and hygiene
for combating SARS-CoV-2


Standard products vs. general decree formulations: What should be considered?

07.05.2020Hygiene Management // Disinfectants

Standard products vs. general decree formulations: What should be considered?

In order to eliminate gaps in supply chains for hand sanitizers and surface disinfectants, the Federal Institute for Occupational Safety and Health (BAuA) issued a general decree which has been updated several times. This authorizes pharmacies and companies in the pharmaceutical and chemical industry to manufacture biocide products that can be used as hand sanitizers and surface disinfectants. Specialist for hygiene and environmental medicine, Prof. Dr. Günter Kampf, explains what healthcare facilities should keep in mind.

What exactly is the reasoning for the general decrees issued by the Federal Institute for Occupational Safety and Health (BAuA) for the approval of biocidal products for hand sanitizers and surface disinfectants?

Prof. Dr. Günter Kampf: As the competent authority for biocidal products, the BAuA issued a general decree on March 4th 2020 regarding the approval of biocidal products for hygienic hand disinfection, which has been updated three times since it was first issued. The latest version is dated April 9th 2020. Additionally, a general decree on the approval of certain biocidal products for surface disinfection was issued on April 2nd 2020. These general decrees significantly expand the circle of manufacturers of disinfectants for hand sanitizers and surface disinfectants. These products may only be placed on the market for a maximum of 180 days as the biocidal products do not fulfill the conditions laid down in Regulation 528/2012 for granting an approval in the typical way.

Is this also the reason why you recommend that healthcare facilities use approved products from the well-known disinfectant manufacturers wherever possible?

Yes, because the antimicrobial effectiveness of approved, commercially available products for hand sanitizers and surface disinfectants has been extensively tested. Many of these products have been certified by the VAH and the skin compatibility or material compatibility is usually well documented.

How do we know how effective these products are against SARS-CoV-2?

Hand sanitizers and surface disinfectants that have a proven efficacy against enveloped viruses and therefore fulfill the “limited virucidal” efficacy spectrum are to be regarded as generally effective against coronaviruses including SARS-CoV-2.

Recipes for hygienic hand disinfection approved according to the BAuA are also effective against coronaviruses. And yet despite this, you critically evaluate these biocide products for healthcare facilities, why?

For the majority of biocidal products for hygienic hand disinfection mentioned in the general decree, there is no or only a small amount public evidence of efficacy in the form of expert opinions, even if the active substances themselves are mostly well investigated by the manufacturers or in the scientific literature. Based on published data, half of the 8 biocidal products for hygienic hand disinfection from the general decree issued by the Federal Institute for Occupational Safety and Health do not have sufficiently strong bactericidal and levurocidal efficacy within 30 seconds. Three of the formulations must even be applied with 2 x 3 ml over 2 x 30 seconds, which is twice the application time and twice the application volume if you compare it to the majority of commercially available products. On top of this, four of the alcohol-water mixtures from the general decree do not include skin care substances.

What consequences do these shortcomings in the formulations have for the practice with regards to the care of patients?

If these alcohol-water mixtures are frequently used, it is to be expected that employees will suffer from skin irritation. If their skin is irritated, it is less likely that employees will continue to comply with hand hygiene recommendations. This will then increase the patient’s risk of nosocomial infection. Clinics continue to treat critically ill patients whose greatest risk of infection is still bacteria and yeast fungi, and increasingly also multi-resistant bacteria. To prevent the transmission of these germs, employees sanitize their hands up to 60 times per shift. For hand sanitizers to provide reliable antimicrobial effectiveness within 30 seconds as well as having good skin compatibility are of the utmost importance for patient care. In the latest version of the general decree, the biocidal products described above with a lower efficacy within 30 s are therefore only recommended for use outside patient care.

According to the general decree from the Federal Institute for Occupational Safety and Health, four biocidal products should also be considered for hand disinfection in the care of patients in the event of a shortage?

These are two alcohol-water mixtures as well as the modified WHO formulations originally developed by the World Health Organization for countries with limited economic resources to locally manufacture products for the care of patients.

