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A hand sanitizer, according to the latest FDA definition, is a supplement or alternative to hand washing with soap and water. Various preparations are available, including gel, foam, and liquid solutions. The active ingredient in hand sanitizers may be isopropanol, ethanol, or n-propanol. Inactive ingredients in alcohol rubs typically include a thickening agent such as polyacrylic acid for alcohol gels, humectants such as glycerin for liquid rubs, propylene glycol, and essential oils of plants. Alcohol based hand sanitizers are more effective at killing germs than soaps and do not dry out hands as much.^[1] Popular alcohol rub brands include Baccide, Purell, Germ-X, Labo, Aqium, Avant, GermOut, and Aquawet. Lysol, and Method Products also produce popular alcohol-based hand sanitizers. Some brands make a non-alcohol sanitizer such as cleanwell.

In recent years, some brands started combining alcohol rubs with natural products and essential oils to provide luxury lines for the growing skin care industry.^[2] Such brands include Burt's Bees, EO, Frais, Jao and The Body Shop.

Contents 1 Hand alcohol 2 Uses 3 Hospital environment 3.1 Brands of hospital hand-rubs 3.2 Composition 3.3 Applications in the hospital environment 3.3.1 Hygienic hand rubbing 3.3.2 Surgical hand disinfection by hand-rubbing 3.3.3 Dosing systems 4 Effectiveness 5 Safety 6 Image gallery 7 Sources 8 See also 9 External links

[edit] Hand alcohol

Hand alcohol, alcohol hand disinfection agent, is a type of disinfection agent that is used within health care to avoid transmission of pathogens. Hand alcohol exist both in easy flowing and in gel form. The level of alcohol varies between 60% to 85%. The most common used level is 70%.

Despite common perceptions, hand alcohol is well-adapted for the skin. Several studies have demonstrated that hand alcohol does not dehydrate the skin ^[3]. In contrast, hand washing with soap and water significantly decreases epidermis water content compared to use of alcohol-based hand gels ^[4]. Hand alcohol should be thoroughly rubbed into the hands and on the lower forearm for a duration of at least 30 seconds ^[5], and then allowed to air dry. Optimal disinfection requires attention to all exposed surfaces such as around the fingernails, between the fingers, on the back of the thumb, and around the wrist. To minimize carryover, jewelery should be removed from hands during use.

Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus. Alcohol rub sanitizers containing 70% alcohol kill 3.5 log₁₀ (99.9%) of the bacteria on hands 30 seconds after application and 4 to 5 log₁₀ (99.99 to 99.999%) of the bacteria on hands 1 minute after application.^[6]

[edit] Uses

When hands are not visibly dirty, the United States Centers for Disease Control and Prevention considers alcohol hand sanitizers as an acceptable alternative to soap and water for hand hygiene.^[7]

Alcohol concentration must be above 60% for alcohol rubs to be effective in killing microbes. Researchers at East Tennessee State University found that products with alcohol concentrations as low as 40% are available in American stores.^[8] For health care settings like hospitals and clinics, optimum alcohol concentration to kill germs is 70% to 95 %.^[9][10] Alcohol rubs containing two different germ killers (i.e. alcohol and chlorhexidine gluconate), are significantly more effective as preoperative skin topical antiseptics in hospitals than alcohol alone.^[11] Most alcohol rub formulations include a moisturizer to keep hands from drying out.

Some hand sanitizer products use agents other than alcohol, such as triclosan or benzalkonium chloride, to kill germs. However, one uncorroborated laboratory study has shown benzalkonium chloride may be associated with, but not cause, antibiotic resistance in MRSA.^[12][13] No mechanism for resistance to alcohol has been described in bacteria.^[14] Triclosan has been shown to accumulate in biosolids in the environment, one of the top seven organic contaminants in waste water according to the National Toxicology Program^[15] Triclosan leads to various problems with natural biological systems ^[16], and triclosan, when combined with chlorine e.g. from tap water, produces dioxins, a probable carcinogen in humans.^[17] In June, 2009, alcohol-free Clarcon Antimicrobial Hand Sanitizer was pulled from the US market by the FDA which found the product contained high levels of various bacteria, including those which can "cause opportunistic infections of the skin and underlying tissues and could result in medical or surgical attention as well as permanent damage".^[18]

[edit] Hospital environment

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Alcohol based hand rubs are extensively used in the hospital environment as an alternative to antiseptic soaps. Alcohol based hand rubs provide a better skin tolerance as compared to antiseptic soap due to the moisturizing and softening agents in the formulation. Hand rubs also prove to have more effective microbiological properties as compared to antiseptic soaps.

