Dermal and pulmonary absorption of ethanol from alcohol-based hand rub

Biosurfactants in the sustainable eradication of SARS COV-2 from the environmental surfaces

The COVID-19 outbreak has brought the world, at least, to one consensus that cleanliness is unavoidable under all circumstances. Hands are the main body part to interact with the environment and thus are prone to receive, initiate and propagate the chain of infection. Hand hygiene has, therefore, been most emphasized by experts to interrupt the spread of infection. Various harsh chemicals like synthetic surfactants and alcoholic preparations have been in practice to eradicate and disinfect the germs. This choice may be unsafe and cause a subsequent chain of adversities. Thereby, biosurfactants have been proposed as sustainable, non-toxic and safe surface cleaners cum disinfectants under a wide range of physiological and environmental conditions. The amphiphilic micellar behavior of biosurfactants makes them promising candidates as hygienic surface cleaners and therapeutic carriers. We overview the possibilities of using biosurfactants in different ways against microbial pathogens, in general, and the SARS COV-2, in specific.

Sensitivity of SARS-CoV-2 towards Alcohols: Potential for Alcohol-Related Toxicity in Humans

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative organism that is highly contagious and has been responsible for more than 240 million cases and 5 million deaths worldwide. Using masks, soap-based hand washing, and maintaining social distancing are some of the common methods to prevent the spread of the virus. In the absence of any preventive medications, from the outset of pandemic, alcohol-based hand sanitizers (ABHS) have been one of the first-line measures to control transmission of Coronavirus Disease 2019 (COVID-19). The purpose of this narrative review is to evaluate the sensitivity of SARS-CoV-2 towards ABHS and understand their potential adverse effects on humans. Ethanol and isopropanol have been the most commonly used alcohols in ABHS (e.g., gel, solution, spray, wipes, or foam) with alcohol in the range of 70–85% v/v in World Health Organization or Food and Drug Administration-approved ABHS. The denaturation of proteins around the envelope of SARS-CoV-2 positive sense single-stranded RNA virus is the major mechanism of action of ABHS. Due to frequent use of high-percentage alcohol-containing ABHS over an extended period of time, the oral, dermal, or pulmonary absorption is a possibility. In addition to the systemic toxicity, topical adverse effects such as contact dermatitis and atopic dermatitis are plausible and have been reported during COVID-19. ABHS appear to be effective in controlling the transmission of SARS-CoV-2 with the concern of oral, dermal, or pulmonary absorption.

Driving under the influence of alcohol during the COVID-19 pandemic

AIM

The main objective of this study was to evaluate the effects of the COVID-19 pandemic on the pattern of alcohol use in drivers.

MATERIALS

and methods. At the National Institute of Legal Medicine from Bucharest, we performed a retrospective study on toxicology reports between January 1st^, 2019 and December 31st, 2020. Breath alcohol concentration (BrAC) was tested using Dräger breathalyzers by police units at the scene, and blood alcohol concentration (BAC) was evaluated using headspace gas chromatography. Most drivers gave two blood samples, separated by a one-hour interval, case in which they could request a retrograde extrapolation of the BAC at the time when they were stopped in traffic.

RESULTS

The distribution of the number of cases depending on the month showed a sharp decline in the first six months of the lockdown, with a slow upward trend afterward. Mean overall values for BrAC were 0.49 +/- 0.40 mg/L, for 1st sample BAC - 1.15 +/- 0.99 g/L and for 2nd sample BAC - 1.29 +/- 0.81 g/L. Mean values obtained for BrAC were 0.48 +/- 0.39 mg/L before the pandemic and 0.52 +/- 0.43 mg/L during the pandemic. The increase was similar in absolute numbers in both male and female drivers (0.03 versus 0.04 mg/L respectively for BrAC and 0.02 g/L for both genders for 1st sample BAC). However, the percentage increase was significantly higher in women. There were 253 cases in which BrAC had values between 0.01 and 0.05, of which 138 occurred before the pandemic and 115 during the pandemic, the increase being highly statistically significant. The percentage of drivers with BAC levels below and above 0.8 g/L (the threshold value for which DUI is a felony in Romania) were similar before and during the pandemic.

CONCLUSIONS

During the lockdown, the number of alcohol tests in traffic has decreased significantly. This reduction was not associated with statistically significant changes in BrAC or BAC. We have seen a substantial increase in the number of minimally elevated BrAC and negative BAC cases, changes that could be caused by an increased use of alcohol-based hand sanitizers.

