The difference in the surface coverage ratio by an adapted hand rubbing technique and the WHO technique; a randomized group comparison

doi:10.21203/rs.3.rs-1767100/v1

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The difference in the surface coverage ratio by an adapted hand rubbing technique and the WHO technique; a randomized group comparison

https://doi.org/10.21203/rs.3.rs-1767100/v1

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Background

The adapted 6-step without interlock (A6Sw/oI) hand rub technique, commonly practised in Japan, adds the “wrist” but omits the “interlock” step compared to the WHO 6-step technique (WHO6S). The first objective of this study was to assess the differences in the efficacy of the two techniques regarding surface coverage, considering hand size. The second objective was to analyse the coverage differences between hand sizes.

Methods

Participants were randomly assigned to either one of the WHO6S or the A6Sw/oI. The coverage ratios of the anatomically divided sections of the hands were evaluated by a digital device using artificial intelligence technology.

Results

The mean dorsum coverage by WHO6S and A6Sw/oI was 90.6% vs 88.4% (p < 0.01), and the ratio of the participants with insufficient coverage of the dorsum of the four fingers was 0.0%-7.4% vs 28.2–51.4% (p < 0.001). Dorsum coverage varied largely between hand size for both techniques, and significant differences were found between small and large hands.

Discussion and Conclusion

The WHO6S was superior to the locally adapted technique regarding hand surface coverage. Hand size should be considered when assessing coverage differences between procedures.

Hand hygiene

Alcohol based hand rub

Hand rubbing technique

WHO 6 steps

Guideline adaptation

Hand size

Hand hygiene (HH) plays a key role in preventing hospital-acquired infections, as it prevents the spread of infectious organisms from patient to patient through the contamination of healthcare workers’ hands [1, 2, 3]. HH by alcohol-based hand rub (ABHR) is widely recommended in Japan; however, national or subnational HH initiatives that are guideline-based or evidence-based still do not exist. Most Japanese healthcare workers refer to the diagram shown on the website of the Japanese Ministry of Health, Labour and Welfare [4] to practise the hand rubbing procedure. This locally adapted diagram consists of 6 steps, which is the same number as that of the World Health Organization (WHO) 6-step technique (WHO6S) [5], but the difference is that the “interlocking” step is replaced by the “wrist” step. There is no publication to explain why and when this replacement occurred. However, this adapted 6-step without interlock technique (A6Sw/oI) is often considered to be officially recommended and is generally used to train health care workers (HCWs) and students in most Japanese health care and educational facilities. Not including the interlocking step, the step to cover the dorsum of the fingers, is not unique to Japan; for example, a subnational programme currently presents a 5-step diagram similar to the WHO6S without the interlocking step [6]. Theoretically, lacking the “interlocking” step in the locally adapted technique would lead to insufficient coverage of the dorsum of the four fingers. However, to date, there is no evidence that compares the efficacy of the two techniques. The primary objective of this study was to assess the difference in the efficacy of the WHO6S and the A6Sw/oI considering hand size, using a newly developed device using artificial intelligence technology. The secondary objective was to compare the coverage between the techniques according to hand size.

Trial design

A parallel randomized group comparison, allocation ratio of 1:1.

Participants

All full-time workers of the facility, including the non-HCWs, were enrolled in the study as a part of the second mandatory infection control training of the fiscal year, from November 2021 to January 2022. Workers with major anomalies and deformations and/or severe hand eczema with exudates were excluded from the data collection.

Settings

The study was conducted at NHO Shimoshizu National Hospital, which has 440 beds and is located in eastern Japan. The hospital is not a typical 'teaching hospital', except for some specialities that have limited teaching functions. The hospital has adopted the WHO HH strategy since 2014 [7], but until 2019, the A6Sw/oI diagram was used throughout the hospital. From 2020, the infection control team changed the diagram to an adapted version of the WHO6S including interlock with some minor changes (fingertips first, thumbs second) throughout the hospital. All participants had received their first mandatory infection control training on this adapted version including interlock procedure in May 2021. The participants were told that they would be randomly assigned to one of the two techniques that were both officially recommended but were both slightly different from the technique that was taught in the training session in May. It was made clear that their data will be used in a study, but the purpose of the study was disclosed. The participants were not rewarded or punished by the results but were given feedback on the results and personal advice on their performance by looking at their coverage data. The participants each came to the infection control room separately according to the predetermined schedule, where all the data were taken by the same investigator throughout the study.

