Is Alcohol in Hand Sanitizers Absorbed Through the Skin or Lungs? Implications for Disulfiram Treatment

A Novel Handrub Tablet Loaded with Pre- and Post-Biotic Solid Lipid Nanoparticles Combining Virucidal Activity and Maintenance of the Skin Barrier and Microbiome

OBJECTIVE

This study aimed to develop a holobiont tablet with rapid dispersibility to provide regulation of the microbiota, virucidal activity, and skin barrier protection.

METHODS

A 23 factorial experiment was planned to define the best formulation for the development of the base tablet, using average weight, hardness, dimensions, swelling rate, and disintegration time as parameters to be analyzed. To produce holobiont tablets, the chosen base formulation was fabricated by direct compression of prebiotics, postbiotics, and excipients. The tablets also incorporated solid lipid nanoparticles containing postbiotics that were obtained by high-pressure homogenization and freeze-drying. The in vitro virucidal activity against alpha-coronavirus particles (CCoV-VR809) was determined in VERO cell culture. In vitro analysis, using monolayer cells and human equivalent skin, was performed by rRTq-PCR to determine the expression of interleukins 1, 6, 8, and 17, aquaporin-3, involucrin, filaggrin, FoxO3, and SIRT-1. Antioxidant activity and collagen-1 synthesis were also performed in fibroblast cells. Metagenomic analysis of the skin microbiome was determined in vivo before and after application of the holobiont tablet, during one week of continuous use, and compared to the use of alcohol gel. Samples were analyzed by sequencing the V3-V4 region of the 16S rRNA gene.

RESULTS

A handrub tablet with rapid dispersibility was developed for topical use and rinse off. After being defined as safe, the virucidal activity was found to be equal to or greater than that of 70% alcohol, with a reduction in interleukins and maintenance or improvement of skin barrier gene markers, in addition to the reestablishment of the skin microbiota after use.

CONCLUSIONS

The holobiont tablets were able to improve the genetic markers related to the skin barrier and also its microbiota, thereby being more favorable for use as a hand sanitizer than 70% alcohol.

Disulfiram: Mechanisms, Applications, and Challenges

Background: Since disulfiram’s discovery in the 1940s and its FDA approval for alcohol use disorder, other indications have been investigated. This review describes potential clinical applications, associated risks, and challenges. Methods: For this narrative review, a PubMed search was conducted for articles addressing in vivo studies of disulfiram with an emphasis on drug repurposing for the treatment of human diseases. The key search terms were “disulfiram” and “Antabuse”. Animal studies and in vitro studies highlighting important mechanisms and safety issues were also included. Results: In total, 196 sources addressing our research focus spanning 1948–2022 were selected for inclusion. In addition to alcohol use disorder, emerging data support a potential role for disulfiram in the treatment of other addictions (e.g., cocaine), infections (e.g., bacteria such as Staphylococcus aureus and Borrelia burgdorferi, viruses, parasites), inflammatory conditions, neurological diseases, and cancers. The side effects range from minor to life-threatening, with lower doses conveying less risk. Caution in human use is needed due to the considerable inter-subject variability in disulfiram pharmacokinetics. Conclusions: While disulfiram has promise as a “repurposed” agent in human disease, its risk profile is of concern. Animal studies and well-controlled clinical trials are needed to assess its safety and efficacy for non-alcohol-related indications.

