Biocidal Hand Products - Essay Example

Dissertation Topic: Determination of the effectiveness of Biocidal Hand Products Objective of the dissertation is to find effectiveness of an alcohol gel called Purell a biocidal product used for hand sanitization. Extensive research was undertaken to ascertain whether alcohol based gel, Purell is effective enough to kill the bacteria using proper hand washing techniques. Methodology: Online journals, publications and studies researched on the internet. Conclusion was that alcohol-based hand rubs are well tolerated and do not dry out or irritate the skin. The active ingredient in sanitizers alcohol iseffective than soap and water in killing bacteria and viruses that cause disease. 1.0 Introduction The number of hospitals using waterless alcohol hand sanitizer has doubled since 2001. These findings apply to nurses washing hands during routine patient-care activities on the general patient floor as well as to pre-op surgical preparation and post-op hand washing in the hospital operating recovery room. Hand hygiene is widely acknowledged as the single most important activity for reducing the spread of disease. (Boyce J M, Pittet D 2002) Hand washing is a simple habit that requires minimal training and no special equipment and is one of the best ways to avoid getting sick. Despite the proven health, benefits of hand washing many people do not practice this habit as often. Infectious diseases commonly spread through hand-to-hand contact as the common cold, flu and several gastrointestinal disorders such as infectious diarrhoea. (A A P, 2003) Inadequate hand hygiene also contributes to food-related illnesses such as Salmonella and E.Coli infection. Hand washing is considered the most effective way of reducing cross infection and the number one way to prevent disease. (Boyce J M, 2001).Earlier people washed their hands with water, sand, animal products, sanitary wipes, bar, liquid, flake and foam soaps.The waterless hand sanitizer gels and sprays is the most recent development in hand washing products. Alcohol-based hand sanitizers that do not require water are an excellent alternative to hand washing particularly when soap and water are not available. (Kelliher S, Vallande N, 2000) They are actually more effective than soap and water in killing bacteria and viruses that cause disease. There is decreased skin irritation and dryness. (Kampf G, et al 2005) The active ingredient in these sanitizers is alcohol. 1.1 There are two different products for hand hygiene: 1.1.1 Antiseptic wash lotions: rinse-off products 1.1.2 Alcohol based liquids: leave-on products used for hand disinfection. The European requirement for medicated soaps in bacterial suspension testing, require a reduction of at least 3 log 10 steps against the test bacteria. Alcoholic hand disinfectants are required to reduce the count of test bacteria by a minimum of 5 log 10 steps within the same application time. The safety margin for the user is 100-fold higher with alcohol-based rub-in products. 1.2 Alcoholic hand wash gels are transparent, uniform, easily deformed dispersed systems consisting of at least two components. One is a fluid acting as a dispersing agent and the other a structure-giving component, a solid colloidal material. This stabilizes the fluid part by forming a three dimensional network. There are many types of gels: 1.2.1 Hydro gels: consist of fluid and water. 1.2.2 Alcohol gels: consist of fluid and alcohol. 1.2.3 Lipogels: fluid and liquid fats e.g. Paraffin. 1.2.4 Surfactant gels: fluid and water or surfactant mixture. Hydro gels and Alcohol gels have a distinct cooling effect mainly due to the evaporation of the water or alcohol. The structure-giving component is organic or inorganic, hydrophilic or lipophilic, synthetic or natural. Polyacrylic acid that has a marked penetration effect is used in alcohol gels. 1.3 Antiseptics and disinfectants are extensively used in hospitals and other health care settings for a variety of topical and hard-surface applications. A wide variety of active chemical agents called biocides are found in these products, many of which have been used for hundreds of years, including alcohols, phenols, iodine, and chlorine. Most of these active agents demonstrate broad-spectrum antimicrobial activity however, little is known about the mode of action of these agents in comparison to antibiotics. The widespread use of these products has prompted some speculation on the development of microbial resistance, in particular whether antiseptics or disinfectants induce antibiotic resistance. Known mechanisms of microbial resistance both intrinsic and acquired to biocides reviewed, with emphasis on the clinical implications. (G Mc Donnell, A D Russell 1999) 1.3.1 Alcohol based hand antiseptics contain iso-propanol, ethanol or n-propanol, alone or in combination. (Boyce J M, Pittet D 2002) Alcohols denature proteins, which are believed to be the main mechanism of antimicrobial action. Solutions containing 60% to 95% alcohol are most effective. The antimicrobial action of alcohols is transient but the effect prolonged by the addition of other chemicals, such as chlorhexidine or triclosan. Alcohols have a wide spectrum of activity, but are less active against bacterial spores, some non-enveloped non-lipophilic viruses and protozoan oocysts. 1.3.1 Activity against non-enveloped viruses: Alcohol based hand rubs do have activity against several non-enveloped viruses e.g., rotavirus, adenovirus, rhinovirus, hepatitis A and poliovirus. However, alcohol may not be effective against hepatitis A and other non-lipophilic viruses, depending on the alcohol concentration and the amount of time that viruses exposed to the alcohol. 1.3.2 Antimicrobial log reduction: Alcohol has an excellent initial antimicrobial log reduction activity because of its ability to denature proteins. Most alcohol hand sanitizer formulations offer excellent initial log reduction of gram-positive and gram-negative bacteria, fungi and multi-drug resistant pathogens such as vancomycin-resistant Enterococcus VRE and methicillin-resistant Staphylococcus aureus MRSA. However, alcohol does not have the residual ability to inhibit microorganisms over the entire patient day. Therefore, it is important that healthcare practitioners use a waterless alcohol hand sanitizer before and after each patient handling episode during the entire patient-handling day to fully utilize alcohol's excellent initial log reduction activity. In addition, not all alcohol hand sanitizer formulas are the same as variance occurs in actual formulations with some alcohol hand sanitizers varying for alcohol from 60 percent to 95 percent. More alcohol is not necessarily better, as less water content in the formulation can actually hinder the effectiveness of alcohol in denaturing proteins. 1.3.3 Alcohol hand sanitizers are available in several formats. Liquids, thick gels and foams. Foams are not widely used, as they are significantly more expensive. Thicker alcohol gel formats are better than the liquid form as they tend not to spill as easily. 1.3.4 Fragrance and Colour in the Formulation: Some manufacturers add fragrance to their alcohol hand sanitizer formulation. Their logic is that the formulation is more appealing to caregivers and patients. Fragrance becomes a problem due to the potential among caregivers and patients for allergic reactions to different fragrances. A fragrance-free product is preferable. Hand rinses, healthcare personnel hand washes and lotions are all regarded as having a degree of personal use preference, so high fragrance levels can become a problem for caregivers and patients. 1.4 Biocides are generally synthetic or semi synthetic molecules that, above certain concentrations and under defined conditions kill living cells within specified time intervals. (Bloomfield S F, 2002) Antimicrobial chemicals or biocides include sterilants, disinfectants and fungicides Sterilants destroy all forms of microbial life, disinfectants eliminate infectious pathogenic bacteria, sanitizers reduce microbial contaminants, and fungicides destroy fungi on inanimate surfaces that are pathogenic to humans and animals. 1.5 Mechanisms of antimicrobial resistance: To enable them to evade the action of antimicrobials Microorganisms have evolved mechanisms. Several different mechanisms of resistance are described in bacteria (Opal S M et al, 2005) These mechanisms are: 1.5.1 Enzymatic inhibition 1.5.2 Membrane impermeability 1.5.3 Efflux pumps 1.5.4 Alteration of the ribosomal target 1.5.5 Alteration of the cell wall precursor target 1.5.6 Alteration of target enzymes 1.5.7 Overproduction of target enzymes and 1.5.8 Auxotroph that bypass inhibited steps. These mechanisms apply to biocides in theory. (Opal S M, Mayer K H, Medeiros A A 2005) Where simultaneous changes in susceptibility to antibiotics and biocides occur, the determinants of resistance have mostly involved genes that encode for multi-drug efflux pumps. These genes may be plasmid-borne in Gram-positive species or chromosomally encoded in Gram-negative species (Bloomfield S F, 2002) 1.6 Reduced susceptibility to biocides: Triclosan-resistant mutants of E coli, S aureus are examples of biocide use and reduced susceptibility. (Bloomfield S F, 2002) The use of triclosan may potentially enhance the growth of resistant strains of Streptococcus pneumoniae and Enterococcus faecalis. (Levy S B, 2001) This has raised concerns regarding the effect of home use of residue-producing biocides on the microbiology of the home and on the long-term effectiveness of biocides. While the development of reduced susceptibility to biocides in response to biocide exposure can occur, in the short-term, it is not likely that this would compromise the effectiveness of these agents in situations where much higher concentrations are used. (Murry L M, 1998) However, the long-term consequences of continued biocide use and emerging resistance are less clear. One concern is not just related to the effectiveness of the biocide, but to the potential for cross-resistance to important antibiotics (Levy S B, 2000) 2.0 Hand Washing Technique: Hands should be washed in the palm areas, in between the fingers, on top of the hand, and underneath the fingernails. It is also important to use enough pressure or friction when rubbing hands together. This comprises of five strokes backwards and five strokes forward. Palm right palm over left dorsum and left palm over right dorsum. Palm to palm with fingers interlaced, back of fingers to opposing palms with fingers interlocked, rotational rubbing of right thumb clasped in left palm and left thumb clasped in right palm. Rotational rubbing with clasped fingers of right hand in palm of left hand. And clasped fingers of left hand in palm of right hand. 2.1 Hand rub procedure: The hand rub procedure is according to the information provided by the manufacturer of hand disinfectant products. It includes the quantity of product and the frequency of application. Usually the total rubbing time is limited to either 30 seconds or 60 seconds. The alcohol gel solution to be used before and after each patient contact in a hospital environment. A dime-size portion of gel should be rubbed over front and back of hands and allowed to be evaporated which takes 10-15 seconds. It is advisable to wash hands with soap and water after using the gel product approximately 10-12 times because hands may feel slightly sticky or if the hands become visibly soiled with patient blood or body fluids. 2.2 Proper hand washing with soap and water: Wet hands with warm, running water and apply liquid or clean bar soap. Lather well. Rub hands vigorously together for at least 15 seconds. Scrub all surfaces, including the backs of hands, wrists, between fingers and under fingernails. Rinse well and dry hands with a clean or disposable towel. 2.3 To use an alcohol-based hand sanitizer: Apply about 1/2 tsp of the product to the palm of the hand. Rub hands together, covering all surfaces of hands, until they are dry. If the hands are visibly dirty, however, wash with soap and water rather than a sanitizer. 2.4 Advantages of Alcohol based gels: 1. Much quicker than soap and water handwashing. 2. Less time 3. Quick drying 4. More accessible than sinks 5. Less skin irritation and dryness 6. Beneficial to skin because it contains emollients. 7. Reduces the time needed for compliance by 75%. 2.5 Disadvantages of Alcohol gels: One of the disadvantages of alcohol gel is reported reluctance of use by staff, particularly due to perceived drying of the skin. Concerns about flammability of alcohol gels led some institutions to ban alcohol gels throughout a hospital. Recently, however, the executive council of the Hospital Fire Marshals' Association voted unanimously to support the installation of alcohol-based hand washing gels in hospital corridors. This clears the way for the convenient alcohol gels to be used throughout hospitals, clinics and physicians' offices. 2.0 Methodology The journals, publications and studies on the related topic were taken from various electronic databases internet sources Pub Med, Journal App Microbiology, Infection Control and Hospital Epidemiology. Healthcare Infection Control Practices, American Society for Microbiology and other sites from 1981 to 2007 Search words used were Biocides; Alcohol based disinfectants, hand washing technique, dermatitis, dermal tolerance etc. 4.0 Discussion 4.1 A Historical View: Dr Ignaz Philipp Semmelweis of Vienna recognised the value of clinicians washing their hands in 1847. Dr Semmelweis as a medical student, worked on a study in a hospital ward where physician-attended births had a mortality rate as high as 31%. This mortality rate contrasted sharply with the low mortality rate in the midwives' ward that was located nearby. Dr Semmelweis reported to his physician associates an incredible idea "washing hands could save lives." His research showed that pregnant women often developed fatal infections following hospital births when treated by doctors with unwashed hands. However, mothers who were treated by doctors that scrubbed their hands thoroughly with soap and water before being examined and treated rarely developed the same type of fatal infections. It has been estimated by Michael Berens that over 103,000 patients died in 2000 as the result of infections acquired after they entered the hospital. Almost three quarters of these hospital patients would be alive if clinicians had just followed well-established standards of care and hygiene. Berens indicates that handwashing alone could prevent up to 20,000 deaths each year. "Clean hands are the single most important factor in preventing the spread of dangerous germs and antibiotic resistance in healthcare settings," says Dr Julie Gerberding, director of the CDC. "Alcohol-based gels can be used much quicker than soap and water hand washing." (CDC, 2001) 4.2 Changing Perceptions: Many clinicians believe that they wash their hands much more than they actually do. Studies indicated that nurses think that they wash their hands up to three times more than they actually do. Hand washing compliance for physicians is only 30 to 50 %. Proper hand hygiene is important to professional organisations and regulatory agencies such as the CDC, the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), OSHA, and APIC they have all made it a top priority. Why healthcare workers do not comply with hand washing guidelines Aren't they aware of the importance of hand washing in preventing nosocomial infections As indicated above, many of the clinicians actually think that they have washed their hands more than they have. Other excuses made by clinicians include: Being too busy Lack of convenient access to a sink The worry of skin irritation and dryness from constant washing Wearing gloves Just not thinking about it In Hospitals, there has been additional emphasis on hand hygiene training to accompany the change of alcohol gel product and the introduction of the personal, staff-held dispensers. To reinforce the hand decontamination policy, the infection control team had an initiative for 2004 called the "clean hands save lives" initiative. This included the change of alcohol gel to a product that complied with the PASA tendering process. The product called Purell from GOJO, which also had a dispenser available, was clipped to staff pockets for quick and easy hand decontamination at the point of use. For hygienic hand disinfection, alcohol-based hand gels are intensively used on wards. However, antimicrobial activity of number of gels is significantly lower in comparison to alcohol-based liquids. (Pietsch H, 2001) Currently there are only a few products on the market that fulfil the European Standard EN 1500 norm within 30 seconds whereas leading liquid hand disinfectants pass the EN 1500 requirements without any problems within this time. 4.3 Several recent research studies have shown that hands are the primary mode of transmitting infectious diseases, with up to 80% of common illnesses resulting from handling ordinary objects like computer keyboards, desks, doorknobs, telephones, copiers and other shared items. The applications of hand washing technique were important in influencing the effectiveness of an alcohol gel. 4.3.1 Study# 1 Proper technique for using hand rubs Prospective study was conducted by Widmer and his team in which 180 healthcare workers in a 450-bed, university-affiliated geriatric hospital where alcohol-based hand rub was introduced in the late 1970s. The Centre for Disease Control and Prevention has recently recommended use of an alcohol-based hand rub for hand hygiene. However, the proper technique for using hand rub has not been well described and not routinely taught in hospitals. Objective was to evaluate the impact of training on proper technique as outlined by the European Standard for testing alcohol-based hand rubs as per European Norm 1500 in a clinical study. There was a structured training program in hand hygiene with alcohol-based hand rub. The number of bacteria eradicated was estimated by calculating the difference between the log (10) number of colony-forming units (cfu) of bacteria on the fingertips before and after the procedure, and reported as reduction factor (RF).Main outcome measure Log (10) cfu bacterial counts on fingertips before and after training in the appropriate technique for using hand rub. The result was only 31% of healthcare workers used proper technique, yielding a low RF of 1.4 log (10) cfu bacterial count. Training improved healthcare workers compliance to 74% and increased the RF to 2.2 log (10) cfu bacterial counts, an increase of almost 50%. Several factors, such as applying the proper amount of hand rub, were significantly associated with the increased RF. The results demonstrated that education on the proper technique for using hand rub, as outlined in EN 1500, could significantly increase the degree of bacterial killing. (Andreas F Widmer, et al 2007) Medical and healthcare staff disinfects their hands up to 60 times per day, is a particular stress for the hands. Beside the efficacy, the dermal tolerance of hand antiseptics is therefore very important too. (CDC, 2001) A healthcare worker is more likely to ignore a procedure or a product that involves a risk of dermatitis, which leads to lower compliance (Pittet D et al, 2000) and thereby expose patients to the risk of nosocomial infection. (Girard R et al 2001) In the past, several publications showed significant advantages of alcoholic disinfectants to wash lotions in terms of skin compatibility. Alcohols do not remove the natural skin lipids. They are not absorbed and do not cause allergies. An efficient care and refitting system of emollients and moisturiser of the rub-in antiseptics provides skin-smoothing properties and avoids desiccation of the skin, even during intensive long-term use. (Winnefeld, M et al 2000) 4.4 Study# 2 Frequency of hand washing by health-care workers In another observational study by Kaplan and McGuckin in two ICUs, frequency of hand washing by health-care workers after contact with patients or their environment was recorded. In the medical ICU, where the sink bed ratio was 1:1, personnel complied with recommended hand washing measures 76% of the time. In the surgical ICU, where the sink bed ratio was 1:4, compliance decreased to 51%, indicating that improved access to hand washing facilities increases hand washing compliance. (Kaplan LM, McGuckin M. 1986) Hand hygiene compliance improved to 41% when one alcohol dispenser was made available for every 4 beds and to 48% when a dispenser was placed next to every bed. This study suggested that better access to hand hygiene facilities results in improved compliance. In studies of acceptance of hand hygiene products by healthcare personnel, hospital personnel, one likely to affect the frequency of use of hand hygiene products was the adverse effects of frequent hand washing on the skin. (Zimakoff J, Kjelsberg AB, 1982) The accessibility of sinks is an important factor, since nurses and other healthcare personnel have to wash their hands frequently. Nurses wash their hands an average of 13 to 30 times each day, with as many as 44 times reported (Ojajarvi J, 1981). If nurses obtain an alcohol hand disinfectant from a bedside dispenser and 15 seconds is required for drying, 100% compliance would require 4 hours of nursing time per shift. (Larson E, Killien M. 1982) A rapidly effective waterless antiseptic agent accessible at each patient's bedside makes it easier for nurses with heavy workloads to comply with recommended hand hygiene practices. (Boyce JM, Kelliher S, Vallande N, 2000) In a study by Freeman the impact of sink location on incidence of nosocomial infections, patients whose beds were located next to a sink had a 26% reduction in risk for infection compared with those whose beds were located farther away from a sink. (Freeman J, 1993) These combined studies showed that the application alcohol gel decreased skin irritation and dryness significantly and acceptance of this product. 4.5 Study#3 Skin irritation and dryness In a recent prospective randomized trial on Non-medicated soap Vs. Alcohol, hand gel Purell conducted by John Boyce, 29 nurses working on three hospital wards volunteered to participate. Half the nurses were randomly assigned to wash their hands with a non-medicated soap (Soft N Sure, Steris, Inc., Mentor, OH) the other half used an alcohol hand gel (Purell, GoJo Industries, Akron, OH) after patient contacts. Dispensers for the alcohol hand gel Purell were placed outside each patient's room or in the patient's cubicle in the ICU. Nurses in both groups were asked not to use hand lotions or creams during the study period. After 2 weeks, all nurses resumed using standard soap and water hand washing and were allowed to use hand lotions or creams the nurses who initially used soap and water switched to the alcohol hand gel Purell regimen and vice versa. Skin irritation and dryness was assessed by three methods. Self-assessment by participating nurses, Visual assessment by a study nurse, and Electrical capacitance measurements of the skin on the dorsal surface of the nurses' hands a measure of epidermal water content. 