Ethanol-based disinfectant sprays drive rapid changes in the chemical composition of indoor air in residential buildings

The COVID-19 pandemic has resulted in increased usage of ethanol-based disinfectants for surface inactivation of SARS-CoV-2 in buildings. Emissions of volatile organic compounds (VOCs) and particles from ethanol-based disinfectant sprays were characterized in real-time (1 Hz) via a proton transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS) and a high-resolution electrical low-pressure impactor (HR-ELPI+), respectively. Ethanol-based disinfectants drove sudden changes in the chemical composition of indoor air. VOC and particle concentrations increased immediately after application of the disinfectants, remained elevated during surface contact time, and gradually decreased after wiping. The disinfectants produced a broad spectrum of VOCs with mixing ratios spanning the sub-ppb to ppm range. Ethanol was the dominant VOC emitted by mass, with concentrations exceeding 103 μg m-3 and emission factors ranging from 101 to 102 mg g-1. Listed and unlisted diols, monoterpenes, and monoterpenoids were also abundant. The pressurized sprays released significant quantities (104-105 cm-3) of nano-sized particles smaller than 100 nm, resulting in large deposited doses in the tracheobronchial and pulmonary regions of the respiratory system. Inhalation exposure to VOCs varied with time during the building disinfection events. Much of the VOC inhalation intake (>60 %) occurred after the disinfectant was sprayed and wiped off the surface. Routine building disinfection with ethanol-based sprays during the COVID-19 pandemic may present a human health risk given the elevated production of volatile chemicals and nano-sized particles.

Washout kinetics of ethanol from the airways following inhalation of ethanol vapors and use of mouthwash

Introduction: Breath analyzers are commonly used to test for alcohol intoxication, i.e., elevated systemic levels of ethanol, at workplaces and among vehicle drivers. However, local low-dose exposure to ethanol in the mouth or airways may temporarily increase the breath-alcohol concentration (BrAC) without the systemic ethanol level being affected, leading to false positive test results. The aim of this study was to assess the impact of local ethanol exposure on the BrAC.Methods: Eleven healthy adults (six women) were exposed to on average 856 mg/m³ ethanol vapor for 15 min, followed by repeat collection of exhaled breath in Tedlar bags. One hour later, the subjects washed their mouth for 30 s with a typical mouthwash containing 22% ethanol and post-exposure breaths were again collected repeatedly. Negligible systemic uptake of ethanol was confirmed by analysis of blood sampled before, between and after the exposures. Ethanol in breath and blood was analyzed by gas chromatography.Results: No or very low levels (less than 0.002 mg/g) of ethanol were detected in blood at any time point, indicating negligible systemic uptake. The decline in breath was mono-exponential after both exposures with average half times of 0.4 (range 0.3-0.8) min after inhalation exposure and 1.9 (1.1-3.0) min after mouthwash. BrAC levels in the first sample, collected a few seconds after exposure, were 0.14 (0.07-0.13) mg/L after inhalation and 4.4 (2.7-6.0) mg/L after mouth wash. On average, it took 0.5 (0.06-0.7) min and 11 (6-15) min, respectively, for the BrAC to fall below the Swedish statutory limit of 0.1 mg/L air.Conclusion: In practice, use of breath analysis should not be a problem even if the subject inhaled ethanol vapors before the test. In contrast, use of ethanol-containing mouthwash results in a false positive test if sampling is done within 15 min.

"We have to clean ourselves to ensure that our children are healthy and beautiful": findings from a qualitative assessment of a hand hygiene poster in rural Uganda

Background

Neonatal sepsis is a major cause of mortality worldwide, with most deaths occurring in low-income countries. The World Health Organisation (WHO) ‘5 Moments for Hand Hygiene’ poster has been used to reduce hospital-acquired infections, but there is no similar tool to prevent community-acquired newborn infections in low-resource settings. This assessment, part of the BabyGel Pilot study, evaluated the acceptability of the ‘Newborn Moments for Hand Hygiene in the Home’ poster. This was an educational tool which aimed to remind mothers in rural Uganda to clean their hands to prevent neonatal infection.

