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Multimodal interventions are effective in increasing hand hygiene (HH) compliance amongst healthcare workers, but it is not known whether such interventions are cost-effective outside high-income countries.To evaluate the cost-effectiveness of multimodal hospital interventions to improve hand hygiene (HH) compliance in a middle-income country.We adopted a conservative approach by developing a model to determine whether reductions in Methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSI) alone would make HH interventions cost-effective in intensive care units (ICUs). Transmission dynamic and decision analytic models were combined to determine the expected impact of HH interventions on MRSA-BSI incidence and evaluate their cost-effectiveness. A series of sensitivity analyses and hypothetical scenarios making different assumptions about transmissibility were explored to generalise the findings.Interventions increasing HH compliance from a 10% baseline to ≥20% are likely to be cost-effective solely through reduced MRSA-BSI. Increasing compliance from 10% to 40% was estimated to cost US$ 2,515 per 10,000 bed-days with 3.8 QALYs gained in a paediatric ICU (PICU) and US$ 1,743 per 10,000 bed-days with 3.7 QALYs gained in an adult ICU. If baseline compliance is not greater than 20%, the intervention is always cost-effective even with only a 10% compliance improvement.Effective multimodal HH interventions are likely to be cost-effective due to preventing MRSA-BSI alone in ICU settings in middle-income countries where baseline compliance is typically low. Where compliance is higher, the cost-effectiveness of interventions to improve it further will depend on the impact on hospital-acquired infections other than MRSA-BSI.

Original publication




Journal article


The Journal of hospital infection

Publication Date



Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; School of Public Health, Queensland University of Technology, Brisbane, Australia. Electronic address: