Presence of unsafe chemical impurities, accelerated evaporation of alcohol, and lack of key labeling requirements are risks and concerns for some alcohol-based hand sanitizers and dispenser practices during the COVID-19 pandemic.

Alcohol-based hand sanitizers (ABHS) have been an important hand hygiene tool during the COVID-19 pandemic. Recently, ABHS from non-traditional drug manufacturers have entered the market, triggered by a lack of ABHS availability. Some of these ABHS contain high levels of chemical impurities that may be harmful with frequent exposure. Additionally, the use of refillable dispensers designed to accept ABHS from bulk containers allows for mixing and evaporation that may compromise ABHS integrity. To understand the risks associated with low quality ABHS and bulk refilling practices, we collected 77 ABHS samples sourced from community settings (restaurants, grocery stores, etc.) and 40 samples from a single school district. All samples were obtained from bulk refillable dispensers that were in use. Samples were analyzed for alcohol content, chemical impurities, aesthetic qualities, and presence of drug labeling information. Additionally, we performed laboratory-based experiments to determine the impact of dispenser design on alcohol evaporation rates. Over 70% of samples for which photos were available showed lack of essential labeling information, including missing "Drug Facts Labels". For ABHS samples acquired from community settings, nearly 14% of samples had visible impurities, and over 30% of samples had concentrations of acetal and acetaldehyde in excess of FDA interim limits. Subpotent ethanol concentrations were observed in 9.09% and 82.05% of samples from community settings and the school district, respectively, with the school district sample results being associated with dispenser misuse. Laboratory-based experiments show dispenser design significantly impacts the rate of ethanol evaporation of ABHS products, especially if stored in open refillable dispensers without an internal reservoir. This study demonstrates risks associated with use of inferior ABHS and bulk refilling practices. Regulatory agencies should issue guidance on best practices in community settings to ensure the integrity of ABHS as an essential public health tool to prevent the spread of COVID-19 and other transmissible diseases.

High Hand Contamination Rates During Norovirus Outbreaks in Long-Term Care Facilities.

We examined norovirus contamination on hands of ill patients during 12 norovirus outbreaks in 12 long-term care facilities (LTCFs). The higher frequency and norovirus titers on hands of residents compared to hands of heathcare workers highlights the importance of adhering to appropriate hand hygiene practices during norovirus outbreaks in LTCFs. Infect Control Hosp Epidemiol 2018;39:219-221.

The effect of 222-nm UVC phototesting on healthy volunteer skin: a pilot study.

BACKGROUND: Frequent topical antiseptic use to hands is now common in healthcare and other work environments. Inevitably, the use of such antiseptics will present an occupational risk for irritancy and allergic dermatitis. New, less irritant and even non-chemical antimicrobial approaches are under investigation. METHODS: A Sterilray disinfectant source (222 nm) conventionally used to sterilize equipment and work surfaces was assessed for tolerability in human skin. Using an escalating dosage study methodology, four skin phototype I and II healthy volunteers had their minimal erythema dose (MED) determined. Punch biopsies of irradiated sites were stained for cyclobutane pyrimidine dimers (CPD). The degree of CPD was compared with that in biopsies from unexposed skin and from areas exposed to UVB (280-315 nm) radiation. RESULTS: Calibrated spectral measurements revealed emission at a peak wavelength of 222 nm with 97% emission at wavelengths less than 250 nm. At low doses below the threshold bacteriostatic effect, the source was capable of inducing both erythema and CPD formation in human skin. In two individuals, cells in the basal layer were not shielded by the overlying tissue as indicated by the presence of CPD. CONCLUSION: The source showed an erythemogenic or CPD potential at lower doses than those required to reach the reported threshold bacteriostatic effect.

Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands.

This study determined whether surrogate organisms can predict activity against Clostridium difficile spores and compared the efficacy of hand hygiene preparations against C. difficile. Our data suggest that surrogate organisms were not predictive of C. difficile spore removal. Four preparations were significantly more effective than tap water at removing C. difficile.

Hand hygiene regimens for the reduction of risk in food service environments.

Pathogenic strains of Escherichia coli and human norovirus are the main etiologic agents of foodborne illness resulting from inadequate hand hygiene practices by food service workers. This study was conducted to evaluate the antibacterial and antiviral efficacy of various hand hygiene product regimens under different soil conditions representative of those in food service settings and assess the impact of product formulation on this efficacy. On hands contaminated with chicken broth containing E. coli, representing a moderate soil load, a regimen combining an antimicrobial hand washing product with a 70% ethanol advanced formula (EtOH AF) gel achieved a 5.22-log reduction, whereas a nonantimicrobial hand washing product alone achieved a 3.10log reduction. When hands were heavily soiled from handling ground beef containing E. coli, a wash-sanitize regimen with a 0.5% chloroxylenol antimicrobial hand washing product and the 70% EtOH AF gel achieved a 4.60-log reduction, whereas a wash-sanitize regimen with a 62% EtOH foam achieved a 4.11-log reduction. Sanitizing with the 70% EtOH AF gel alone was more effective than hand washing with a nonantimicrobial product for reducing murine norovirus (MNV), a surrogate for human norovirus, with 2.60- and 1.79-log reductions, respectively. When combined with hand washing, the 70% EtOH AF gel produced a 3.19-log reduction against MNV. A regimen using the SaniTwice protocol with the 70% EtOH AF gel produced a 4.04-log reduction against MNV. These data suggest that although the process of hand washing helped to remove pathogens from the hands, use of a wash-sanitize regimen was even more effective for reducing organisms. Use of a high-efficacy sanitizer as part of a wash-sanitize regimen further increased the efficacy of the regimen. The use of a well-formulated alcohol-based hand rub as part of a wash-sanitize regimen should be considered as a means to reduce risk of infection transmission in food service facilities.

SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable.

The risk of inadequate hand hygiene in food handling settings is exacerbated when water is limited or unavailable, thereby making washing with soap and water difficult. The SaniTwice method involves application of excess alcohol-based hand sanitizer (ABHS), hand "washing" for 15 s, and thorough cleaning with paper towels while hands are still wet, followed by a standard application of ABHS. This study investigated the effectiveness of the SaniTwice methodology as an alternative to hand washing for cleaning and removal of microorganisms. On hands moderately soiled with beef broth containing Escherichia coli (ATCC 11229), washing with a nonantimicrobial hand washing product achieved a 2.86 (±0.64)-log reduction in microbial contamination compared with the baseline, whereas the SaniTwice method with 62 % ethanol (EtOH) gel, 62 % EtOH foam, and 70 % EtOH advanced formula gel achieved reductions of 2.64 ± 0.89, 3.64 ± 0.57, and 4.61 ± 0.33 log units, respectively. When hands were heavily soiled from handling raw hamburger containing E. coli, washing with nonantimicrobial hand washing product and antimicrobial hand washing product achieved reductions of 2.65 ± 0.33 and 2.69 ± 0.32 log units, respectively, whereas SaniTwice with 62 % EtOH foam, 70 % EtOH gel, and 70 % EtOH advanced formula gel achieved reductions of 2.87 ± 0.42, 2.99 ± 0.51, and 3.92 ± 0.65 log units, respectively. These results clearly demonstrate that the in vivo antibacterial efficacy of the SaniTwice regimen with various ABHS is equivalent to or exceeds that of the standard hand washing approach as specified in the U.S. Food and Drug Administration Food Code. Implementation of the SaniTwice regimen in food handling settings with limited water availability should significantly reduce the risk of foodborne infections resulting from inadequate hand hygiene.