Methods

The BabyGel pilot was a cluster randomised trial that assessed the post-partum use of alcohol-based hand rub (ABHR) to prevent neonatal infections in Mbale, Uganda. Fifty-five women in 5 village clusters received the ABHR and used it from birth to 3 months postnatally, with use guided by the new poster. Following the study, 5 focus group discussions (FGDs) were conducted consisting of 6–8 purposively sampled participants from intervention villages. FGDs were audio-recorded, transcribed then translated into English. Transcripts were inductively coded using ATLAS.ti® and qualitatively analysed using thematic content analysis.

Results

Most mothers reported that they understood the message in the poster (“The picture shows me you must use these drugs to keep your baby healthy”) and that they could adhere to the moments from the poster. Some participants used the information from the poster to encourage other caregivers to use the ABHR (“after explaining to them, they liked it”). Other potential moments for hand hygiene were introduced by participants, such as after tending to domestic animals and gardening.

Conclusion

The poster was well-received, and participants reported compliance with the moments for hand hygiene (although the full body wipe of the baby has since been removed). The poster will be adapted into a sticker format on the ABHR bottle. More focus could be put into an education tool for other caregivers who wish to hold the baby. Overall, the study demonstrated the acceptability of an adapted version of the WHO Moments for Hand Hygiene poster in the introduction of an intervention in the community.

Trial registration

ISRCTN67852437, registered 02/03/2015.

Trial funding

Medical Research Council/ Wellcome Trust/ DfID (Global Health Trials Scheme).

Preventing neonatal sepsis in rural Uganda: a cross-over study comparing the tolerance and acceptability of three alcohol-based hand rub formulations

BACKGROUND

Neonatal sepsis causes 0.5 million deaths annually, mostly in low resource settings. Babies born in African rural homes without running water or toilet facilities are especially vulnerable. Alcohol-based hand rub (ABHR) may be used by mothers and carers as an alternative to hand washing with soap to prevent neonatal infection. However, no definite study has established the preferred formulation of hand rub for the mothers. This study aimed to assess the effects of addition of bitterants and perfume towards the acceptability of the alcohol-based hand rubs by the mothers in their homes after childbirth.

METHODS

This was a 3-way blinded cross-over study design. Mothers with children aged ≤3 months were recruited from immunisation clinics at 3 local health facilities in rural eastern Uganda and received 3-different ABHR formulations (in the order plain, bitterant and perfumed) packed in 100 ml bottles. Each ABHR was used for 5 consecutive days followed by a 2-day 'washout' period (evaluation period). Overall satisfaction with each hand rub was evaluated at the end of each week using a 7-point Likert scale.

RESULTS

A total of 43 women were recruited, whose ages ranged from 16 to 45 years (mean 26.2 years old). None of the participants normally used a hand protective lotion/cream. The three formulations were used for a mean of 5 (range 3-7) days. A significantly greater volume of the "bitterant" and "perfumed" formulations (mean 91 and 83 ml respectively) were used in comparison to the "plain" formulation (mean 64 ml). Overall satisfaction was high with all the hand rubs, but the perfumed formulation had a significantly higher overall satisfaction score [mean 6.7, range 4-7] compared with the plain [6.4, 3-7] and bitterant [6.2, 2-7] formulations.

CONCLUSIONS

All the 3 ABHR formulations were well accepted with little to choose between them. The ABHR with added perfume scored highest on overall satisfaction and was used significantly more often than plain ABHR. ABHR with bitterant additive did, however, score highly and may be a preferable choice to those with concern over alcohol misuse.

TRIAL REGISTRATION

ISRCTN67852437 , prospectively registered on 18/03/2018.

Neonatal ethanol exposure from ethanol-based hand sanitisers in isolettes

OBJECTIVE

The aims of this study is to measure the ethanol vapours in the isolette after use of hands cleaned with ethanol-based hand sanitiser (EBHS).

METHODS

Two squirts (1.5 mL) of hand sanitiser were rubbed on hands for 10 or 20 s before inserting the hands in the isolette for 5 min. Ethanol vapours were measured in the isolette with photoionisation detector and alcohol breathalyser for 30 min.

RESULTS

Peak ethanol concentration in the isolette was considerably higher with a 10 s hand rub (381±192 ppm) compared with a 20 s hand rub (99±50 ppm), and dissipated to ≤5 ppm within 30 min. Under routine care, EBHS use by care providers exposes neonates in isolettes to 3.7-7.3 or 1.4-2.8 mg/kg ethanol per day with 10 or 20 s hand rubs, respectively. The expected blood level from average single exposure is 0.036 mg/dL with 10 s hand rub and may increase further with multiple exposures in a short period.

