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Hand Sanitizers

This page is from the P2RIC's SustainUpdates section from the University of Nebraska-Omaha

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Overview


Hand Sanitizers are a type of hand antiseptic that are used as an alternative to supplement hand washing with soap and water and are an important part of an infection control program.  They come in the form of gels, liquids, foams, mists or wipes and usually contain a form of alcohol as the active ingredient.  Other antiseptic agents include chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds (benzalkonium chloride), and triclosan.  Using hand sanitizers are an effective method of hand hygiene and are recommended for use in order to reduce the transmission of infectious disease.  Hand sanitizers should not replace proper regular hand washing but is very effective at killing microorganisms on the skin.  Recent studies have suggested that some forms of hand sanitizers are safer and more effective than others and that when choosing what kind of hand sanitizer to use, it is important to take the environment into consideration.   

Environmental Impact


The hand sanitizer market has grown tremendously in the past 5 years to roughly $100 million in sales annually.  The significant increase in use has created controversy regarding their safety and effectiveness.  Hand sanitizers contain an active chemical, usually a form of alcohol, that kills microorganisms on contact.  Alcohol based sanitizers are the most popular followed by those that contain triclosan or benzalkonium chloride.  Alcohol based sanitizers are flammable, can irritate the skin, and have been found to be able to enter the bloodstream if significant amount is applied.  Benzalkonium chloride may be harmful as well by creating allergy and asthma problems when consistently exposed.  Triclosan is considered a possible human carcinogen because it combines with chlorine water to form chloroform and has also been linked to other health problems.  However, the Environmental Protection Agency considers it not likely to be a human carcinogen.  Triclosan has also been found to disrupt hormones in animals and possibly humans with long term exposure.  The large amounts of antimicrobial products being used that contain triclosan are being released into the environment and may affect the health of some animals, especially aquatic ones.  It has also been found that tirclosan and benzalkonium chloride use in hand sanitizers can lead to antimicrobial resistance to these chemicals and create bacteria that is is resistant to several antibiotics when present for long period of times at sublethal concentrations.  However, most studies have concluded that even though it is theoretically possible based on the chemical and biological mechanism, EPA registered products have never been shown evidence of resistance.

Best Practices


Studies on the effectiveness of hand sanitizers have been somewhat conflicting.  Some findings suggest that sanitizers are actually better than normal hand washing at killing microorganisms where others have discovered that hand washing is still superior.  The research indicates that there are many variables that could be causing these discrepancies.  First of all, the concentration of alcohol-based sanitizers needs to be at least 60% to be effective.  Alcohol based sanitizers at this concentration or higher are very effective at killing microbes but the alcohol evaporates quickly on the hands and may not be present on the skin long enough for adequate protection.  As a result, unless the product can maintain high alcohol concentrations for a longer period of time, it is probably not effective as regular hand washing.  A Federal Drug advisory panel concluded in 2005 that, for general use, antibacterial soaps are no more effective than regular plain soap at removing germs.  

For alcohol based sanitizers, ethanol is more effective at killing microbes than isopropanol.  However, both alcohols are effective at eliminating bacteria, fungi, and viruses.  Products using triclosan or benzalkonium chloride are effective at high concentrations and usually maintains protection for a longer period of time.  However, they have been found to possibly contribute to antibiotic resistant microbes and many products do not contain a high enough concentration of these chemicals to be as effective as normal hand washing.  The potential of antibiotic resistance increases if these products are overused or used inappropriately.  Triclosan has also been found to have the potential to cause damaging health effects to humans and the environment.  The American Public Health Association proposed a resolution to ban the non-medical use of Triclosan™ in February of 2009.  Thus, the standard suggestion from health organizations is to maintain proper hand washing practices and using hand sanitizers to supplement normal soap and water.  

Many studies and resources suggest that hand sanitizers only be used in high risk settings such as health clinics, hospitals, prisons, and those with weakened immune systems.  These studies conclude that they should not be used on a regular basis in our homes, offices, and schools.  However, during a flu outbreak, a non-scented, alcohol based sanitizer with a minimum 60% alcohol percentage should be used. 

Recommendations


Center for Disease Control reccomendations include:

*  When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.

*  If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands or wash hands with an antimicrobial soap and water.

*  Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.

*  Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.

*  No recommendation can be made regarding the routine use of non alcohol-based hand rubs for hand hygiene in health-care settings.

*  Use hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times.

Suggested Products


Hospitals- Alcohol based hand sanitizers with a 60% minimum alcohol percentage and preferably 70-90%. (when not visibly soiled).

Food Service Providers- Normal soap and water.  Hand sanitizers are not recommended but if used, they should be alcohol based hand sanitizers with a 60% minimum alcohol percentage (only after hands have been cleaned with soap and water).
 
Schools- Normal soap and water.  Hand sanitizers are not recommended but if a flu outbreak occurs, an alcohol based hand sanitizers with a 60% minimum alcohol percentage should be used.  If alcohol based sanitizers are used, they must be stored out of reach and supervised when applied.  

General Public- Alcohol based hand sanitizers with a 60% minimum alcohol percentage (only when soap and water are not available).

Fact Sheets/References


Ethanol Antiseptic Material Safety Data Sheet

Hand Sanitizers for Food Service Industry

Hand Hygiene Fact Sheet

CDC Hand Hygiene in the Healthcare Setting

University of Florida Hand Hygiene and Hand Sanitizers Information

Yazdankhah, S.P et al. 2006.  Triclosan and Antimicrobial Resistance in Bacteria: An Overview.  ''Microbial Drug Resistance'' Summer;12(2):83-90.

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