Interventions

Hand rubbing procedures

One full push, 1.1 ml of fluorescent-marked formula, a 1:1 mixture of fluorescent dye and gel type ABHR (Pure Rubbing, 83% ethanol with lipidure, Schuelke Japan, Tokyo, Japan), was given to each participant by an investigator. The participants were requested to hand rub exactly according to their assigned technique, either (1) WHO6S or (2) A6Sw/oI, by looking at the corresponding diagram poster carefully, regardless of the hand rubbing technique in their daily practice. Hand rubbing was performed along with the investigator who performed the same procedure, standing by the side and saying out loud only the key words written on the poster. Each hand rubbing procedure took approximately 25 seconds to complete 6 steps, approximately 4 seconds per step. Individual comments or advice regarding the hand rubbing technique were not given prior to or during the rubbing process. These were given personally to the participants just after the analysed data were obtained, looking together at the digital images and the score of their result. Therefore, no corrections were made during the rubbing procedure, and performances with differences from the diagrams were included in the study.

Coverage ratio assessments

The efficacy of each hand rubbing procedure was evaluated by SCORE! (Moraine Corporation, Tokyo, Japan). SCORE! is a new digital device using artificial intelligence technology that anatomically divides the hands into 72 sections and quantifies the coverage ratios based on image analysis. This consists of a black box with ultraviolet (UV) lighting inside and a dedicated iPhone with the SCORE! application installed. After hand rubbing with the fluorescent-marked ABHR formula, the participants inserted their hands into the box, and digital images of the palmar and dorsal sides of both hands were recorded and sent to the server along with the participant’s ID. The image analysis server recognised the shape of the palm and the dorsum of both hands from the image, divided the image into 18 sections each, for a total of 72, and calculated the ratio of the fluorescently marked ABHR coverage of each section; the fluorescently marked ABHR covered area as the numerator, and the total area of the divided section as the denominator. The anatomical segmentation is similar to that of a previous study by Ghazali et al. [8], which was validated in their study. Then, a heatmap, colour-coded in five stages based on the uncovered percentage score (0-10, 10-15, 15-23, 23-32, 32-100%) for each section was generated; and a quantitative evaluation was obtained. The total coverage (%) for the palm and the dorsum was also automatically calculated as the participant’s “total score”. The total palm/dorsum coverage calculations by the original SCORE! programme included all 72 sections, but for this investigation, the total score was recalculated by excluding 4, the palmar and the dorsum of the wrist section of both hands. Because the programme recognised the entire arm area inserted into the black box, excluding the hand, as the ‘wrist’ section, the proximal end of these sections were not determined anatomically and could be inconsistent with different hand sizes. The images and the “total score” were displayed on the dedicated terminal within 30 seconds, and the participants were given immediate feedback. The data were saved on the server and were downloaded later for confirmation and analysis of the results.

Hand Size Calculations

Hand surface area (HSA, cm²) was measured according to the method previously described by Lee et al. [9]. (HSA = 1.29 × circumference of the metacarpophalangeal joint × hand length.) Using the definitions of hand size presented by Pires et al. [10], the participants’ hand size was categorised as “small” (surface area ≤ 375 cm²), “medium” (surface area 376–424 cm²), or “large” (surface area ≥ 425 cm²). The size of the medical gloves each participant uses in daily practice (small/medium/large), which was referred to in the randomisation process, and the dominant hand (right/left), was also recorded.

Outcomes

Total palm/dorsum coverage ratio assessments were evaluated by the mean coverage percentage. The coverage of an anatomical region less than 85% was assessed as “insufficient coverage”. The percentage of participants with insufficient coverage was compared in the two techniques.

Sample size

Sample size of this study was not calculated as it was conducted as part of a mandatory training session involving all staff members of the hospital to aim for a large-scale study [11].

Randomisation

Each participant was randomly assigned to either the (1) WHO6S or (2) A6Sw/oI procedure by drawing lots immediately before the data collection. To reduce the hand size bias that may affect the results, the participants randomly drew their lot from boxes with the letters S (small), M (medium), or L (large), corresponding to the size of the medical gloves they are using on a daily basis.