CONCLUSION

Preterm neonates in the isolette are at risk of inadvertent exposure to ethanol. The expected blood alcohol level from this exposure is small and below 1 mg/dL level recommended by European Medicines Agency to limit the ethanol exposure in children. The unintended ethanol exposure can be avoided by rubbing hands for at least 20 s after applying EBHS.

The Effect of Alcohol-Based Hand Sanitizer Vapors on Evidential Breath Alcohol Test Results

This study was undertaken to determine if the application of alcohol-based hand sanitizers (ABHSs) to the hands of a breath test operator will affect the results obtained on evidential breath alcohol instruments (EBTs). This study obtained breath samples on three different EBTs immediately after application of either gel or foam ABHS to the operator's hands. A small, but significant, number of initial analyses (13 of 130, 10%) resulted in positive breath alcohol concentrations, while 41 samples (31.5%) resulted in a status code. These status codes were caused by ethanol vapors either in the room air or their inhalation by the subject, thereby causing a mouth alcohol effect. Replicate subject samples did not yield any consecutive positive numeric results. As ABHS application can cause a transitory mouth alcohol effect via inhalation of ABHS vapors, EBT operators should forego the use of ABHS in the 15 min preceding subject testing.

Inhalation of Alcohol Vapor: Measurement and Implications

Decades of alcohol research have established the health risks and pharmacodynamic profile of oral alcohol consumption. Despite isolated periods of public health concern, comparatively less research has evaluated exposure to alcohol vapor. Inhaled alcohol initially bypasses first-pass metabolism and rapidly reaches the arterial circulation and the brain, suggesting that this route of administration may be associated with pharmacological effects that increase the risk of addiction. However, detailed reviews assessing the possible effects of inhaled alcohol in humans are lacking. A comprehensive, systematic literature review was conducted using Google Scholar and PubMed to examine manuscripts studying exposure to inhaled alcohol and measurement of biomarkers (biochemical or functional) associated with alcohol consumption in human participants. Twenty-one publications reported on alcohol inhalation. Fourteen studies examined inhalation of alcohol vapor associated with occupational exposure (e.g., hand sanitizer) in a variety of settings (e.g., naturalistic, laboratory). Six publications measured inhalation of alcohol in a controlled laboratory chamber, and 1 evaluated direct inhalation of an e-cigarette with ethanol-containing "e-liquid." Some studies have reported that inhalation of alcohol vapor results in measurable biomarkers of acute alcohol exposure, most notably ethyl glucuronide. Despite the lack of significantly elevated blood alcohol concentrations, the behavioral consequences and subjective effects associated with repeated use of devices capable of delivering alcohol vapor are yet to be determined. No studies have focused on vulnerable populations, such as adolescents or individuals with alcohol use disorder, who may be most at risk of problems associated with alcohol inhalation.

Effects of alcohol-based hand hygiene solutions on breath alcohol detection in the emergency department

This study aimed to investigate the effects of alcohol-based hand hygiene solution (ABHS) use by care providers on point-of-care alcohol breath analyzer interpretation under different clinically relevant conditions. Among each test condition (foam vehicle with immediate testing, gel vehicle with immediate testing, allowing hands to dry after the use of ABHS, and donning gloves after the use of ABHS), alcohol was detected in breath at 1 minute after use of ABHS. Because the use of ABHS by individuals administering breath alcohol detection may result in false-positive detection of alcohol, staff using these devices should consider traditional hand hygiene with soap and water.

Ethanol and ethyl glucuronide urine concentrations after ethanol-based hand antisepsis with and without permitted alcohol consumption

BACKGROUND

During hand antisepsis, health care workers (HCWs) are exposed to alcohol by dermal contact and by inhalation. Concerns have been raised that high alcohol absorptions may adversely affect HCWs, particularly certain vulnerable individuals such as pregnant women or individuals with genetic deficiencies of aldehyde dehydrogenase.

METHODS

We investigated the kinetics of HCWs' urinary concentrations of ethanol and its metabolite ethyl glucuronide (EtG) during clinical work with and without previous consumption of alcoholic beverages by HCWs.

