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Show Me the Science - When & How to Use Hand Sanitizer

Washing hands with soap and water is the best way to reduce the number of microbes on them in most situations. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol.

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Why? Many studies have found that sanitizers with an alcohol concentration between 60–95% are more effective at killing germs than those with a lower alcohol concentration or non-alcohol-based hand sanitizers 1,2. Non-alcohol-based hand sanitizers may 1) not work equally well for all classes of germs (for example, Gram-positive vs. Gram-negative bacteria, Cryptosporidium, norovirus); 2) cause germs to develop resistance to the sanitizing agent; 3) merely reduce the growth of germs rather than kill them outright, or 4) be more likely to irritate skin than alcohol-based hand sanitizers 1,2.

References
  1. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004 Oct;17(4):863-93.
  2. Todd EC, Michaels BS, Holah J, Smith D, Greig JD, Bartleson CA. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps. J Food Prot. 2010 Nov;73(11):2128-40.

When using hand sanitizer, apply the product to the palm of one hand (read the label to learn the correct amount) and rub the product all over the surfaces of your hands until your hands are dry.

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Why? The steps for hand sanitizer use are based on a simplified procedure recommended by CDC 1. Instructing people to cover all surfaces of both hands with hand sanitizer has been found to provide similar disinfection effectiveness as providing detailed steps for rubbing-in hand sanitizer 2.

References
  1. CDC. Guideline for Hand Hygiene in Health-Care Settings. MMWR Morb Mortal Wkly Rep. 2002;51(RR16):1-44.
  2. Kampf G, Reichel M, Feil Y, Eggerstedt S, Kaulfers PM. Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection. BMC Infect Dis. 2008;8:149.

Alcohol-based hand sanitizers can quickly reduce the number of microbes on hands in some situations, but sanitizers do not eliminate all types of germs.

Why? Although alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly 1-10, people may not use a large enough volume of the sanitizers or may wipe it off before it has dried 10. Furthermore, soap and water are more effective than hand sanitizers at removing or inactivating certain kinds of germs, like Cryptosporidium, norovirus, and Clostridium difficile 11-15.

References
  1. CDC. Antimicrobial spectrum and characteristics of hand-hygiene antiseptic agents. MMWR Morb Mortal Wkly Rep. 2002;51(RR16):45.
  2. Edmonds SL, Mann J, McCormack RR, Macinga DR, Fricker CM, Arbogast JW, Dolan MJ. SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable. J Food Prot. 2010 Dec;73(12):2296-300.
  3. Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis. 2009 Feb 1;48(3):285-91.
  4. Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer use on elementary school absenteeism. Am J Infect Control. 2000 Oct;28(5):340-6.
  5. Hübner NO, Hübner C, Wodny M, Kampf G, Kramer A. Effectiveness of alcohol-based hand disinfectants in a public administration: Impact on health and work performance related to acute respiratory symptoms and diarrhoea. BMC Infect Dis. 2010;10:250.
  6. Kramer A, Galabov AS, Sattar SA, Döhner L, Pivert A, Payan C, Wolff MH, Yilmaz A, Steinmann J. Virucidal activity of a new hand disinfectant with reduced ethanol content: comparison with other alcohol-based formulations. J Hosp Infect. 2006 Jan;62(1):98-106.
  7. Lee GM, Salomon JA, Friedman JF, Hibberd PL, Ross-Degnan D, Zasloff E, Bediako S, Goldmann DA. Illness transmission in the home: a possible role for alcohol-based hand gels. Pediatrics. 2005 Apr;115(4):852-60.
  8. Sandora TJ, Taveras EM, Shih MC, Resnick EA, Lee GM, Ross-Degnan D, Goldmann DA. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics. 2005 Sep;116(3):587-94.
  9. Stebbins S, Cummings DA, Stark JH, Vukotich C, Mitruka K, Thompson W, Rinaldo C, Roth L, Wagner M, Wisniewski SR, Dato V, Eng H, Burke DS. Reduction in the incidence of influenza A but not influenza B associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial. Pediatr Infect Dis J. 2011 Nov;30(11):921-6.
  10. Kampf G, Marschall S, Eggerstedt S, Ostermeyer C. Efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers. BMC Infect Dis. 2010 Mar 26;10:78.
  11. Barbee SL, Weber DJ, Sobsey MD, Rutala WA. Inactivation of Cryptosporidium parvum oocyst infectivity by disinfection and sterilization processes. Gastrointest Endosc. 1999 May;49(5):605-11.
  12. Blaney DD, Daly ER, Kirkland KB, Tongren JE, Kelso PT, Talbot EA. Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007. Am J Infect Control. 2011 May;39(4):296-301.
  13. Charbonneau DL, Ponte JM, Kochanowski BA. A method of assessing the efficacy of hand sanitizers: use of real soil encountered in the food service industry. J Food Prot. 2000 Apr;63(4):495-501.
  14. Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis. 2009 Feb 1;48(3):285-91.
  15. Oughton MT, Loo VG, Dendukuri N, Fenn S, Libman MD. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol. 2009 Oct;30(10):939-44.