Statistical methods

Chi-squared tests were used to assess differences in each of the demographics, glove size and hand surface area between the groups. Student’s t-test was used to compare hand surface area. The differences in coverage ratios (percentage) between WHO6S and A6Sw/oI were tested by Student’s t-test or Welch's t-test for each surface of the hand. One-way analysis of variance and Tukey’s honestly significant difference test were used to evaluate the differences in coverage ratios (percentage) among the three classifications for the size of the hand surface area by Pires [10]. Pearson's chi-square test or Fisher's exact test was used to assess differences in the ratio of the participants with insufficient coverage (under 85%) for each anatomical section of the hand. Bonferroni adjustment for multiple comparisons was used.

The analysis was undertaken using IBM SPSS version 28 (IBM; Armonk, New York, USA).

Characteristics of the participants

A total of 488 workers were working full-time at the time of the study. Other than the 3 workers with major anomalies and deformations, 26 with severe eczema, and 4 who could not participate for other reasons during the study period, 445 workers were enrolled in the study. After excluding the 18 participants whose data could not be obtained from SCORE! due to tremor of the hands or some other unknown reasons and the 10 participants whose hand size was not measured, data were obtained from 427 participants. A total of 407 participants (95.3%) were right-handed. The number of professions was as follows: 29 physicians, 278 nursing staff, 21 rehabilitation therapists, 26 recreational staff, 97 other comedical staff, and 41 back-office workers. Details of the characteristics of the participants in the two study groups are shown in Table 1. The WHO6S technique was performed by 215 participants, and the A6Sw/oI technique was performed by 212. There were no significant differences between the two groups regarding sex, profession, glove size, or hand surface area. The study population in each hand size group was 155 (155 female: 100%) in “small hands” (surface area ≤ 375 cm²), 166 (17 male: 10.2% 149 female: 89.8%) in “medium hands” (surface area 376–424 cm²), and 106 (83 male: 78.3% 23 female: 6.6%) in “large hands” (surface area ≥ 425 cm²). The distribution of the number of participants according to the hand surface area is shown in Fig. 1. The relationship between glove size and classification of hand surface area is shown in Fig. 2. All male participants had medium or large hands, although some of them used small gloves.

Table 1

Characteristics of the study participants
		WHO6S		A6Sw/oI		p value
		n	%	n	%	p value
Total		215	100.0	212	100.0
Sex	Females	162	75.3	165	77.8	0.545^c
	Males	53	24.7	47	22.2
Professions	Physicians	17	7.9	11	5.2	0.862^c
	Nursing staff	131	60.9	133	62.7
	Rehabilitation therapists	9	4.2	12	5.7
	Recreational staff	14	6.5	12	5.7
	Other co-medical staff	24	11.2	25	11.8
	Back office workers	20	9.3	19	9.0
Glove size^a	Small	83	38.6	82	38.7	0.971^c
	Medium	104	48.4	104	49.1
	Large	28	13.0	26	12.3
Hand surface area group^b	Small	81	37.7	74	34.9	0.719^c
	Medium	84	39.1	82	38.7
	Large	50	23.3	56	26.4
		Mean	SD	Mean	SD
Hand surface area (cm²)		397.3	51.4	397.9	45.6	0.896^d
a: Glove size used in daily work
b: Classification of hand surface area by Pires et al. [10]: Small ≤ 375, Medium376-424, Large ≥ 425 (cm²).
c: Pearson's chi-square test
d: Student t-test
WHO6S: World Health Organization (WHO) 6-Step
A6Sw/oI: Adapted 6-Step without Interlock
SD: standard deviation

Mean coverage

Mean palm coverage was between 98.2% and 97.2% by the WHO6S technique and 98.4% and 97.1% by the A6Sw/oI technique. Coverage by the A6Sw/oI technique was slightly but statistically higher than the WHO6S in the right hand; this significant difference was seen only in medium hands when assessed by hand size groups (Table 2).

Mean dorsum coverage varied from 93.7% (right, small hands, WHO6S) to 83.0% (left, large hands, A6Sw/oI). Coverage of more than 90% was obtained for both hands and both techniques by small hands, whereas the coverage for large hands was under 86%. Coverage was higher by the WHO6S in both hands of all hand sizes, and significant differences between the two techniques were found in both small hands and right medium hands (Table 2).

Significant coverage differences were found between hand size groups, especially in the dorsum.