RESULTS

The median ethanol concentration was 0.7 mg/L (interquartile range [IQR], 0.5-1.9 mg/L; maximum, 9.2 mg/L) during abstinence and 12.2 mg/L (IQR, 1.5-139.6 mg/L; maximum, 1,020.1 mg/L) during alcohol consumption. During abstinence, EtG reached concentrations of up to 958 ng/mL. When alcohol consumption was permitted, the median EtG concentration of all samples was 2,593 ng/mL (IQR, 890.8-3,576 ng/mL; maximum, 5,043 ng/mL). Although alcohol consumption was strongly correlated with both EtG and ethanol in urine, no significant correlation for the frequency of alcoholic hand antisepsis was observed in the linear mixed models.

CONCLUSIONS

The use of ethanol-based handrub induces measurable ethanol and EtG concentrations in urine. Compared with consumption of alcoholic beverages or use of consumer products containing ethanol, the amount of ethanol absorption resulting from handrub applications is negligible. In practice, there is no evidence of any harmful effect of using ethanol-based handrubs as much as it is clinically necessary.

Safety assessment for ethanol-based topical antiseptic use by health care workers: Evaluation of developmental toxicity potential

Ethanol-based topical antiseptic hand rubs, commonly referred to as alcohol-based hand sanitizers (ABHS), are routinely used as the standard of care to reduce the presence of viable bacteria on the skin and are an important element of infection control procedures in the healthcare industry. There are no reported indications of safety concerns associated with the use of these products in the workplace. However, the prevalence of such alcohol-based products in healthcare facilities and safety questions raised by the U.S. FDA led us to assess the potential for developmental toxicity under relevant product-use scenarios. Estimates from a physiologically based pharmacokinetic modeling approach suggest that occupational use of alcohol-based topical antiseptics in the healthcare industry can generate low, detectable concentrations of ethanol in blood. This unintended systemic dose probably reflects contributions from both dermal absorption and inhalation of volatilized product. The resulting internal dose is low, even under hypothetical, worst case intensive use assumptions. A significant margin of exposure (MOE) exists compared to demonstrated effect levels for developmental toxicity under worst case use scenarios, and the MOE is even more significant for typical anticipated occupational use patterns. The estimated internal doses of ethanol from topical application of alcohol-based hand sanitizers are also in the range of those associated with consumption of non-alcoholic beverages (i.e., non-alcoholic beer, flavored water, and orange juice), which are considered safe for consumers. Additionally, the estimated internal doses associated with expected exposure scenarios are below or in the range of the expected internal doses associated with the current occupational exposure limit for ethanol set by the Occupational Safety and Health Administration. These results support the conclusion that there is no significant risk of developmental or reproductive toxicity from repeated occupational exposures and high frequency use of ABHSs or surgical scrubs. Overall, the data support the conclusion that alcohol-based hand sanitizer products are safe for their intended use in hand hygiene as a critical infection prevention strategy in healthcare settings.

Assessment of transpulmonary absorption of ethanol from alcohol-based hand rub

BACKGROUND

Alcohol-based hand rubs (ABHRs) have been associated with a reduction of nosocomial infections. Despite the worldwide introduction of these products in health care settings, the aim of this study was to assess the transpulmonary absorption of ethanol contains in ABHRs used by health care workers (HCWs) in real conditions of work shift.

METHODS

Twenty-six HCWs of Nancy University Hospital were included. Research consisted in monitoring participants during 4 hours of work shift to assess their exposure to ethanol. The measurement of ethanol vapors in exhaled breath was performed using a class B ethylometer (Alco-Sensor FST). Ethanol concentration in inhaled breath was measured using Gilian pump LFS-113. Concentration of ethanol, acetaldehyde, and acetate in blood and urine samples were determined using gas chromatography with flame ionization detector.

RESULTS

Participants were 12% male and 88% female. The mean age was 40 ± 8 years. None of the employees included in the study presented any traces of ethanol or its metabolites in the blood or urine. Ethanol (0.08 ± 0.07 mg/L) was detected in the breath of 10 HCWs at 1 to 2 minutes postexposure. The mean concentration of ethanol in the inhaled air was 46.2 mg/m.

CONCLUSION

Absorption of ethanol vapor from ABHRs among HCWs during their care activities was not detected. Quantification of ethanol fumes inhaled during 4 hours of work shift was below the regulatory limitations of exposure to ethanol.