Can intensive use of alcohol-based hand rubs lead to passive alcoholization?

High risk and low prevalence diseases: Toxic alcohol ingestion

INTRODUCTION

Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis.

CONCLUSIONS

An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Assessment of Ethanol Exposure from Hand Sanitizer Use and Potential for Developmental Toxicity in Nursing Infants

Ingestion of ethanol during pregnancy is known to have detrimental effects on the fetus. Although the potential developmental effects of maternal ethanol intake during lactation are less well characterized, public health guidelines recommend avoidance of alcohol or, if alcohol is consumed, to allow for 1–2 h to pass before nursing. A proposal to classify ethanol as potentially harmful to breast‐fed children warrants an investigation of the potential adverse neurodevelopmental effects of low‐dose ethanol exposure during lactation. There currently are no studies that have examined neurodevelopmental outcomes from lactational exposure to ethanol from the use of topical products that contain ethanol, such as alcohol‐based hand sanitizers (ABHS). Furthermore, the epidemiological literature of lactational ethanol exposures from maternal alcohol consumption is limited in design, provides equivocal evidence of neurological effects in infants, and is insufficient to characterize a dose–response relationship for developmental effects. Toxicological studies that observed neurodevelopmental effects in pups from ethanol via lactation did so at exceedingly high doses that also caused maternal toxicity. In this investigation, blood ethanol concentrations (BECs) of breastfeeding women following typical‐to‐intense ABHS use were computationally predicted and compared to health benchmarks to quantify the risk for developmental outcomes. Margins of 2.2 to 1000 exist between BECs associated with ABHS use compared to BECs associated with neurotoxicity adverse effect levels in the toxicology literature or oral ethanol intake per public health guidelines. Neurodevelopmental effects are not likely to occur in infants due to ABHS use by breastfeeding women, even when ABHSs are used at intense frequencies.

Adverse neurodevelopmental effects of ethanol exposure are supported by toxicological studies; ethanol as a potential “lactation hazard” needs evaluation. A lactation hazard may not be applicable for all ethanol‐containing products, such as hand sanitizers. Furthermore, internal dose assessments of hand sanitizer use are lacking. Computationally modeled blood ethanol concentrations following hand sanitizer use are lower than concentrations associated with toxicological and guideline benchmarks. Therefore, there is low potential for the use of ethanol‐containing hand sanitizers to be a lactation hazard.

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.

Production of first- and second-generation ethanol for use in alcohol-based hand sanitizers and disinfectants in India

Emergence of "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" causing "COVID-19" or "coronavirus disease 19" as pandemic has got worldwide attention towards hygiene as the first line of defense for the infection control. It is first line of defense not only from COVID-19 but also from other infectious diseases caused by deadly pathogens such as cholera, hepatitis, tuberculosis, polio, etc. Absence of any particular vaccine or treatment let World Health Organization (WHO) recommend to the public to maintain social distancing along with regularly washing their hands with soap, sanitize their hands (where washing is not possible), and disinfect their belongings and buildings to avoid the infection. Out of various formulations available in the market, WHO has recommended alcohol-based hand sanitizers, which mainly comprise of ethanol, isopropyl alcohols, and hydrogen peroxides in different combinations due to their high potential to kill the broad range of pathogens including bacterial, viral, fungal, helminthes, etc. Therefore, alcohol-based sanitizers are in high demand since centuries to prevent infection from pathogenic diseases. Ethanol is the most common and popular alcohol in terms of vanishing wide range of pathogens, convenient to use and its production. Ethanol is produced worldwide and is used in various sectors, e.g., beauty and cosmetics, food and beverages, and as the most demanding gasoline additive. The present review is focused on the ethanol production in India, its diversified applications emphasizing hand sanitizers with discussions on formulation of sanitizer and disinfectants, and viability of lignocellulosic and food grain-based ethanol. The review article also emphasizes on the technological details of 1G and 2G ethanol production, their associated challenges, and inputs for the improved ethanol yields so as to strengthen the supply chain of ethanol in India, and making "Atmanirbhar Bharat" (Self-reliant India) campaign of Indian government successfully viable.

Toxicology of alcohol-based hand rubs formulated with technical-grade ethanol

Alcohol-based hand rubs (ABHRs) formulated with technical-grade ethanol were temporarily permitted in Canada and the U.S beginning April 2020 to meet the current demand due to COVID-19. ABHRs formulated with technical-grade ethanol are low risk for general use. In this review, we discuss the toxicity of common contaminants found in technical-grade ethanol, as well as contaminants that may have been introduced into the products during formulation and packaging of ABHRs. Although primary route of exposure is via dermal absorption and inhalation, there have been reported elevated concerns regarding to ingestion of ABHRs. Overall, the highest risks were associated with methanol (for its toxicity), ethyl acetate (skin defattening), and acetaldehyde (carcinogenic and teratogenic). For these reasons Health Canada and the United States Food and Drug Administration have issued recalls on products containing some of these contaminants. More vigilant policing by regulatory agencies and general product users are required to ensure compliance, safety, and efficacy of these new products, as demand continue to rise during this unprecedented pandemic.

Bentonite Clay: A Potential Natural Sanitizer for Preventing Neurological Disorders

SARS-CoV-2 is a positive stranded-RNA human viral pathogen that attacks the central nervous system (CNS), causing interminable diseases. Although alcohol-based hand sanitizers (ABHS) control the widespread transmission of such pathogens through dermal contact, excessive exposure to alcohol mists and vapors causes CNS disorders, apart from skin infections and negative impacts on the useful microbiome. Herein, we propose bentonite paste, which interacts strongly with different +RNA viruses such as SARS-CoV-2/poliovirus, for dermal sanitization. Repeated hand cleansing with bentonite paste not only provides complete protection against any viruses but also improves the skin condition. The proposed method is useful for contact isolation and as a strict infection control tool in hospital settings and in public.

In Vivo Comparison of Chlorine-Based Antiseptics versus Alcohol Antiseptic for Surgical Hand Antisepsis

Despite being commonly used as effective preparation for surgical hand antisepsis, alcohol solutions have major drawbacks, such as drying effect, emergence of hand eczema, and other diseases. This study aimed to demonstrate the effectiveness of sodium hypochlorite (NaOCl) and hydrogen peroxide (H₂O₂) as antiseptic in comparison to single sodium hypochlorite and 70% ethanol. In 5-day tests, the effects of 3 antiseptics were established according to standard test methods. The antiseptics were applied to the hands of 82 volunteers, and samples of bacteria were collected on days 1 and 5, immediately after drying and 6 hours later after antiseptic application. Student's t test and ANOVA were applied in a statistical study. The NaOCl with H₂O₂ composition demonstrated noninferiority to both sodium hypochlorite only and alcohol products and superiority to these antiseptics on day 5 (P < 0.05 at a significance level of 5% for each comparative trial in this day) at equivalence margin of 20%. The effectiveness of the NaOCl plus H₂O₂ composition as an antiseptic was explained by the formation of singlet oxygen in the system. Together, these data suggest that NaOCl and H₂O₂ may be an effective hand antisepsis that avoids the drawbacks seen with alcohol solutions.

Rinse-free hand wash for reducing absenteeism among preschool and school children

BACKGROUND

Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.

OBJECTIVES

1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest.

SEARCH METHODS

In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.

DATA COLLECTION AND ANALYSIS

Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.

MAIN RESULTS

This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.

Developing chlorine-based antiseptic by electrolysis

The use of Alcohol-based antiseptics is efficient and approved, however it has some limitations. This paper examined the possibility of using hypochlorite water as a chlorine-based antiseptic for handwashing in public buildings and healthcare facilities. The electrolysis method was used, which produces Hypochlorous acid (HOCl) from mixing drinking water with small amounts of sodium hydroxide. Hypochlorous acid is usually produced by blood cells to surround pathogens when the skin is cut and exposed to pathogens. The methods used were based on hydrolysing drinking water at a different salt concentration (from 0 up to saline water 0.9% NaCl) under the different power supply. The results showed that 0.005-0.01% hydrochloride water can be a perfect antiseptic that can kill most bacteria and pathogenies within 12 s. In one prototype set up one litter of the prepared solution needed the only 2 g of NaCl, 12 V and 3 amps' power. However, the pH value should be maintained to be around 5-6. The results also showed that the most efficient way was to produce the solution on-site. However, if stored properly it can be used for 7-10 days after production.

Toxic alcohol diagnosis and management: an emergency medicine review

Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.

Effect of multiple alcohol-based hand rub applications on the tensile properties of thirteen brands of medical exam nitrile and latex gloves

Current CDC guidance for the disinfection of gloved hands during the doffing of personal protective equipment (PPE) following the care of a patient with Ebola recommends for multiple applications of alcohol-based hand rub (ABHR) on medical exam gloves. To evaluate possible effects of ABHR applications on glove integrity, thirteen brands of nitrile and latex medical exam gloves from five manufacturers and two different ABHRs were included in this study. A pair of gloves were worn by a test operator and the outside surfaces of the gloves were separately treated with an ABHR for 1-6 applications. Tensile strength and ultimate elongation of the gloves without any ABHR treatments (control gloves) and gloves after 1-6 ABHR applications were measured based on the ASTM D412 standard method. In general, tensile strength decreased with each ABHR application. ABHRs had more effect on the tensile strength of the tested nitrile than latex gloves, while ethanol-based ABHR (EBHR) resulted in lesser changes in tensile strength compared to isopropanol-based ABHR (IBHR). The results show that multiple EBHR applications on the latex gloves and some of the nitrile gloves tested should be safe for Ebola PPE doffing based on the CDC guidance. Appropriate hospital staff practice using ABHR treatment and doffing gloves is recommended to become more familiar with changes in glove properties.

VOC contamination in hospital, from stationary sampling of a large panel of compounds, in view of healthcare workers and patients exposure assessment

BACKGROUND

We aimed to assess, for the first time, the nature of the indoor air contamination of hospitals.

METHODS AND FINDINGS

More than 40 volatile organic compounds (VOCs) including aliphatic, aromatic and halogenated hydrocarbons, aldehydes, alcohols, ketones, ethers and terpenes were measured in a teaching hospital in France, from sampling in six sampling sites--reception hall, patient room, nursing care, post-anesthesia care unit, parasitology-mycology laboratory and flexible endoscope disinfection unit--in the morning and in the afternoon, during three consecutive days. Our results showed that the main compounds found in indoor air were alcohols (arithmetic means ± SD: 928±958 µg/m³ and 47.9±52.2 µg/m³ for ethanol and isopropanol, respectively), ethers (75.6±157 µg/m³ for ether) and ketones (22.6±20.6 µg/m³ for acetone). Concentrations levels of aromatic and halogenated hydrocarbons, ketones, aldehydes and limonene were widely variable between sampling sites, due to building age and type of products used according to health activities conducted in each site. A high temporal variability was observed in concentrations of alcohols, probably due to the intensive use of alcohol-based hand rubs in all sites. Qualitative analysis of air samples led to the identification of other compounds, including siloxanes (hexamethyldisiloxane, octamethyltrisiloxane, decamethylcyclopentasiloxane), anesthetic gases (sevoflurane, desflurane), aliphatic hydrocarbons (butane), esters (ethylacetate), terpenes (camphor, α-bisabolol), aldehydes (benzaldehyde) and organic acids (benzoic acid) depending on sites.

CONCLUSION

For all compounds, concentrations measured were lower than concentrations known to be harmful in humans. However, results showed that indoor air of sampling locations contains a complex mixture of VOCs. Further multicenter studies are required to compare these results. A full understanding of the exposure of healthcare workers and patients to complex mixtures of chemical compounds can then be related to potential health outcomes.

Common hand sanitizer may distort readings of breathalyzer tests in the absence of acute intoxication

OBJECTIVES

The use of alcohol-based hand sanitizers has recently become widespread. To the authors' knowledge, no previous study has examined whether application of ethanol-based hand sanitizers by the person operating a common breathalyzer machine will affect the accuracy of the readings. This was a prospective study investigating whether the use of hand sanitizer applied according to manufacturer's recommendations (Group I), applied improperly at standard doses (Group II), or applied improperly at high doses (Group III) had an effect on breathalyzer readings of individuals who had not ingested alcohol.

METHODS

The participants of the prospective study were divided into three groups to assess the effect of hand sanitizer on breathalyzer readings. Group I used one pump (1.5 mL) of hand sanitizer (Purell), allowing the hands to dry per manufacturer's recommendations; Group II used one pump (1.5 mL), without allowing the hands to dry; and Group III used two pumps (3 mL), without allowing the hands to dry. Breathalyzer measures for each group are presented as medians with interquartile ranges (IQR) and ranges. Differences between each sequential group (I vs. II and II vs. III) were assessed using a Mann-Whitney U-test (p < 0.05 significant).

RESULTS

There were 25 study participants in each group for a total of 75 participants. The initial breathalyzer readings of all study participants were 0.000 g/dL. The median breathalyzer reading was 0.004 g/dL in Group I (IQR = 0.001 to 0.008 g/dL), 0.051 g/dL in Group II (IQR = 0.043 to 0.064 g/dL), and 0.119 g/dL in Group III (IQR = 0.089 to 0.134 g/dL). Measures between each subsequent group were all statistically different (p < 0.001).

CONCLUSIONS

The use of common alcohol-based hand sanitizer may cause false-positive readings with a standard hospital breathalyzer when the operator uses the hand sanitizer correctly. The breathalyzer readings are further elevated if more sanitizer is used or if it is not allowed to dry appropriately.

Assessment of exposure to alcohol vapor from alcohol-based hand rubs

This study assessed the inhaled dose of alcohol during hand disinfection. Experiments were conducted with two types of hand rub using two hand disinfection procedures. Air samples were collected every 10 s from the breathing zone, by bubbling through a mixture of K₂Cr₂O₇ and H₂SO₄. The reduction of dichromate ions in the presence of alcohols was followed by UV-vis spectrophotometry. The difference in intensity of the dichromate absorption peak was used to quantify the alcohol concentration expressed in ethanol equivalent. During hygienic hand disinfection, the mean ethanol equivalent concentrations peaked at around 20–30 s for both hand rubs (14.3 ± 1.4 mg/L for hand rub 1 and 13.2 ± 0.7 mg/L for hand rub 2). During surgical hand disinfection, two peaks were found at the same time (40 and 80 s) for both hand rubs. The highest mean concentrations were 20.2 ± 0.9 mg/L for hand rub 1 and 18.1 ± 0.9 mg/L for hand rub 2. For hand rub 1, the total absorbed doses, calculated from ethanol with an inhalation flow of 24 L/min and an absorption rate of 62%, were 46.5 mg after one hygienic hand disinfection and 203.9 mg after one surgical hand disinfection. Although the use of ABHRs leads to the absorption of very low doses, sudden, repeated inhalation of high alcohol concentrations raises the question of possible adverse health effects.