Table 2

Coverage area according to hand rubbing techniques
		Palm					Dorsum
		WHO6S		A6Sw/oI		p value	WHO6S		A6Sw/oI		p value
		Mean	SD	Mean	SD	p value	Mean	SD	Mean	SD	p value
All participants	Both	97.9	1.4	98.1	1.7	0.144	90.6	6.9	88.4	8.3	0.004
n = 427	Left	97.8	1.5	97.9	2.6	0.845	89.7	7.7	88.0	9.1	0.032
	Right	97.5	2.0	97.9	1.5	0.031	90.9	7.0	88.4	8.8	< 0.001
Small	Both	98.1	1.5	98.4	0.9	0.226	93.6	4.2	91.3	5.8	0.005
n = 155	Left	98.2	1.0	98.2	1.1	0.948	93.1	5.0	91.1	6.4	0.042
	Right	97.7	2.7	98.1	1.0	0.201	93.7	4.4	90.9	6.2	0.002
Medium	Both	97.9	1.2	98.2	2.0	0.296	90.8	6.0	89.1	6.7	0.085
n = 166	Left	97.9	1.3	97.7	3.7	0.707	89.9	6.7	88.5	7.8	0.229
	Right	97.6	1.5	98.3	0.9	< 0.001	91.2	6.2	89.2	7.2	0.046
Large	Both	97.4	1.5	97.6	2.0	0.544	85.2	8.5	83.6	11.0	0.415
n = 106	Left	97.2	2.1	97.7	1.9	0.186	84.1	9.4	83.0	11.5	0.594
	Right	97.3	1.5	97.1	2.3	0.725	85.9	8.9	83.8	11.7	0.320
SD: standard deviation, p value: Student t-test or Welch's t-test

Differences in the coverage area of according to hand size

		Palm		Dorsum
		WHO6S	A6Sw/oI	WHO6S	A6Sw/oI
Both	Small vs Medium	0.630	0.808	0.010	0.198
	Small vs Large	0.011	0.036	< 0.001	< 0.001
	Medium vs Large	0.087	0.122	< 0.001	< 0.001
Left	Small vs Medium	0.343	No significant difference by one-way ANOVA	0.009	0.134
	Small vs Large	< 0.001		< 0.001	< 0.001
	Medium vs Large	0.021		< 0.001	< 0.001
Right	Small vs Medium	No significant difference by one-way ANOVA	0.803	0.034	0.390
	Small vs Large		< 0.001	< 0.001	< 0.001
	Medium vs Large		< 0.001	< 0.001	< 0.001
WHO6S: World Health Organization (WHO) 6-Step, A6Sw/oI: Adapted 6-Step without Interlock
P value of one way ANOVA and Tukey's multiple comparison test
Classification of hand surface area by Pires et al. [10]: Small ≤ 375, Medium376-424, Large ≥ 425 (cm²).

Insufficient coverage for each anatomical section of the hand

The differences in the ratio of the participants with insufficient coverage for each anatomical section of the hands, including all hand sizes, are shown in Fig. 3. The ratios of the participants with insufficient coverage of the palm were similar for both techniques and hands. In most sections, less than 6% of the participants showed insufficient coverage for both techniques for both hands, except for the small area from the crotch between the thumb and the index finger to the middle part of the thumb. Regarding the regions of the four fingers, less than 1.5% of the participants showed insufficient coverage. However, the results of the dorsum showed different, characteristic tendencies. Regarding the regions of the four fingers, the ratio of the participants with insufficient coverage was less than 8% for the WHO6S, whereas for the A6Sw/oI, this was more than 28% for both hands, all significantly higher. This tendency was reversed in the proximal region of the hand, just above the wrist. This region was most often missed by the WHO6S; more than 50% of the participants showed insufficient coverage for both hands. This ratio was lower for the A6Sw/oI group, 36.3% for both hands, and the left hand showed a significant difference.

The differences in the ratio of the participants with insufficient coverage for each anatomical section of the right hand, according to hand size, are shown in Fig. 4. The right hand was chosen because it was the dominant hand for more than 95% of the study population, and hence, it would take more part in transmitting microbes. The results of the palm for both techniques, for all hand sizes, were similar to the results shown in Fig. 3, and no significant differences were found. The results of the dorsum varied between the techniques and the hand sizes. Regarding the four fingers, the ratio of the participants with insufficient coverage was significantly lower by the WHO6S in all hand sizes. The proximal region of the hand was most likely to be missed by the WHO6S in all hand sizes and by the A6Sw/oI in large hands. Statistical differences between hand size were found between small and large hands in 2 sections for the WHO6S technique and 3 for the A6Sw/oI technique, both including the proximal region of the hand.