What do you think about biocidal products that are manufactured in accordance with the general decrees from the Federal Institute for Occupational Safety and Health (BAuA) for approval as surface disinfectants?

Biocide products that are temporarily approved by the Federal Institute for Occupational Safety and Health for surface disinfection are based on 80% v/v ethanol, 0.5% w/w sodium hypochlorite or 2.5% w/w chloramine T.

According to the general decree, ethanol can only be used on areas of up to 2 m2 and should be effective over a period of 15 minutes. Therefore, this biocidal product is only suitable for small areas. The manufacturer must also ensure that the ethanol does not contain hazardous impurities. Sodium hypochlorite should only be used against enveloped viruses and should only be applied to non-polluted dry surfaces for 30 minutes.

Aqueous chloramine T solution must also not contain any hazardous impurities and should be effective for over 2 hours. This all means that the practicability and application safety of these three temporarily approved biocidal products must still be critically questioned for routine use on surfaces in the care of patients.

Prof. Dr. Kampf, thank you for speaking with us.

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The new normal

15.05.2020Hygiene Management // Standard Care

The new normal

At the moment, routine operations are gradually being carried out again – even the outpatient departments are filling up more and more. The German Society for General and Visceral Surgery (DGAV e.V.) has given recommendations on how to prevent so-called “nosocomial infection clusters”. Ward modules help to manage the different groups of patients.

With courses of infection that come in waves and different infection frequencies in the general population – as long as there is no vaccine available, COVID-19 patients are part of everyday hospital life. Healthcare facilities will have to live and work with the risk of nosocomial spread of SARS-CoV-2 in the near future. The German Society for General and Visceral Surgery (DGAV e.V.) has issued recommendations that summarize how infections can be prevented as far as possible during the gradual return to standard care.

Ward management during the COVID-19 pandemic

The new normal – working with the coronavirus: Clinics must prepare to treat patients who have different issues or who are not affected by COVID-19 at all – and at the same time keep an eye out for the risk of a nosocomial coronavirus outbreak. Even a single cluster of patients within a hospital can paralyze an entire clinic.

At organizational level, the DGAV experts are suggesting different ward modules for caring for different groups of patients. Depending on the size of the clinic, these can be organized as separate units or as isolation areas within a specialist department. The different units correspond to the groups of patients affected by other issues or not affected by COVID-19: In addition to the isolation area for COVID-19 patients, having wards for COVID-19 positive patients, but also for COVID-19 asymptomatic patients (i.e. those patients who come into hospital treatment due to other indications) are useful. In addition, wards for patients without COVID-19 will have to be managed. The concept reflects the diversity of patient care during the coronavirus pandemic and, at the same time, makes it possible to provide risk-adapted infection protection.

Ward modules or units in specialist departments:

  • The holding area
    New admissions wait for their swab results in the admission unit for inpatients. The patients and all employees shall wear face masks. If the swab is negative, the patients can be admitted by the respective specialist units.
  • The suspected COVID-19 ward
    Here the patients are cared for exclusively under consideration of the barrier care.
  • Ward for patients who test positive for COVID-19
    Isolation ward with barrier care. Depending on the leading clinical symptoms, the isolation ward can be further divided into subareas:
    - internal (COVID-19 patients) or e.g.
    - surgical department (patients who are also COVID-19 positive)
  • Patients without COVID-19
  • Intensive care unit/intermediate care
    - COVID-19 isolation
    - COVID-19 negative area

Furthermore, the professional association recommends that occupancy should not be based on the number of beds available. Rather, the possible capacity of surgical and interventional units (e.g. endoscopy, catheter laboratory, radiology) should be taken as a basis. The number of patients admitted daily is adjusted to the daily capacities. If a renewed increase of COVID-19 patients is noted, this should be included in the overall occupancy planning.

German Society for General and Visceral Surgery (DGAV e.V.) COVID-19 recommendations. Friday, April 24, 2020. https://www.awmf.org Last accessed on 05/14/2020

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Conflict: There are always two versions of the truth

20.05.2020Practice Example // Personal Protection

Conflict: There are always two versions of the truth

There’s no question about it, the coronavirus pandemic has been a stressful situation for many people. This is evident, for example, from conflicts in the workplace. These conflicts usually have basic causes. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Germany, talks about how to recognize what’s behind the conflicts and how to deal with these situations in a better way.

