Caring for Our Children (CFOC)

Chapter 3: Health Promotion and Protection

3.2 Hygiene

3.2.2 Hand Hygiene

3.2.2.1: Situations that Require Hand Hygiene

Content in the STANDARD was modified on 8/23/2016, 8/9/2017, 10/18/2018 and 01/22/2019.

COVID-19 modification as of August 10, 2022. 

 

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

All staff, volunteers, and children should follow the procedure in Standard 3.2.2.2 for hand hygiene at the following times:

a. On arrival for the day, after breaks, or when moving from one child care group to another

b. Before and after

  1. Preparing food or beverages
  2. Eating, handling food, or feeding a child
  3. Giving medication or applying a medical ointment or cream in which a break in the skin (eg, sores, cuts, scrapes) may be encountered
  4. Playing in water (including swimming) that is used by more than one person

c. After

  1. Diapering*
  2. Using the toilet or helping a child use a toilet
  3. Handling bodily fluid (mucus, blood, vomit) from sneezing, wiping and blowing noses, mouths, or sores
  4. Handling animals or cleaning up animal waste
  5. Playing in sand, on wooden play sets, or outdoors
  6. Cleaning or handling the garbage
  7. Applying sunscreen and/or insect repellent

d. When children require assistance with brushing, caregivers/teachers should wash their hands thoroughly between brushings for each child. 

Situations or times that children and staff should perform hand hygiene should be posted in all food preparation, hand hygiene, diapering, and toileting areas. Also, if caregivers/teachers smoke off premises before starting work, they should wash their hands before caring for children to prevent children from receiving thirdhand smoke exposure .1

*Hand hygiene after diaper changing must always be performed. Hand hygiene before changing diapers is required only if the staff member’s hands have been contaminated since the last time the staff member practiced hand hygiene.2

COVID-19 modification as of August 10, 2022:  

In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, it is recommended that program staff, and children:

  • Practice hand hygiene during key times in the day (for example, before/after eating, after recess and after touching or handling masks.)
  • Provide adequate handwashing supplies, including soap and water.
  • Provide hand sanitizer containing at least 60% alcohol if hand washing with soap and water is not available.
    • Store hand sanitizers up, away, and out of sight of younger children and only with adult supervision for children ages 5 years and younger.

Additional Resources:

Centers for Disease Control and Prevention. Your Guide to Masks

CFOC Standard 3.2.2.5 Hand Sanitizers

 

RATIONALE
Hand hygiene is the most important way to reduce the spread of infection. Many studies have shown that improperly cleansed hands are the primary carriers of infections. Deficiencies in hand hygiene have contributed to many outbreaks of diarrhea among children and caregivers/teachers in child care centers.3

Child care centers that have implemented good hand hygiene techniques have consistently demonstrated a reduction in diseases transmission.3 When frequent and proper hand hygiene practices are incorporated into a child care center’s curriculum, there is a decrease in the incidence of acute respiratory tract diseases.4

Hand hygiene after exposure to soil and sand will reduce opportunities for the ingestion of zoonotic parasites that could be present in contaminated sand and soil.5

Thorough handwashing with soap for at least twenty seconds using clean running water at a comfortable temperature removes organisms from the skin and allows them to be rinsed away.6 Hand hygiene with an alcohol-based sanitizer is an alternative to traditional handwashing with soap and water when visible soiling is not present.
 
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately.7

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount.7 As with any hand hygiene product, supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.7
Infectious organisms may be spread in a variety of ways:
  1. In human waste (urine, stool);
  2. In body fluids (saliva, nasal discharge, secretions from open injuries; eye discharge, blood);
  3. Cuts or skin sores;
  4. By direct skin-to-skin contact;
  5. By touching an object that has live organisms on it;
  6. In droplets of body fluids, such as those produced by sneezing and coughing, that travel through the air.
Since many infected people carry infectious organisms without symptoms and many are contagious before they experience a symptom, caregivers/teachers routine hand hygiene is the safest practice.8
COMMENTS
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms).8 These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene. 
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.1.5.2 Toothbrushes and Toothpaste
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
REFERENCES
  1. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/secondhand-smoke/art-20043914.
  2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.26.
  3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.20.

  4. American Academy of Pediatrics. Enterovirus D68 In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 331-334, 658, 692

  5. Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, clinical practice, and public health control. New York: Oxford University Press.
  6. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
  7. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5. 

  8. American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 148-149, 154, 164

NOTES

Content in the STANDARD was modified on 8/23/2016, 8/9/2017, 10/18/2018 and 01/22/2019.

COVID-19 modification as of August 10, 2022. 

 

3.2.2.2: Handwashing Procedure

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.2.2

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.2.2: Handwashing Procedure

Question:
This standard recommends that children and staff members rub their hands with a soapy lather for at least 20 seconds. Why was this changed from 10 seconds?

Answer:
This recommendation follows the recommendation of the Centers for Disease Control (CDC). This reference can be found at: http://www.cdc.gov/handwashing/.