(Brief summary)

The A6Sw/oI technique showed significantly low coverage regarding the dorsum of the four fingers and the total dorsum coverage for both hands compared to the WHO6S. The coverage of the proximal region of the dorsum, just above the wrist, was low in both techniques and lower in larger sized hands. Only small hands could obtain more than 90% coverage for the dorsum of both hands by the 1.1 ml ABHR-based substance used in this study. The coverage of the palm was generally greater than 90% and was not affected by the difference in techniques or hand size. A significant difference in dorsum coverage was found between small and large sized hands for both techniques.

(Comparison with previous studies, Possible explanations and implications)

Some current locally adapted hand rubbing procedure diagrams [4, 6] do not include the interlock step. This step tends to be unconsciously ignored in HH practice, in circumstances where the WHO technique is not strictly followed. Reilly et al., in their study comparing the Centers for Disease Control and Prevention (CDC) 3-step and the WHO-6 step, showed that in the CDC group, where the participants were requested to “cover all surfaces” following the fingers and thumbs, ‘the back of the fingers in opposite palm’ (= the interlock step), was the least observed of the WHO’s 6 steps [12]. Another study referring to the WHO guidelines excludes the interlock step, as the authors considered that this can be covered by the “palm over dorsum” step [13]. Some other local adaptations add the ‘wrist’ step to the WHO’s 6 steps [14, 15]. However, the evidence for these local adaptations is not clarified. Our study demonstrated that adding the wrist step and omitting the interlock step, as in A6Sw/oI, resulted in lower dorsum coverage and lower coverage of the dorsum of the fingers.

The clinical significance of disinfecting the dorsum of the fingers is not yet clear; however, this area of the hand is likely to touch body fluid during oral care or changing diapers, touch the patients’ skin in some blood sampling techniques, and may also be contaminated when doffing gloves. Longtin et al. showed that the region of the hand that gets closer to the patients’ skin during physical examination tended to become more contaminated in their study on the contamination of stethoscopes [16]. The dorsum of the fingers was not analysed in their study; however, as they are relatively closer to the patients’ skin, they are much more likely to touch patients and environments frequently than the proximal region of the dorsum of the hand and/or the wrist.

Insufficient amount of ABHR applied for the hand size has been discussed as responsible for the poor dorsal coverage in many previous studies [17, 18, 19], and we also found that the ratio of the participants with insufficient dorsal coverage increased as the hands were larger. While taking our data, we also observed that many participants tended to focus more on rubbing the crotch of the fingers rather than the dorsal surface of the hand at the “palm over dorsum” step, which follows the findings from the study by Durso et al. [20]. A certain proportion of the participants rubbed the dorsum of the hand differently, naturally and unintentionally; instead of placing one hand over the other in the same direction, they placed the hands at right angles, moved the top hand sideways, and rubbed the dorsum of the hand and the fingers in long strokes. Although the crotch of the fingers was being missed, this seemed to better cover the dorsum of the hand (and the fingers) than the WHO “palm over dorsum” step. As mentioned in a systematic review by Price et al. [21], the WHO6S technique is based on EN1500, the standardised testing method for hand hygiene products [22], which was originally not intended to be performed heavily in everyday clinical practice. Pursuing an effective technique to rub the dorsum of the hand may also contribute to achieving better coverage, along with applying an adequate amount of ABHR for hand size.

The 1.1 ml ABHR used in our study could obtain a mean total coverage of over 90% for both sides of the hands, only for small hands. Voniatis et al. reported that 3 ml is a reasonable volume for medium-sized hands [17], whereas Kenters et al. reported that 2.25 ml is needed to cover both sides of the hands adequately (82–90%), although the hand size of the participants was not described in their report [18]. They also reported that 86% of HCWs use only one push per event regardless of hand size [18], and we observed similar trends in our direct observation sessions in everyday practice. Therefore, from this perspective, the volume used in this study reflects current practices in reality. Over 60% of all participants and 100% of the male participants had medium to large hands, which suggests the possibility that the majority of the workers in our hospital are not using enough ABHR for their hand size. We gave the healthcare workers a choice between different high-quality hand rubs to ensure maximum acceptability, as in [23], and the one push volume of the ABHR product available in our hospital varied from 1.1 to 1.8 ml. However, the workers choose the products they use based on their tastes, such as texture and moisturisation to the skin, and not the volume per push. The amount of ABHR needs to be customised according to hand size [24], and personal carriable dispensers with controllable ‘volume per push’ might be helpful.