Is there anything we need to know in order to be better prepared for conflict situations at work?

Interpersonal conflicts are first of all characterized by contrasting thoughts, desires and feelings between two people or groups. That being said, it’s not the differences themselves that create the conflict, but the following two aspects: Do the people involved accept that these differences exist and is there a general willingness to face these differences in an open and constructive way?

What are the general signs of a conflict?

Zwischenmenschliche Konflikte sind zunächst einmal durch Unterschiede im Denken, Wollen und Fühlen zwischen zwei Menschen oder Gruppen gekennzeichnet. Doch nicht die Unterschiede an sich machen den Konflikt, sondern folgende zwei Aspekte: Gibt es für die bestehenden Unterschiede eine Akzeptanz und gibt es eine generelle Bereitschaft, diesen Unterschieden offen und konstruktiv zu begegnen?

How do the factors of differences, acceptance and willingness relate to each other and how does this play into conflicts?

To make this clear, I’ve put this into two simple formulas with plus and minus signs. Difference is always a factor in these:

Difference + acceptance + willingness = absence of conflict is possible.

Difference – acceptance – willingness = there is a risk of conflict.

This clearly shows that difference is the main characteristic, but does not necessarily always lead to conflict breaking out. It is rather a question of how people choose to deal with this difference.

Can there also be physical reactions to conflict?

Yes, we all already know three of the reactions to conflict: Fight, flight or shock. Simply put, the brain can switch to “danger mode” during conflicts. Then we react automatically from the limbic system, one of the most primitive areas of the brain. The brain switches to survival mode and controls the supply to the muscle and cardiovascular system. The body reacts instinctively as “thinking” is left in the background.

Fight: Aggression and threatening gestures in volume and posture.

Flight: Run out of the room and slam the door behind you.

Shock: You feel as if you are stuck, unable to move and think.

This also explains why it’s only afterwards that we often realize what we should have said or how we might have acted differently.

So, the differences and physical reactions apply to all conflicts. What else is typical for professional conflicts?

In the professional context we act out of our professional role. The issue of role is so important because many professional conflicts arise from unresolved roles. As a hygiene specialist, for example, I have an understanding of how to act in this role. In addition to this concept of oneself, there are also the expectations that my superiors and colleagues have of my role. Sometimes your own understanding of roles and responsibilities on the one hand and the expectations your superiors have on the other hand clash – this is often not discussed at all and then leads to conflicts.

How can we avoid these conflicts around understanding our roles?

It all comes down to taking the time to clearly coordinate tasks and expectations as this is important. So it’s helpful to clearly clarify with your superiors what you’re responsible for and what your tasks are. You need to know what to do and what not to do in your role. Clarifying expectations is crucial when it comes to avoiding role conflicts. In situations of crisis and pressure, the time factor is a scarce commodity. However, it’s precisely in these kinds of situations that clarifying roles in advance can effectively save time, as energy losses which are caused by misunderstandings do not occur.

Are there any personal conflict strategies that prove helpful in these situations?

You should consider the following points when looking to resolve conflict: There are always two versions of the truth. The truth is never simple or one-sided. There are different points of view and there is at least always a second, third or fourth truth. So if you have a point of view that you can support with good arguments, you can still be open to the perhaps opposite point of view advocated by your counterpart. If you want to solve a conflict constructively, being willing to listen to and understand your counterpart helps. It’s important to remember that you can understand the other person without having to agree with them.

But how do you arrive at a solution when you have two different points of view?

If both people accept that the other has a different point of view, you can then move on and find common ground in spite of your differences. And people can often find ways of doing this without having to harmonize positions. Points of view then become starting points for something new. This constructiveness often results in something that didn’t exist before the conflict. And often this is more than just the lazy compromise, but really leads to something great.

Ms. Lutter, thanks for speaking with us.

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Do surface disinfectants that are used to kill COVID-19 have to contain certain concentrations of active ingredients?