[edit] Brands of hospital hand-rubs

The most common brands of alcohol hand rubs include Avant, Aniosgel 85 NPC, Sterillium, Desderman and Allsept S. All hospital hand rubs must conform to certain regulations like EN 12054 for hygienic treatment and surgical disinfection by hand-rubbing. Products with a claim of “99.99% reduction” or 4Log reduction are ineffective in hospital environment, since the reduction must more than “99.99%”.^{[citation needed]}

[edit] Composition

The same ingredients used in over-the-counter hand-rubs are used in hospital hand-rubs and include alcohols (ethanol, isopropanol, and others), sometimes combined with other compounds like quats (benzalkonium chloride). The use of quats is primarily to increase the antimicrobial effectiveness of the product, but it can cause allergic reactions in some people. However, allergic reactions due to quats are extremely rare, and the benefits of using quats (increased antimicrobial effectiveness) far exceed the risks. The concentration of quats in one well-known hand antiseptic is 200 parts per million. This concentration will never become "sticky" even if applied dozens of times per day. Quats also tend to build up on the skin, and since medical staff use hand rubs heavily during the day, this build up might cause a “sticky effect”. Sanitizing gels used many times a day will leave a "sticky" residue due to the gel. The gel does not evaporate. It stays on the hands until it is removed with soap and water. Hand rubs based solely on alcohol eliminate the sticky effect as well as the risk of allergic reactions. The alcohol in the alcohol gel evaporates, but the gel remains on the hands and can cause allergic reactions.

[edit] Applications in the hospital environment

Hand-rubs in the hospital environment have two applications: hygienic hand rubbing and surgical hand disinfection.

[edit] Hygienic hand rubbing

Hygienic hand rubbing is recommended when administering medical treatments and in all circumstances where hand disinfection is necessary (during contact with the patient or the patient's environment, particularly before medical examination between each treatment, if the treatment is interrupted). Hygienic hand rubbing in addition to the hospital staff is strongly recommended to be practiced by visitors and patients themselves whenever possible.

However, There is an enuciated need for a New Hand Sanitizing Technology. The CDC as well as professional organizations such as APIC espouse the most basic thesis of infection prevention is that the most important surfaces to keep sanitized are the surfaces of the bare hand or gloved hand. This is most certain way to limit cross contamination. These recommendations need to OVER EMPHASIZE that just prior to touching the patient or handling medical devices that will be inserted into the patient, the hands MUST BE SANITARY, better yet, STERILE.

Surfaces are constantly compromised by the patient, the nurse or doctor, the patients surround etc. Cross contamination is the root cause, and transmission of pathogens to the patient causes infection. This has been enunciated by the CDC. There is even a video on their hand hygiene website that clearly enunciates this thesis. However, they did not advise a technology capable of enabling this.

A new approach based upon applying the germicidal properties of UVC is one technology that can enable effective hand hygiene at the point of care, before each and at the moment of inserting catheters and other patient care tasks, and they do this right in front of the patient and the patient’s family.

An UVC based unit could be a small portable box that is plugged in but could also operate on batteries if required for portability. The cover opens up automatically and the healthcare worker places both hands in the box which then closes automatically around the forearm. The hands within the box are spread fingered automatically. Once the cover closes the UVC goes on and would stay on for 3 seconds, the proven time needed to sanitize the entire surface of the bare hand or gloved hand. The cover then opens and the hands are removed. When the UVC comes on the box is completely closed and no UVC enters the room. There will be automatic means to ID and record the user thereby partly resolving the issue of 'is it being used'. However, it will not record if it is being used every time the HCW is about to touch the patient as CDC recommends and enunciated in its hand hygiene video.

During the 3 second exposure the integrated UVC dose will be ~1200 joules per meter squared (m^2); uniform and isotropic. Every vegetated bacteria or virus that we know or have tested requires a dose of < 100 joules/m^2 for -1 log10 reduction. There are many industry references since UVC is well documented and our tests roughly confirm the published values. Hence >-12 log10 reduction (meaningless) would be expected for bacteria and virus. Endospores such as anthrax or C. diff would have about -2 log10 reduction. A 6 second exposure would be required for -4 log10 reduction for these two types of hardy spores. We are working on supplying more optical energy to lower the time for sanitation to 3 seconds. This approach could also be used in the OR for re-sterilization of hands or gloves during surgery and for drastically cutting down peri-operative scrub time.