Recently, studies based on “fluorescent dye-based hand rubbing quality assessment”, which was validated by Lehotzky et al. with microbiological assessments [25], have been increasing. Additionally, showing the missed areas by heatmaps is visually informative when assessing the coverage of the hand. Some such studies have compared the differences and relation between the amount and the hand size [17, 26]. Another recent study reported the effect of the missed areas between different techniques, but the amount of the substance used, and the hand size of the participants were not described [20]. Our study is the first to quantitatively evaluate the difference in the coverage of the regions of the hands, visualised by heatmaps, between two different hand rubbing techniques, with the description of both the amount of ABHR and the hand size of the participants.

As stated in a recent systematic review, HH research should standardise volume and application time and consider hand size [27]. Our study standardised the volume to 1.1 ml, which is the ‘one push amount’, application time of 25 seconds, and considered hand size by applying the size of the medical gloves in the randomisation process to minimise the hand size differences between the two techniques. Significant differences in coverage between hand sizes within both technique groups were found; therefore, studies comparing the efficacy of techniques without description of hand size may reflect differences in hand size between the technique groups, and further research is needed.

“Adapt to adopt” is widely recommended for embedding the WHO HH strategy effectively in different areas of the world. However, it is not always as clear as to what extent arrangements and modifications can be regarded as “adaptations”. Careful considerations based on scientific evidence are needed when applying local empirical practice as an adaptation of the WHO guideline.

(Limitations)

The lack of training may have affected the results. This was the first mandatory technique training session for all hospital workers, with visual feedback taught directly by the Infection Control Nurse. Better results may have been achieved if such training had been continued.

The lateral sides of the hands were not analysed, as the device used in this study is not based on 3D scanning, and the coverage ratio of the 360° hand surface area was not evaluated. Therefore, especially for the participants with thick hands, total hand coverage may be much lower.

The WHO 6-step technique was superior to a locally adapted 6-step technique without interlock regarding dorsum surface coverage, especially for the dorsum of the 4 fingers. Careful consideration is necessary when applying locally practised techniques as adaptations of guidelines. Hand size should be considered when assessing coverage differences between procedures.

adapted 6-step without interlock technique (A6Sw/oI) alcohol-based hand rub (ABHR) Centers for Disease Control and prevention (CDC) hand hygiene (HH) hand surface area (HSA) health care workers (HCWs) ultraviolet (UV) World Health Organization (WHO) World Health Organization 6-step technique (WHO6S)

Ethics approval and consent to participate

Ethics approval was obtained from the NHO Shimoshizu National Hospital’s Institutional Review Board for this study (authorization number 1, November 2021). The study was conducted as part of a mandatory training session of the hospital, and each participant's consent was confirmed just before the first digital recording of the image of their hands.

Consent for publication

Not applicable.

Availability of data and materials

Available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Author’s contributions

Y Suzuki defined the objectives of the study and led the study design and development.

MM recorded the hand coverage data, and SO recorded the hand size data.

IM performed the data analysis and interpretation.

Y Suzuki wrote the manuscript, and IM prepared the tables and figures.

All authors critically reviewed the manuscript and approved the final version.

Acknowledgements

The authors acknowledge all the workers of NHO Shimoshizu National Hospital, who participated in the study. The authors would also like to thank Moraine Corporation for providing the SCORE! system, and the testing formula for the study.

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No competing interests reported.

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Editorial decision: Major revision
29 Aug, 2022
Reviews received at journal
19 Jul, 2022
Reviewers agreed at journal
06 Jul, 2022
Reviewers invited by journal
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Editor assigned by journal
20 Jun, 2022
Submission checks completed at journal
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The difference in the surface coverage ratio by an adapted hand rubbing technique and the WHO technique; a randomized group comparison

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