No. Any proven “limited virucidal agent” is sufficient for reliably inactivating enveloped viruses such as SARS-CoV-2. Evidence based on test methods according to the German Association for the Control of Virus Diseases (DVV) or EN 14476 or EN 16 777 (for products without mechanical/spray disinfection) proves that these surface disinfectants reduce viruses by at least 4 log-10 units under the standard conditions that were tested. This means that out of 1 million virus particles, a maximum of 100 remain. The Robert Koch Institute also recommends using limited virucidal agents against COVID-19.

All marketable products that are labeled accordingly achieve the required effectiveness. The fact that the formulations and mixtures of active ingredients may be very different and also contain different concentrations of active ingredients does not make a difference to the effectiveness.

However, if pure active ingredient solutions are used instead of marketable products, certain concentrations have been identified as necessary. This has been shown by a review that evaluated 22 studies. These studies mainly used pure active ingredients in aqueous solution and no marketable products were used. None of the alcohols mentioned in the studies that were examined had a lower or medium active substance content, meaning no statement could be made about their effectiveness against coronaviruses.

With this in mind, the German research team came to the conclusion that when using pure active ingredient solutions, the following concentrations must be used in order to inactivate coronaviruses: Ethanol: 62–71%, hydrogen peroxide: 0.5% or sodium hypochlorite 0.1%. The studies showed that other agents such as 0.05–0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate were less effective.

Conclusion: The review of the studies does not allow conclusions to be drawn about products on the market: Disinfectants available on the market are often have formulations that are much more complex than pure active ingredient solutions in water and are optimized for the individual usage conditions. For example, certain formulations may also contain small amounts of benzalkonium chloride and yet the product is still effective due to the entire formulation. Therefore, it’s not a specified active substance content that makes a marketable surface disinfectant suitable for inactivating SARS-CoV-2, but rather evidence of the limited virucidal agent documented by current test methods and standards.

How to process medical devices that have been in direct contact with COVID-19 patients?

The Robert Koch Institute (RKI) recommends that all medical devices, such as stethoscopes or electrodes, that have been in direct contact with COVID-19 patients should always be used in on a patient-specific basis.

The medical devices must be disinfected after use. During transport, care should be taken to ensure that the transport containers are closed properly and are disinfected on the outside. Thermal disinfection methods are preferred for processing medical devices. According to the RKI, the thermal processes used in washer-disinfectors offer more reliable efficacy, such as reduced impairment due to residual contamination for example.

If thermal processes are not possible, the RKI recommends the use of disinfectants where the limited virucidal agent has been proven to be effective at least.

Robert Koch Institute, recommendations from the Robert Koch Institute on hygiene measures in the treatment and care of patients with a SARS-CoV-2 infection, as of 04/01/2020.
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Hygiene.html (Last accessed on 04/07/2020)
Robert Koch Institute, hygiene requirements for the processing of medical devices, October 1st 2012.
https://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Kommission/Downloads/Medprod_Rili_2012.html (Last accessed on 04/07/2020)

How can laundry and textiles from COVID-19 patients be safely reprocessed?

It is possible to safely reprocess laundry and textiles from COVID-19 patients by following the recommendations of the Robert Koch Institute using a disinfecting laundry disinfection procedure according to the RKI list.
The list describes the different processes and active substances such as the required concentrations of disinfectants and detergents as well as liquor ratio, temperature and exposure time. It is important to remember that the washing machines used for this purpose should also comply with the required parameters. This means that the washing machines must be operated in accordance with the operating instructions, be serviced regularly and checked to ensure they function properly.
COVID-19 patients should use disposable tissues as handkerchiefs. It is recommended that covers that can be disinfected by wiping are used for beds and mattresses.

RKI. List of disinfectants and disinfection methods tested and approved by the Robert Koch Institute. As of: October 31st 2017 (version 17). https://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Desinfektionsmittel/Downloads/BGBl_60_2017_Desinfektionsmittelliste.pdf (Last accessed on 04/07/2020)
Recommendations from the Robert Koch Institute on hygiene measures in the treatment and care of patients with a SARS-CoV-2 infection.
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Hygiene.html (Last accessed on 04/07/2020)

What are the criteria for visitation regulations in care homes and nursing homes during the COVID-19 pandemic?