Content in the STANDARD was modified on 8/9/2017 and 5/17/19.

 

Children and staff members should wash their hands using the following method:

  1. Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
  2. Turn on clean, running water to a comfortable temperature.1
  3. Moisten hands with water and apply liquid or powder soap to hands.
    1. Antibacterial soap should not be used.
    2. Bar soaps should not be used.
  4. Rub hands together vigorously until a soapy lather appears (hands are out of the water stream) and continue for at least 20 seconds (sing “Happy Birthday to You” twice).2 Rub areas between fingers, around nail beds, under fingernails and jewelry, and on back of hands. Nails should be kept short; acrylic nails should not be worn.3
  5. Rinse hands under clean, running water that is at a comfortable temperature until they are free of soap and dirt. Leave the water running while drying hands.
  6. Dry hands with the clean, disposable paper or single-use cloth towel.
  7. If faucets do not shut off automatically, turn faucets off with a disposable paper or single-use cloth towel.
  8. Throw disposable paper towels into a lined trash container; place single-use cloth towels in the laundry hamper. Use hand lotion to prevent chapping of hands, if desired.

Children and staff who need to open a door to leave a bathroom or diaper-changing area should open the door with a disposable towel to avoid possibly re-contaminating clean hands. If a child cannot open the door or turn off the faucet, he or she should be assisted by an adult.

Use of antimicrobial soap is not recommended in early care and education settings. There are no data to support use of antibacterial soaps over other liquid soaps. Premoistened cleansing towelettes do not effectively clean hands and should not be used as a substitute for washing hands with soap and running water.

When running water is unavailable or impractical, the use of alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative. The use of alcohol-based hand sanitizers is an alternative to traditional handwashing (with soap and water) if

  1. Soap and water are not available and hands are not visibly dirty.4,5
  2. Hands are rubbed together, distributing sanitizer to all hand and finger surfaces, and allowed to air-dry.

Alcohol-based hand sanitizers should contain at least 60% alcohol and be kept out of reach of children. Active supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.6,7

Single-use towels should be used unless an automatic electric hand dryer is available. The use of cloth roller towels is not recommended because children often use cloth roller towel dispensers improperly, resulting in more than one child using the same section of towel.

Washbasins should not be used as an alternative to running water. Camp sinks and portable commercial sinks with foot or hand pumps dispense water like plumbed sinks and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and washbasin daily.
RATIONALE

Running clean water over the hands removes visible soil. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution.
 
Alcohol-based hand sanitizers do not kill norovirus and spore-forming organisms, which are common causes of diarrhea in child care settings.4 This is enough reason to limit or even avoid the use of hand sanitizers with infants and toddlers (children younger than 2 years) because they are the age group at greatest risk of spreading diarrheal disease due to frequent diaper changing. Handwashing is the preferred method. However, while hand sanitizers are not recommended for children younger than 2 years, they are not prohibited.

 

Outbreaks of disease have been linked to shared wash water and washbasins.8
COMMENTS

Current handwashing procedure states that water remains on throughout the handwashing process. However, there is little research to prove whether a significant number of germs are transferred between hands and the faucet while performing hand hygiene.8  Turning off the faucet after wetting and before drying hands saves water for those early care and education programs practicing water conservation.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
5.4.1.10 Handwashing Sinks
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES

  1. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. http://www.cdc.gov/handwashing. Reviewed October 9, 2018. Accessed January 28, 2019

  2. American Academy of Pediatrics. Isolation precautions. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:148–157

  3. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–45

  4. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017

  5. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—situations where hand sanitizer can be effective & how to use it in community settings. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Reviewed October 15, 2018. Accessed January 28, 2019

  6. Centers for Disease Control and Prevention. CDC features. Wash your hands. https://www.cdc.gov/features/handwashing/index.html. Updated December 6, 2018. Accessed January 28, 2019

  7. Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers—United States, 2011–2014. MMWR Morb Mortal Wkly Rep. 2017;66(8):223–226

  8. Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med. 2008;27(1):24–28

  9. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—how to wash your hands. https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html. Reviewed October 2, 2018. Accessed January 28, 2019

NOTES

Content in the STANDARD was modified on 8/9/2017 and 5/17/19.

 

3.2.2.3: Assisting Children with Hand Hygiene


Caregivers/teachers should provide assistance with handwashing at a sink for infants who can be safely cradled in one arm and for children who can stand but not wash their hands independently. A child who can stand should either use a child-height sink or stand on a safety step at a height at which the child’s hands can hang freely under the running water. After assisting the child with handwashing, the staff member should wash his or her own hands. Hand hygiene with an alcohol-based sanitizer is an alternative to handwashing with soap and water by children over twenty-four months of age and adults when there is no visible soiling of hands (1).
RATIONALE
Encouraging and teaching children good hand hygiene practices must be done in a safe manner. A “how to” poster that is developmentally appropriate should be placed wherever children wash their hands.