Validation experiments using UVC have been done on gloved hands by a certified independent lab. Each test included multiple test sites on the glove including the spaces between fingers and at the base where fingers come together. The CDC, NIH, AHRQ find no issue on the experiments.

Gloves are opaque to UVC. For bare hands, the skin requires application of a proprietary prophylactic coating that absorbs 99.999% of the incident radiation. The transient pathogens that contaminate the surface of the coating get the full dose and the Stratum Corneum gets 1/100,000 the dose. This allows 500 exposures in 8 hours before the maximum allowed dose to the skin of 60 joules/m^2 is accumulated. Erythema tests will need to be done but absorption tests make it clear that there will be no erythema. Given that use of alcohol rubs and hand washing does cause erythema, this is a huge advancement in skin health for nurses and doctors. Counter intuitive at first, but clearly the way to go.

The inventors of UVC based hand hygiene technology have accounted for all adverse effects but surprises are always possible. However, UVC exposure of the skin is common among welders etc and is well documented by OSHA, so there should be no surprises.

Needless to say this approach is one that allows consistency and control, offers broad efficacy, does not depend too much on the healthcare worker, and saves enormous time; even 100 uses per day takes only 5 minutes. (as opposed to 50 minutes of alcohol rubbing). ICPs could expect many informed patients will play a role as CDC teaches by insisting that the box be used before being treated or touched by the HCW or visitor in any way. proven science and common sense should prevail with respect to adoption of this hand hygiene technology and there should be a more patient centric approach. In addition, It also adds another of protection for healthcare workers especially if their gloves have micro pin holes.

[edit] Surgical hand disinfection by hand-rubbing

Surgical hand disinfection by hand-rubbing is to be practiced before any surgical procedure. Surgical hand-rubbing is to be preceded by hand washing with mild soap. Hand washing prior to hygienic hand rubbing is not necessary unless hands are visibly dirty. Surgical hand disinfection by hand-rubbing generally requires a larger dose of the hand-rub and a longer rubbing time, usually done in two applications.

Both hygienic hand treatment and surgical hand disinfection must be applied and rubbed according to a specific hand-rubbing technique EN 1499 and EN 1500. This technique is specifically designed to ensure that the antiseptic is applied everywhere on the hand surface.

[edit] Dosing systems

Different dosing systems are available for hospital hand-rubs, those are usually dosing systems incorporated into the bottle itself like dosing pumps screwed into the bottle or airless pump systems. The dosing systems are designed to deliver a certain amount of the product, and thus to assist the staff to correctly measure out the correct dose. Application of the hand-rub can also be assisted by placing the bottle in specially designed dispensers, dispensers for surgical hand disinfection are usually equipped with elbow controlled mechanism or infrared sensors to avoid any contact between with the pump. It is strongly recommended use the product in its original packaging and never to pour the product into a dispenser, as the dispenser itself may become the cause of infection.^{[citation needed]} 1

The Centers for Disease Control specifies at least a 62% alcohol content is needed to kill germs. It also recommends that the access to the dispenser be both frequent and prevalent. Newer wrist worn sanitizers are more effective since the supply and access to the sanitizer is worn by the individual. The wearable system should also maintain an antibacterial property and have no less then a Class VI medically approved rating. A system developed by Pure-Go is a wrist worn hand sanitizer dispenser that meets the CDC guidelines. ^[19]

[edit] Effectiveness

The Centers for Disease Control says the most important way to prevent the transmission of dangerous diseases is to frequently wash your hands with soap and water. If soap and water are not available it is recommended to use a hand sanitizer that contains at least 60 percent alcohol.^[20][21] Alcohol rubs kill many different kinds of bacteria, including antibiotic resistant bacteria and TB bacteria. It also has high viricidal activity against many different kinds of viruses, including enveloped viruses such as the flu virus, the common cold virus, and HIV, though is notably ineffective against the rabies virus.^{[22] [23] [24]} Alcohol rubs also kill fungi.^[25]