In principle, the following applies: Whether and under what conditions a care home or nursing home should allow visitors is decided by the home itself, depending on the local situation and possibly in consultation with the public health department.

However, the following aspects should be considered in general:

  • It is preferable that social contact is made via telecommunications, such as telephone calls, and not through personal visits.
  • If someone is displaying signs of a cold, they should stay away from the home. The same applies to people who have been in contact with someone who is infected with COVID-19.
  • If a home decides to permit visitors, each visit must be registered (visitor’s name, date of visit, name of the resident visited). Furthermore, visits should be kept to a minimum and visitors should be informed about the necessary protective measures. This includes maintaining a minimum distance of 1.5 to 2 meters from the resident, wearing protective gowns as well as a face covering and disinfecting your hands when leaving the resident’s room.

Robert Koch-Institute, Prevention and management of COVID-19 in care homes and nursing homes and facilities for people with disabilities, Recommendations for care homes and nursing homes and facilities for people with disabilities and for the public health service, status: 4/14/2020. https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile


Hygienically safe all day long

05.05.2020Hygiene Management // Hand Hygiene

Hygienically safe all day long

In light of the Coronavirus pandemic, nursing staff in particular are required to carefully observe hygiene rules. The hotspots set up in healthcare facilities for hand hygiene during a working day that are vital in preventing infection can be found in a brief summary in our diagram on 05/05.

PDF download info diagramm

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Use without personalization

03.05.2020Practice Example // Reprocessing

Use without personalization

Together with experts in medical technology and hygiene, Helios Kliniken GmbH has developed a safe procedure for reprocessing FFP2 and FFP3 masks. According to their own statements, the processing method exceeds the security level specified by the Robert Koch Institute (RKI) and allows masks to be reused without personalization.

Clinics and other healthcare facilities are still complaining about bottlenecks in personal protective equipment for their employees – there is a lack of high-quality FFP2 masks and FFP3 masks in particular. The methods of reprocessing that are currently being discussed are either considered to be not safe enough or require masks to be personalized before they are used again – a requirement that cannot be met by most healthcare facilities, either technically or logistically.

Now Helios Kliniken, together with experts in medical technology and hygiene, have developed a reprocessing procedure that allows healthcare workers to reuse masks without personalization and yet guarantees a high safety standard. The procedure was shared online in order to help other healthcare facilities to reprocess respiratory masks in a safe and at the same time practicable way.

There are several steps to the procedure:

  • Drying the masks according to the recommendations from the RKI for 35 minutes at 70 degrees in washer-disinfectors
  • Processing in recirculated air convectors at 70–75 degrees for a total of nine hours

Both procedures together achieve a processing value which corresponds to the value A0 of 3000. Such a high A0 value also includes the safe inactivation of thermostable viruses. For comparison, the procedure described by the RKI only achieves an A0 value of 60.

The experts at Helios were able to prove that SARS-Cov-2 and other pathogens can be safely inactivated with the procedure. This meant that FFP2 masks and FFP3 masks no longer had to be reused in a personalized way.

Process instruction by Helios Clinics Germany

PDF download info diagramm

Step 1: Collection

Collecting masks used for protection against Covid-19, sorting out and disposing of visually damaged or soiled masks. Masks worn in connection with TBC (tuberculosis patients) are destroyed directly*.

Step 2: Transport to Central Sterile Services Department (ZSVA)/Processing Unit for Medical Devices (AEMP)

Transporting the masks to the Central Sterile Services Department or to the Processing Unit for Medical Devices in suitable containers (or equipment that is similarly used).

Step 3: Quality Control

Inspect the masks again for contamination and damage.

Step 4: Thermal Processing

Pre-treating the masks according to the recommendations from the RKI: Drying/heating in washer-disinfectors that are already available to at least 65 degrees with a holding time of 35 minutes. The total process time is just under one hour and takes into account the time required to heat up the machines**.

Step 5: Packaging

After another visual inspection is carried out in the Central Sterile Services Department, the masks are then wrapped in a single layer of sterile fleece and packaged in cartons. These cartons are then transferred to another Central Sterile Services Department, where only the next process step 6 is carried out.