Impact of an Alcohol-based hand sanitizer usage during COVID-19 pandemic on disulfiram treatment: A South Indian psychiatrist's practice experiences

Background: Alcohol-based hand sanitizer (ABHS) usage has become one of the COVID-19 pandemic-related adapted responses. Some disulfiram-ethanol reactions are reported in people who use alcohol-based hand rub/sanitizer and take Disulfiram as a treatment for their alcohol use disorders. Aim & Objective: To determine the practice experiences of psychiatrists on disulfiram prescription to alcohol use disorder victims. Methodology: A cross-sectional study on the psychiatrists to find the experiences of disulfiram prescription to their clients with alcohol use disorders during the COVID-19 pandemic. Results: Nearly 84 (51%) were reverted with a completed questionnaire. Among the respondents, 28 (33.3%) of the respondents decreased to prescribe Disulfiram, 48 (57.1%) reported that their patients stopped using ABHS due to fear of Disulfiram-Ethanol Reaction (DER), and 20 (23.8%) responders notified that their patients were expressed their worry on DER with Disulfiram and ABHS. Conclusion: Disulfiram prescribed for alcohol use disorders; treatment got peculiar experiences with the incidences of DER reported with Alcohol-based hand sanitizer. Many practitioners were scared to prescribe disulfiram due to DER with ABHS. The prevailing evidence that there is no possibility of cutaneous application of ABHS producing enough significant DER. Hence using ABHS is not a contraindication for disulfiram prescription.

Evaluation of the Safety and Efficacy of Hand Sanitizer Products Marketed to Children Available during the COVID-19 Pandemic

Hand sanitizer use in the United States (U.S.) increased after the SARS-CoV-2 outbreak. The U.S. Food and Drug Administration (FDA) released temporary manufacturer guidance, changing impurity level limits for alcohol-based hand sanitizers (ABHSs). Since the guidance took effect, the FDA has recommended against using these hand sanitizers due to concerns over safety, efficacy, and/or risk of incidental ingestion. To address current gaps in exposure characterization, this study describes a survey of ABHSs marketed to children available in the U.S., as defined by several inclusion criteria. A subset of ABHSs (n = 31) were evaluated for ethanol and organic impurities using a modified FDA method. Products with detectable impurity levels were compared to the FDA's established interim limits. Seven children's products had impurity levels exceeding the FDA's recommended interim limits, including benzene (up to 9.14 ppm), acetaldehyde (up to 134.12 ppm), and acetal (up to 75.60 ppm). The total measured alcohol content ranged from 52% to 98% in all hand sanitizers tested, ranging from 39% below, and up to 31% above, the labeled concentration. Future studies should confirm impurity contamination sources. A risk assessment could determine whether dermal application or incidental ingestion of impurity-containing hand sanitizers pose any consumer risk.

The Environmental Footprint Of Single versus Reusable Cloths For Clinical Surface Decontamination: A Life Cycle Approach

Global sustainability is a major health concern facing our planet today. The healthcare sector is a significant contributor to environmentally damaging activity. Reusable cloths should be considered as an environmentally friendly alternative to the predominantly used single-use surface wipes in cleaning and disinfection of environmental surfaces in healthcare settings. To understand its feasibility, a rapid review of current policies on surface decontamination in healthcare settings was conducted. A life cycle impact assessment (LCIA) was then carried out to compare the impact of reusable cotton and microfibre cloths versus conventional single-use cloths, with three compatible disinfectants. Seven countries were included in the rapid review of policies. For the LCIA, inputs, outputs, and processes across the life cycle were included, using EcoInvent database v3.7.1 and open LCIA software. Sixteen European-recommended environmental impact categories and eight human health categories were considered. Infection prevention policies examined do not require single-use wipes for cleaning and disinfection. The disinfectant with the highest environmental impact was isopropyl-alcohol. The most environmentally-sustainable option for clinical surface decontamination was the microfibre cloth when used with a quaternary ammonium compound. The least environmentally sustainable option was cotton with isopropyl-alcohol. Impacts were primarily attributed with the use of the disinfectant agent and travel processes.

Hand hygiene with hand sanitizer versus handwashing: what are the planetary health consequences?

