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Stranger, Danger!

As children we were taught to shout the phrase “Stranger, Danger!” to alert those around us of unfamiliar people in our surroundings. As a means of infection control, perhaps we should yell “Stranger, Danger” when visitors enter our healthcare facilities.

While visiting a dear friend recently in a skilled nursing facility, I was surprised that I could walk through the facility without any staff intervention and without any posted or verbalized encouragement to wash my hands. Handwashing is critical in preventing the spread of infections1

Studies indicate that visitors do not consistently use good handwashing practices2, 3, 4 and these “strangers” could be a source of many illnesses, including norovirus5. Norovirus, easily transmitted person-to-person, most frequently impacts at-risk individuals and 64% of outbreaks occur in healthcare facilities6 Following the Centers for Disease and Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations5 is essential for visitor-related infection control within our acute and long-term health care facilities.

  • Stranger, Danger – Just as all visitors should check in at a security desk for a visitor badge, establish and implement policies for visitor health assessment and screening5. Visitors with symptoms of acute gastroenteritis and other transmissible illness symptoms should be denied entry.
  • Control the Danger - Actively promote visitor hand hygiene by providing readily visible handwashing and/or handcare stations at reception desks and ward entrances5. In addition to signs and free-standing hand sanitizer dispensers3, audible7 and audio-visual hand hygiene reminders8 have been shown to be an inexpensive and successful tool to promote hand hygiene compliance among visitors. In one study, an audible reminder increased visitor compliance from 10.6% to 63.7% (P < .001) and the positive behavior change was also shown to be sustained7.
  • Wanted Posters – Provide education to visitors on recognizing transmittable illness symptoms and methods for preventing infection5. Use culturally appropriate and emotionally impactful flyers and signage9 to make a lasting impact. Visitors pose a threat to infection control in the healthcare setting. Minimize your risk by implementing “Stranger, Danger” protocols.


  1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002;51(No. RR-16)
  2. Willison-Parry TA, Haidar EA, Martini LG, Coates AR. Handwashing adherence by visitors in poor: Is there a simple solution? Am J Infect Control. 2013 Oct;41(10):928-9.
  3. Birnbach DJ, Nevo I, Barnes S, Fitzpatrick M, Rosen LF, Everett-Thomas R, Sanko JS, Arheart KL. Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby. Am J Infect Control. 2012 May;40(4):340-3.
  4. Randall j, Arthur A, Vaughn N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect. 2010 Nov;76(3):252-5.
  5. MacCannell T, Umschei C, Agarwal R, Lee I, Kuntz G, Stevenson K and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings . 2011
  6. Hall AJ, Lopman BA, Payne DC, Patel MM, Gastañaduy PA, Vinjé J, et al. Norovirus disease in the United States. Emerg Infect Dis. 2013:19
  8. Fakhry M, Hanna GB, Anderson O, Holmes A, Nathwani D. Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control. 2012 May;40(4):320-3.
  9. Taylor RJ, El-Kafrawy U. A simple inexpensive audio-visual reminder of infection control procedures on entry to a neonatal intensive care unit. J Hosp Infect. 2012 Nov;82(3):203-6.  
  10. FDA Oral Culture Learner Project

Jamie Stamey, MS, RDN, LDN, CP-FS is food safety and applied nutrition consultant with