Step 6: Thermal Treatment

The masks are heat-treated at 70°C for a holding time of 9 hours in recirculating air ovens (A0 value greater than 3000).

Step 7: Quality Management

Implementing a comprehensive QM system: Samples are taken from each batch, which are tested microbiologically, structurally and with regard to the filter effect. Only after all of this will the masks be approved.

Step 8: Storage

Investigations into the safety of the procedure

The team of experts at Helios carried out multi-stage comprehensive microbiological and structural investigations on masks from various established manufacturers using X-ray microtomography (micro-CT) methods and downstream tests on particle retention capacity (following the FIT test).

The process of “thermal disinfection” inactivates all vegetative microorganisms, including SARS-CoV-2 in the masks. The procedure complies with DIN 149, which requires that new masks must retain their material and shape when subjected to a continuous test at 70°C for 24 hours. In this way, the experts see no change in the masks during their thermal processing. According to Helios, endurance tests have already been initiated.

However, at the moment Helios is assuming that the masks will lose their structure or be damaged after repeated use. This is considered to be a limiting factor for multiple reprocessing. The filter function and the microbiological integrity of the processing, on the other hand, are currently considered to be less problematic.

Further information:


* Although Helios assumes that the downstream processes also ensure that tuberculosis bacteria is eliminated, microbiological detection in the laboratory requires a cultivation period of approx. six weeks. This period of time to provide evidence was not yet available and it was therefore decided to follow this approach.

** For this purpose, special temperature maintenance programs were agreed with the manufacturers of the washer-disinfectors in the air circulation procedure and programmed in the systems.

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Patient protection begins with the nursing staff

03.05.2020Hygiene Management // Hand Hygiene

Patient protection begins with the nursing staff

On this year’s International Hand Hygiene Day, the World Health Organization (WHO) is celebrating the contribution of nurses and midwives. The WHO reminds us that “clean and safe care” begins with the nursing staff. Policy makers should increase nurse staffing levels and provide more support to ensure infection control and improve quality of care.

Half of all healthcare workers worldwide are nurses and midwives. Both professions play a key role in protecting against infection and will be the focus of this year's WHO hand hygiene campaign on May 5th.

To recognize the achievements and responsibilities of nurses, the WHO has dedicated both the International Day of Hand Hygiene and the year 2020 to nurses and midwives.

With this decision, the 72nd World Health Assembly simultaneously celebrates the 200th birthday of Florence Nightingale. The British nurse reformed nursing care and was among the first to recognize that nurses could harm patients by spreading infections.

High-quality, safe care begins with nurses, but it also requires the extensive support of society as a whole. This is why the WHO is again addressing different tasks to different groups in society this year:

WHO 2020 Calls to Action:

• Nurses: “Clean and safe care starts with you.”

• Midwives “Your hands make all the difference for mothers and babies.”

• Policy makers: “Increase nurse staffing levels to prevent infections and improve quality of care. Create the means to empower nurses and midwives in their tasks”.

• Managers for hygiene and infection control: “Support nurses and midwives in providing hygienic care.”

• Patients and families: “Safer care for you, with you.”

International Hand Hygiene Day and COVID-19

Especially during the current Coronavirus pandemic, nurses and other healthcare workers deserve special recognition and appreciation, as the World Health Organization emphasizes: They are the heroes who stand on the frontline to save the lives of patients with COVID-19.

Nursing staff have a special responsibility in the current pandemic. Here, the WHO mentions correct hand hygiene, physical distancing and disinfecting surfaces as the most important measures in containing the Coronavirus pandemic.

Nursing staff need protection too

In order for nurses to be able to perform as well as possible in their important role in infection control, they must be protected themselves. Studies show the stresses to which nurses are exposed:

• Contradictory or inconsistent work instructions instead of targeted interprofessional cooperation

• Postponement of tasks: mainly taking over non-nursing activities

• Interprofessional tensions

• Lack of social support from colleagues and superiors (often in large institutions)

• Confronting death, illness and suffering

• Working extremely long hours

• Emotional and psychological strain and stress

On the other hand, the increase in personnel capacities and a more diverse mix of personnel and qualifications, also known as skill-mix teams, has a positive effect.