In order to reduce the transmission of pathogens, and COVID-19, WHO and NHS England recommend hand washing (HW) and/or the use of hand sanitizer (HS). The planetary health consequences of these different methods of hand hygiene have not been quantified. A comparative life cycle assessment (LCA) was carried out to compare the environmental impact of the UK population practising increased levels of hand hygiene during the COVID-19 pandemic for 1 year. Washing hands with soap and water was compared to using hand sanitizer (both ethanol and isopropanol based sanitizers were studied). The isopropanol-based HS had the lowest environmental impact in 14 out of the 16 impact categories used in this study. For climate change, hand hygiene using isopropanol HS produced the equivalent of 1060 million kg CO₂, compared to 1460 million for ethanol HS, 2300 million for bar soap HW, and 4240 million for liquid soap HW. For both the ethanol and isopropanol HS, the active ingredient was the greatest overall contributing factor to the environmental impact (83.24% and 68.68% respectively). For HW with liquid soap and bar soap, there were additional contributing factors other than the soap itself: for example tap water use (28.12% and 48.68% respectively) and the laundering of a hand towel to dry the hands (10.17% and 17.92% respectively). All forms of hand hygiene have an environmental cost, and this needs to be weighed up against the health benefits of preventing disease transmission. When comparing hand sanitizers to handwashing with soap and water, this study found that using isopropanol based hand sanitizer is better for planetary health. However, no method of hand hygiene was ideal; isopropanol had a greater fossil fuel resource use than ethanol based hand sanitizer. More research is needed to find hand hygiene sources which do not diminish planetary health, and environmental impact is a consideration for public health campaigns around hand hygiene.

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.

Alcohol, COVID-19 and the smell of relapse: a case report

The global pandemic lockdown created a risk factor for increased alcohol consumption in people with alcohol use disorder and relapse for those who were previously abstinent, with evidence suggesting that pre-lockdown abstinence status is not protective against lockdown-related relapse. We report a unique case of a middle-aged male with alcohol use disorder who experienced alcohol cravings and a fear of relapse due to exposure to disinfectants. A 54-year-old public transportation company worker, previously treated for an alcohol use disorder three times, and abstinent since his last treatment in 2017, reported anxiety, irritability, and constant fear of relapse due to increased exposure to sanitizers during the pandemic. He explained that while the diluted disinfectant made him think of alcohol, the now ever-present undiluted disinfectant makes him constantly crave alcohol and it makes it harder for him to work. Although he started group therapy treatment and had several follow-up visits, his poor performance at work and the fear of relapse resulted in him requesting a position change to work in open spaces and avoid the smell of disinfectant, which helped him remain abstinent. Disinfectants are a part of the "new normal," and their increased use is likely to be continued in the years to come, even after the pandemic resolves. Introducing a new behavioral pattern, such as the daily use of disinfectants in the general population, should prompt us to explore all possible consequences regarding its propagation.

The Role of Alcohol Biomarkers in Detecting a Physician's COVID-19-Related Acute Stress Response: A Case Report

OBJECTIVES

Alcohol biomarkers are used to detect alcohol exposure in clinical and forensic settings. This includes professional health program (PHP) monitoring of healthcare workers in recovery from substance use disorders. Here we present the case of a physician whose positive alcohol biomarker test result was complicated by a traumatic stress response to frontline work during COVID-19.

METHODS

An anesthesiologist under PHP monitoring for substance use disorder and depression was interviewed extensively, urine and blood biomarkers were obtained, and longitudinal structured and semi-structured interviews related to anxiety, depression, posttraumatic stress, and cravings were used to monitor responses to the unanticipated death of a patient who succumbed to COVID-19.

RESULTS

After an initial positive ethylglucuronide (EtG) and ethylsulfate (EtS) toxicology test result, all subsequent testing was negative. Standardized assessments and clinical interviews provided documentation of a post-traumatic stress reaction. The physician described compulsive sanitizing of hands/arms and mask with highly concentrated ethanol-based products.