According to Rotter (1999), “alcohol rubs are approximately 100 times more effective against viruses than any form of hand washing”. Isopropyl alcohol will instantly kill 99.99 percent or more of all non-spore forming bacteria in less than 30 seconds, both in the laboratory and on human skin.^[11][20] A controlled study of 200 workers at FedEx in 2004 showed that placing hand sanitizer dispensers in an office and educating workers about their use resulted in a 21% reduction in absenteeism.^[26] Controlled studies showed an even greater reduction in absenteeism (51%) in elementary schools^[27] and college dormitories (43%).^[28]

The alcohol in hand sanitizers may be ineffective in low quantities or concentrations. Though Isopropyl alcohol is efficient in killing most bacteria, the exposure time required to lyse cells is not met since alcohol tends to evaporate in less than 10–15 seconds.^{[citation needed]} If the correct amount of alcohol rub hand sanitizer is used, it will not evaporate in 10–15 seconds.^{[citation needed]} Mackintosh (1984) found that application of 0.3 milliliters alcohol rub to the hands was no more effective than plain soap-and-water hand washing, but that increasing the volume to 0.5 milliliters increased the effectiveness of alcohols substantially.[1] In environments with high lipids or protein waste (such as food processing), the use of alcohol hand rubs alone may not be sufficient to ensure proper hand hygiene.^{[citation needed]}

Not all pathogens are equally susceptible. Certain bacteria, especially the spore-forming gram positives (e.g. Clostridium difficile) are relatively resistant and remain biologically viable. During the Anthrax attacks on the United States Postal Service, authorities warned that alcohol hand rubs would not kill anthrax spores.

Alcohol kills both pathogenic (disease causing) microorganisms as well as resident bacterial flora, which generally do not cause illness. ^[29] Research shows that alcohol hand sanitizers do not pose any risk by eliminating "good" germs that are naturally present on the skin. The body quickly replenishes the good germs on the hands, often moving them in from just up the arms where there are fewer harmful germs.^[30]

Alcohol also strips the skin of the outer layer of oil, which may have negative effects on barrier function of the skin. However, washing with detergents, such as commonly used hand soaps, results in a greater barrier disruption of skin compared to alcohol solutions, suggesting a increased loss of skin lipids ^{[31] [32]}

[edit] Safety

Alcohol gel can catch fire, producing a dim blue flame. This is due to the flammable alcohol in the gel. Some hand sanitizer gels may not produce this effect due to a high concentration of water or moisturizing agents. There have been some rare instances where alcohol has been implicated in starting fires in the operating room, including a case where alcohol used as an antiseptic pooled under the surgical drapes in an operating room and caused a fire when a cautery instrument was used. Alcohol gel was not implicated. To minimize the risk of fire, alcohol rub users are instructed to rub their hands until dry, which indicates that the flammable alcohol has evaporated.^[33]

The US FDA controls antimicrobial handsoaps and sanitizers as over-the-counter drugs because they are intended for topical anti-microbial use to prevent disease in humans. ^[34] The FDA requires strict labeling which informs consumers as to proper use of this OTC drug and dangers to avoid, including warning adults not to ingest, not to use in the eyes, to keep out of the reach of children, and to allow children to use only under adult supervision. ^[35] According to the American Association of Poison Control Centers, there were nearly 12,000 cases of hand sanitizer ingestion in 2006. ^[36] If ingested, alcohol-based hand sanitizers can cause alcohol poisoning in small children.^[37] However, the Centers for Disease Control recommends using hand sanitizer with children to promote good hygiene, under supervision, and furthermore recommends parents pack hand sanitizer for their children when traveling, to avoid their contracting disease from dirty hands. ^[38]

There have been cases reported of people drinking the gel (with mixers) in prisons and hospitals to become intoxicated leading to its withdrawal from some establishments. ^[39]

[edit] Image gallery

Alcohol liquid – a type of alcohol rub

Colourless alcohol gel

[edit] Sources

[edit] See also

• Hand washing
• Soap
• Antibacterial soap
• Rubbing alcohol
• Ignaz Semmelweis

[edit] External links

• "Executive Summary: National Stakeholders Meeting on Alcohol-Based Hand-Rubs and Fire Safety in Health Care Facilities, July 22, 2003". American Hospital Association, Co-Hosted by the U.S. Centers for Disease Control & Prevention (CDC) and AHA. Archived from the original on 2008-03-08. http://web.archive.org/web/20080308220645/www.cdc.gov/handhygiene/firesafety/aha_meeting.htm. 
• SkinWearShop