key: cord-284532-b6tsjmfs
authors: Thampi, N.; Longtin, Y.; Peters, A.; Pittet, D.; Overy, K.
title: It’s in our hands: a rapid, international initiative to translate a hand hygiene song during the COVID-19 pandemic
date: 2020-05-06
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.05.003
sha: 
doc_id: 284532
cord_uid: b6tsjmfs

nan

Sir,

The novel coronavirus disease-2019 (COVID-19) continues to affect the global community deeply and rapidly, with more than 200 countries impacted at the time of writing (May 2, 2020). In order to manage the extent of this pandemic, there is a need to develop, disseminate and implement infection prevention and control strategies in both healthcare settings and the community. Early on in the outbreak, there were general recommendations to frequently wash hands to reduce the spread of infection. With the current, relentless global scale of COVID-19, international compliance with handwashing frequency and technique is more important than ever.

A prominent strategy to improve hand hygiene, developed by the World Health Organization (WHO), includes an effective six-step handwashing technique and has led to broad uptake through the use of a multimodal approach; however encouraging consistent compliance can be challenging [1] . In addition to needing to remember all six steps of the technique and needing to wash hands for the required duration of time, there can be a lack of awareness regarding the importance of handwashing technique on reducing the microbial burden on hands. This lack of awareness may not be surprising, as most hand hygiene promotion campaigns focus on indications for action ("when to clean hands") rather than on technique ("how to clean hands") [2] . Thus, continuing to promote correct handwashing technique is currently of utmost importance to the world population, especially given the disproportionate burden of COVID-19 on older adults, and emerging evidence of asymptomatic shedding [3, 4] .

In order to assist children with remembering the effective six-step technique, we recently published a musical mnemonic to the tune of the well-known nursery rhyme Frère Jacques, or Brother John [2, 5] .

This memory aid reinforces inclusion of all six handwashing steps using self-instruction, via engaging with the familiar melody and singing (or imagining singing) the lyrics ( Figure 1A ). In the context of the 3/6 evolving COVID-19 pandemic, the near-ubiquitous melody of Brother John provided an opportunity for international, interdisciplinary collaboration to translate and rapidly disseminate the musical mnemonic globally. On 19 th March, drawing on our combined network of music neuroscience researchers, music education specialists and healthcare professionals, we invited approximately 40 international colleagues to create a new version of the handwashing song that a) included all six WHO handwashing steps; b) worked musically in the new language; and c) had been checked by a healthcare professional for accuracy. Each translator was also invited to submit an audio or video file of the translated song. We Brother John is an ideal tune to use in this context: it is widely known across cultures; the melody involves very simple, repeating patterns; the vocal range centres around a small interval of a sixth (e.g. middle C to A), which is easy to sing even by non-musically trained individuals; and the duration, when sung at a steady tempo, is between 20 and 25 seconds. Singing is a highly sequential, structured activity and has been used throughout history to remember text or coordinate movement, from ballads and religious scriptures to work songs and children's action songs. Experimentally, music has been shown to facilitate verbal and motor learning in a variety of contexts, likely using neural resources shared between music, language and motor networks [6] [7] [8] . In practice, we have observed that, once the handwashing song becomes highly familiar through repetition and rehearsal, a missed step is immediately noticed, leading to important self-correcting behavior.

A clear advantage of this six-step handwashing song is that it highlights the importance of correct technique, in addition to the recommended 20-second duration (such as singing "happy birthday" twice, another popular approach). A demonstration, prior to introducing the song, will ensure full understanding of each step. In launching these translated songs during a pandemic that underlines our global interconnectedness, and to highlight 2020 World Hand Hygiene Day on 5 th May, we have made these songs available at www.CleanHandsSaveLives.org/hand-washing-song/, hoping this mnemonic will inspire individuals to take matters into their own hands and reduce their risk of acquiring or spreading COVID-19. Music is known to have the capacity to entertain, bring joy and be a powerful, positive shared experience; the 28 languages included here allow access to this musical mnemonic to more than half of the world's population in their native language.

Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study

Hygiene: Why, How & When? In: WHO

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention

Virological assessment of hospitalized patients with COVID-2019

Longtin Y Wash your hands

Cognitive and neural mechanisms underlying the mnemonic effect of songs after stroke

Singing can facilitate foreign language learning

Schaefer RS Auditory rhythmic cueing in movement rehabilitation: findings and possible mechanisms

Figure 1: WHO six-step handwashing technique 1 and handwashing song lyrics, set to the tune of Brother John. (A) visual handwashing aid, lyrics and musical notes for each step. Figure (B) 28 translations of the handwashing song

Additional thanks go to Tom Howey for the figures and to Giuliano Avanzini and Maria Majno for sparking and facilitating this initiative, respectively.

A B