CONCLUSIONS

Inhalation of ethanol vapors is a possible explanation for the initial positive EtG/EtS results. To our knowledge, this case represents the highest reported levels of EtG/EtS likely due to workplace exposure. The importance of rapid intervention to thoroughly assess positive toxicology testing and its source(s) cannot be overstated, particularly as it relates to frontline healthcare workers during the pandemic. The PHP monitoring process provides an opportunity to promptly detect healthcare workers in distress, allowing for efficient connection to supportive resources and/or treatment when indicated, and possibly preventing escalation of symptoms or disease recurrence.

Alcohol-Based Hand Sanitizers in COVID-19 Prevention: A Multidimensional Perspective

The global use of alcohol-based hand sanitizers (ABHS) as an important means of controlling the transmission of infectious disease has increased significantly as governments and public health agencies across the world advocated hand hygiene as a preventative measure during the COVID-19 pandemic. Although the performance of these products is most commonly defined as a function of their alcohol concentration, they are multifaceted products in which an interplay of several factors is important in determining efficacy. This paper discusses the interplay between ABHS input (formulation) factors and output (product performance) factors in the context of a multidimensional perspective using a novel representative paradigm. In the model, represented in the form of a three-dimensional tetrahedron, each of the faces represents inputs in the manufacturing of the ABHS product, which are the type and amount of alcohol, the inactive ingredients, the formulation and the manufacturing practices. The four corners of the tetrahedron represent the product performance factors which include product efficacy, sensory characteristics, usage and compliance and product safety. The multidimensional approach to the formulation and evaluation of ABHS shows that several factors contribute to the effectiveness and utility of these products. The paradigm provides a useful framework for manufacturers of ABHS and related healthcare products.

Drug Repurposing of the Alcohol Abuse Medication Disulfiram as an Anti-Parasitic Agent

Parasitic infections contribute significantly to worldwide morbidity and mortality. Antibiotic treatment is essential for managing patients infected with these parasites since control is otherwise challenging and there are no vaccines available for prevention. However, new antimicrobial therapies are urgently needed as significant problems exist with current treatments such as drug resistance, limited options, poor efficacy, as well as toxicity. This situation is made worse by the challenges of drug discovery and development which is costly especially for non-profitable infectious diseases, time-consuming, and risky with a high failure rate. Drug repurposing which involves finding new use for existing drugs may help to more rapidly identify therapeutic candidates while drastically cutting costs of drug research and development. In this perspective article, we discuss the importance of drug repurposing, review disulfiram pharmacology, and highlight emerging data that supports repurposing disulfiram as an anti-parasitic, exemplified by the major diarrhea-causing parasite Entamoeba histolytica.

Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study

Aims

We conducted a cross-sectional survey to estimate the prevalence and clinical manifestation of disulfiram ethanol reaction (DER) and isopropanol toxicity (IT) in patients with alcohol use disorders, on disulfiram. Alcohol-based hand rub contains either ethanol or isopropanol or both. COVID-19 pandemic has led to wide scale usage of sanitizers. Patients with alcohol use disorders, on disulfiram, might experience disulfiram ethanol like reactions with alcohol-based sanitizers.

Methods

We telephonically contacted 339 patients, prescribed disulfiram between January 2014 and March 2020. The assessment pertained to the last 3 months (i.e. third week of March to third week of June 2020).

Result

The sample consisted of middle-aged men with a mean 16 years of alcohol dependence. Among the 82 (24%) patients adherent to disulfiram, 42 (12.3%) were using alcohol-based hand rubs. Out of these, a total of eight patients (19%; 95% CI 9–33) had features suggestive of DER; four of whom also had features indicative of IT. Five patients (62.5%) had mild and self-limiting symptoms. Severe systemic reactions were experienced by three (37.5%). Severe reactions were observed with exposure to sanitizers in greater amounts, on moist skin or through inhalation.

Conclusion

Patients on disulfiram should be advised to use alternate methods of hand hygiene.

Use of Ethanol-Based Hand Disinfectants: Source of Increased Ethyl Glucuronide Levels in Hair?