Hand sanitizers may not be as effective when hands are visibly dirty or greasy.

Why? Many studies show that hand sanitizers work well in clinical settings like hospitals, where hands come into contact with germs but generally are not heavily soiled or greasy 1. Some data also show that hand sanitizers may work well against certain types of germs on slightly soiled hands 2,3. However, hands may become very greasy or soiled in community settings, such as after people handle food, play sports, work in the garden, or go camping or fishing. When hands are heavily soiled or greasy, hand sanitizers may not work well 1,4,5Handwashing with soap and water is recommended in such circumstances.

References
  1. Todd ECD, Michaels BS, Holah J, Smith D, Grieg JD, Bartleson CA. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps. J Food Prot. 2010 Nov;73(11):2128-40.
  2. Pickering AJ, Davis J, Boehm AB. Efficacy of alcohol-based hand sanitizer on hands soiled with dirt and cooking oil. J Water Health. 2011 Sep;9(3):429-33.
  3. Pickering AJ, Boehm AB, Mwanjali M, Davis J. Efficacy of waterless hand hygiene compared with handwashing with soap: a field study in Dar es Salaam, Tanzania. Am J Trop Med Hyg. 2010 Feb;82(2):270-8.
  4. Charbonneau DL, Ponte JM, Kochanowski BA. A method of assessing the efficacy of hand sanitizers: use of real soil encountered in the food service industry. J Food Prot. 2000 Apr;63(4):495-501.
  5. Edmonds SL, Mann J, McCormack RR, Macinga DR, Fricker CM, Arbogast JW, Dolan MJ. SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable. J Food Prot. 2010 Dec;73(12):2296-300.

Swallowing alcohol-based hand sanitizers can cause alcohol poisoning.

Why? Ethyl alcohol (ethanol)-based hand sanitizers are safe when used as directed, 1 but they can cause alcohol poisoning if a person swallows more than a couple of mouthfuls 2.

From 2011 – 2015, U.S. poison control centers received nearly 85,000 calls about hand sanitizer exposures among children 3. Children may be particularly likely to swallow hand sanitizers that are scented, brightly colored, or attractively packaged.  Hand sanitizers should be stored out of the reach of young children and should be used with adult supervision. Child-resistant caps could also help reduce hand sanitizer-related poisonings among young children 2. Older children and adults might purposefully swallow hand sanitizers to become drunk 4.

References
  1. Miller MA, Rosin A, Levsky ME, Patel MM, Gregory TJ, Crystal CS. Does the clinical use of ethanol-based hand sanitizer elevate blood alcohol levels? A prospective study. Am J Emerg Med. 2006;24(7):815-7.
  2. Rayar P, Ratnapalan S. Pediatric ingestions of house hold products containing ethanol: a review. Clin Pediatr (Phila). 2013;52(3):203-9.
  3. Georgia Poison Center. 2015.
  4. Gormley NJ, Bronstein AC, Rasimas JJ, Pao M, Wratney AT, Sun J, Austin HA, Suffredini AF. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. [PDF – 10 pages] Crit Care Med. 2012;40(1):290-4.

Hand sanitizers might not remove harmful chemicals, like pesticides and heavy metals, from hands.

Why? Although few studies have been conducted, hand sanitizers probably cannot remove or inactivate many types of harmful chemicals. In one study, people who reported using hand sanitizer to clean hands had increased levels of pesticides in their bodies 1. If hands have touched harmful chemicals, wash carefully with soap and water (or as directed by a poison control center).

Reference
  1. Coronado GD, Holte SE, Vigoren EM, Griffith WC, Barr DB, Faustman EM, Thompson B. Do workplace and home protective practices protect farm workers? Findings from the “For Healthy Kids” study. [PDF – 17 pages] J Occup Environ Med. 2012;54(9):1163-9.

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