For examples of handwashing posters, see:

California Childcare Health Program at http://www.ucsfchildcarehealth.org;

North Carolina Child Care Health and Safety Resource Center at http://www.healthychildcarenc.org/training_materials.htm.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers
REFERENCES
  1. Centers for Disease Control and Prevention. 2013. Information for schools and childcare providers. http://www.cdc.gov/flu/school/index.htm

3.2.2.4: Training and Monitoring for Hand Hygiene


The program should ensure that staff members and children who are developmentally able to learn personal hygiene are instructed in, and monitored on performing hand hygiene as specified in Standard 3.2.2.2.
RATIONALE
Education of the staff and children regarding hand hygiene and other cleaning procedures can reduce the occurrence of illness in the group of children in care (1,2).

Staff training and monitoring of hand hygiene has been shown to reduce transmission of organisms that cause disease (3-6). Periodic training and monitoring is needed to result in sustainable changes in practice (7).

COMMENTS
Training programs may utilize some type of verbal cue such as singing the alphabet song, twinkle, twinkle little star or the birthday song during handwashing.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
REFERENCES
  1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. 1994. Science, prevention, and practice VII: Improving child day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics national health and safety guidelines for child-care programs; featured standards and implementation. Pediatrics 95:1110-12.
  2. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics 105:738-42.
  3. Black, R. E., A. C. Dykes, K. E. Anderson. 1981. Handwashing to prevent diarrhea in day care centers. Am J Epidemiol 113:445-51.
  4. Roberts, L., L. Jorm, M. Patel, W. Smith, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of diarrheal episodes in child care: A randomized, controlled trial. Pediatrics 105:743-46.
  5. Carabin, H., T. W. Gyorkos, J. C. Soto, L. Joseph, P. Payment, J. P. Collet. 1999. Effectiveness of a training program in reducing infections in toddlers attending daycare centers. Epidemiol 10:219-27.
  6. Bartlett, A. V., B. A. Jarvis, V. Ross, T. M. Katz, M. A. Dalia, S. J. Englender, L. J. Anderson. 1988. Diarrheal illness among infants and toddlers in day care centers: Effects of active surveillance and staff training without subsequent monitoring. Am J Epidemiol 127:808-17.
  7. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.

3.2.2.5: Hand Sanitizers

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.2.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Standard 3.2.2.5: Hand Sanitizers

Question:
Is there evidence to address the flammability risk of hand sanitizers and the recommended countermeasures with this product?

Answer:
Hand sanitizers are flammable as noted on product labels. Standard 5.5.0.5: Storage of Flammable Materials was updated in the CFOC Online Database to address that hand sanitizers in volume should be stored in a separate building, in a locked area, away from high temperatures and ignition sources, and inaccessible to children.

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

 

The use of hand sanitizers by children and adults in child care programs is an appropriate alternative to the use of traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2). ECE programs should provide hand sanitizer containing at least 60% alcohol. Hand sanitizers should be stored up, away, and out of sight of younger children and should be used only with adult supervision for children ages 5 years and younger.
 
Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes (3).
The technique for using hand sanitizers is:
  • For visibly dirty hands and soap is not available, rinsing under running water or wiping with a water-saturated towel should be used to remove as much dirt as possible before using a hand sanitizer.
  • Apply the product to the palm of one hand (read the label to learn the correct amount);
  • Rub hands together; and
  • Rub the product over all surfaces of the hands and fingers until hands are dry (4).
Hand sanitizers using an alcohol-based active ingredient must contain 60% to 95% alcohol to be effective in killing most germs including multi-drug resistant pathogens. Child care programs should follow the manufacturer’s instructions for use, check instructions to determine how much product and how long the hand sanitizer needs to remain on the skin surface to be effective.
 
Where alcohol-based hand sanitizer dispensers are used:
  1. The maximum individual dispenser fluid capacity should be as follows:
  2. 0.32 gal (1.2 L) for dispensers in individual rooms, corridors, and areas open to corridors;
  3. 0.53 gal (2.0 L) for dispensers in suites of rooms;
  4. Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
  5. Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
  6. Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
  7. Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (5).
When alcohol based hand sanitizers are offered in a child care facility, the facility should encourage parents/guardians to teach their children about their use at home.
RATIONALE
Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (6-8).
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately (5).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (1,3,4). 
COMMENTS
Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).
 
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene.

Some hand sanitizing products contain non-alcohol and “natural” ingredients. The efficacy of non-alcohol containing hand sanitizers is variable and therefore a non-alcohol-based product is not recommended for use.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
5.5.0.5 Storage of Flammable Materials
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
  2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
  3. Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing.html. 
  4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
  5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.

  6. American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 148-149, 154, 164

  7. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nurs 33:368-72.
  8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Handwashing: Clean hands save lives!  http://www.cdc.gov/handwashing/.
  9. ADDITIONAL REFERENCE:
     
    American Association of Poison Control Centers. 2016. Hand sanitizer. http://www.aapcc.org/alerts/hand-sanitizer/. 
NOTES

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.