Aim

Due to the COVID-19 pandemic increasing the use of hand disinfectants, we investigated the effect of frequent use of ethanol-based hand disinfectants (EBHD) on the levels of the alcohol marker ethyl glucuronide (EtG) in hair.

Method

Hair samples were collected from 10 health professionals (8 nondrinkers, 2 rarely drinking individuals) and EtG was examined in hair.

Result

EtG (~2 pg/mg) was only detected in the hair sample of a nondrinker using EBHD 60–70 times per working day.

Conclusion

Our data provide no evidence that frequent EBHD use results in hair EtG levels above the recommended Society of Hair Testing cutoff for repeated alcohol consumption (5 pg/mg).

Antiseptic drugs and disinfectants with special scrutiny of COVID-19 pandemic related side effects

This review covers publications during the period of January 2020 to December 2020 on adverse reactions to antiseptic drugs and disinfectants. Specific agents discussed are alcohols (ethanol, isopropanol), aldehydes (formaldehyde), guanidines (chlorhexidine, polyhexamethylene guanidine, and polyhexamethylene biguanidine), benzalkonium compounds, triclocarban, povidone-iodine, and sodium hypochlorite. No new data were identified for glutaraldehyde, cetrimide, ethylene oxide, tosylchloramide, triclosan, iodine, and phenolic compounds. The use of antiseptic drugs and disinfectants has been considerably increased during 2020 in a variety of medical and occupational settings, in commerce and gastronomy, as well as in the household, due to their antiviral properties against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the Coronavirus Disease 2019 (COVID-19) pandemic. Exposure was additionally increased by widespread misinformation on social media for non-evidence based disinfectant use, even including ingestion or injection, as well as by questionable practices such as environmental spraying or disinfectant gates. Irritant effects on the respiratory system, skin and eyes were the most common adverse reaction, while the widespread and sometimes excessive use led to increased reports of poisonings, as well as cases of disinfectant adulteration including dilution into ineffective concentrations or addition of toxic agents such as methanol.

Recognition of a disulfiram ethanol reaction in the emergency department is not always straightforward

OBJECTIVES

Disulfiram is an adjunct in the treatment of alcohol use disorders, but case reports indicate that disulfiram ethanol reactions are not always recognized in the emergency department. Our first aim is to remind of this risk with two case reports of life-threatening reactions not immediately considered by the emergency physician. The second aim is to estimate the probability that a disulfiram reaction goes unrecognized with the use of a retrospective study of patients admitted to the emergency department.

METHODS

Clinical files of patients admitted between October 1, 2010 and September 30, 2014 to the emergency department were retrospectively screened for the key words "ethanol use" and "disulfiram". Their diagnoses were then scored by a panel regarding the probability of an interaction.

RESULTS

Seventy-nine patients were included, and a disulfiram-ethanol reaction was scored as either 'highly likely', 'likely' or 'possible' in 54.4% and as 'doubtful' or 'certainly not present' in 45.6% of the patients. The interrater agreement was 0.71 (95% CI: 0.64-0.79). The diagnosis was not considered or only after a delay in 44.2% of the patients with a 'possible' to 'highly likely' disulfiram interaction. One patient with a disulfiram overdose died and was considered as a 'possible' interaction.

DISCUSSION AND CONCLUSIONS

A disulfiram ethanol interaction can be life threatening and failure to consider the diagnosis in the emergency department seems frequent. Prospective studies with documentation of the intake of disulfiram and evaluation of the value of acetaldehyde as a biomarker are needed to determine the precise incidence. Improving knowledge of disulfiram interactions and adequate history taking of disulfiram intake may improve the care for patients.

Sanitization During and After COVID-19 Pandemic: A Short Review

Sanitization is a preventive and strategic method to contain the spread of SARS-CoV2. Since there is no foolproof method to tackle the present COVID-19 pandemic, sanitization has a central role to play. The present article briefly reviews various methods of sanitization for individuals, surfaces and ambience. The article reviews different approaches toward sanitization and examines the historicity of the methods employed.