This means that there is an increase in:

• The quality of care

• Job satisfaction

The following is reduced:

  • Adverse events in patients who are hospitalized, including nosocomial infections such as catheter-associated urinary tract infections, bloodstream infections and ventilator-associated pneumonia.

World Health Organization (WHO): Save lives: Clean Your Hands. „Nurses an Midwifes Clean care is in Your Hands. Adovocacy Slides. 5 May 2020. https://www.who.int/infection-prevention/campaigns/clean-hands/advocacy-slides-2020_long-version.pdf?ua=1 Last accessed May 2nd 2020

Gill CJ, Gill G. Nightingale in Scutari: her legacy reexamined. Clin Infect Dis. 2005; 40:1799-805 Allegranzi B et al. Infection prevention: laying an essential foundation for quality universal health coverage. Lancet Global Health 2019. 7(6):e698–e700. doi:10.1016/S2214-109X(19)30174-3

Klaus Jacobs / Adelheid Kuhlmey / Stefan Greß / Jürgen Klauber / Antje Schwinger (Hrsg.) Pflege-Report 2016 „Die Pflegenden im Fokus“. Schattauer (Stuttgart) 2016

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Lack of hand hygiene and working long hours

03.05.2020Publications // Studies

Lack of hand hygiene and working long hours

The number of staff suffering from a COVID-19 infection during their nursing or medical work is on the rise. Almost 10,000 cases (situation report dated 05/03/2020) were recently recorded by the Robert Koch Institute with a high estimated number of unreported cases. A current retrospective cohort study at the University Hospital in Wuhan with 3,300 beds provides information about the specific risks for health workers.

The most important risk factors of COVID-19 infection in staff:

• Working in a high risk department

• Working shifts of more than 10 hours

• Lack of hand hygiene compliance before and after contact with patients

• Insufficient personal protective equipment

The development of the pneumonia pandemic COVID-19, caused by SARS-Cov-2, remains a cause for concern. More and more healthcare workers are among those infected. Communicable respiratory diseases are considered to be a particular risk for nurses and physicians. During the SARS outbreak in 2002, approximately 1,725 healthcare workers were infected with Severe Acute Respiratory Syndrome (SARS) while caring for patients who had contracted SARS.

For this reason, greater importance should be placed on the protection of health workers. In order to better understand how staff can be protected, a research team at a 3,300-bed clinic responsible for the medical treatment of COVID-19 patients carried out a retrospective cohort study of 72 health workers. All study participants were suffering from an infection of the respiratory tract or showed typical symptoms.

Participants from different departments were divided into two groups for the study based on their risk exposure:

  • High-risk department

This included staff working in the intensive care unit, the infection ward or the surgical ward or performing activities that generated respiratory aerosols.

  • General groups

This included staff from all other departments where a low risk of infection was assumed.

A follow-up observation confirmed COVID-19 infection in 39% of the participants. Staff were asked to fill out an online questionnaire, which contained detailed information on socio-demographic characteristics, symptoms and course of illness, contact history, occupation, working hours, hand hygiene and the wearing of personal protective equipment (PPE). A total of 72 questionnaires were valid and were included in order to analyze the risk factors. Of these 72 individuals, 39 were assigned to the general low-risk department and 33 to the high-risk department.

Staff from the high-risk department had a risk of developing COVID-19 that was 2.13 times higher compared to the general department group. The higher the number of daily working hours, the higher the risk was that staff would fall ill with COVID-19. This scenario applied to the high-risk department in particular. The researchers assumed that all of the staff there would have been infected if they had had to work 15 hours a day.

According to the authors, the four most important risk factors of COVID-19 infection in staff are working in a high-risk department, working shifts of more than 10 hours, a lack of hand hygiene compliance before and after contact with patients and inadequate personal protective equipment.

Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of Wuhan in China. Clin Infect Dis. 2020 Mar 17 [Epub ahead of print]. https://doi.org/10.1093/cid/ciaa287 Last accessed 5/3/2020

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