4.5.1 Electrical capacitance measurements showed that nurses had more skin dryness if they washed their hands with soap and water than if they used the alcohol hand gel. 4.5.2 Self-assessments by participants and 4.5.3 Visual assessments by the study nurse also showed that nurses had substantially greater skin irritation and dryness when using the soap-and-water regimen. On a questionnaire, assessing attitudes toward the alcohol hand gel Purell, 88% of nurses agreed or strongly agreed that the alcohol gel Purell caused less dryness than soap and water hand washing 92% agreed or strongly agreed that they would be willing to use the alcohol hand gel Purell routinely. This study demonstrated that an alcohol hand gel Purell containing appropriate emollients can achieve a high degree of acceptance by hospital personnel. (Boyce J M, 2000) 4.6 Study#4 Skin tolerances to alcohol-based disinfecting gels In another study a combination of biophysical and sensorial data by Houben in 2006 on skin condition associated with intensive use of alcoholic gels for hand disinfection. This study by Houben and Evi was designed to investigate skin tolerance to alcohol-based disinfecting gels and changes in skin condition depending on humectants concentration, alcohol grades, as well as type of alcohol used (Draelos Z. 2005) Although hand hygiene is an important and inexpensive measure to prevent nosocomial infections in clinical settings, the compliance of healthcare workers remains low. In Europe, alcoholic hand disinfection is first choice, but there exists limited user acceptability due to estimated adverse effects on skin condition. (Kampf G, et al 2005) A comparison of 6 alcohol-based gels was made based on a randomized double-blind study under in use conditions for 1 day. Skin condition was evaluated by measuring transepidermal water loss (TEWL), stratum corneum hydration, apparent skin pH, redness and degree of scaliness. All gels were sensorially evaluated using a questionnaire. It was evident that none of the alcohol-based gels, applied under in use conditions, altered TEWL or caused irritation. All gels hydrated the skin, proportionally to their glycerin content, and decreased skin pH. Elevated ethanol concentrations resulted in increased scaliness. Sensorial assessment revealed less appreciation for isopropanol. From this study, it was concluded that gels containing an elevated glycerin concentration and 70% (v/v) ethanol are preferred. (Houben, Evi, 2006) 4.7 Study#5 Skin condition and microbial counts The study by Elaine Larson was on effect of Antiseptic hand washing Vs. Alcohol sanitizer, on health care associated infections in Neonatal Intensive care units. It recommends use of waterless alcohol hand products in lieu of traditional hand washing for patient care. The objective of the study was to compare the effect of two hand hygiene regimens on infection rates, skin condition and microbial counts of nurses' hands in neonatal intensive care units. The participants for this clinical trial used a crossover design in two neonatal intensive care units. It included 2932 neonatal hospital admissions in 51760 patient days and 119 Nurse participated. Two hand hygiene products were tested. A traditional antiseptic hand wash and an alcohol hand sanitizer. Each product was used for 11 consecutive months in each neonatal intensive care unit in random order. There were no significant differences in neonatal infections between the two products. Odds ratios for alcohol compared with hand washing were 0.98 for any infection, 0.99 for bloodstream infections, 1.61 for pneumonia 1.78 for skin and soft tissue infections and 1.26 for central nervous system infections. The skin conditions of participating nurses were significantly improved during the alcohol phase but there were no significant differences in mean microbial counts on nurses' hands. It was concluded that infection rates and microbial counts on nurses' hands were equivalent during hand washing and alcohol phases and nurses' skin condition was improved using alcohol. (Elaine L Larson, 2005) 4.8.1 Alcohol works by denaturing proteins. According to the American Journal of Infection Control, Aug. 1995, "Alcohols applied to the skin are among the safest known antiseptics." Purell combines 62% ethyl alcohol with a special blend of moisturizers to kill germs on hands and leave them feeling soft and refreshed. The alcohol breaks down the germs' cell walls causing them to die. A light layer of moisturizers remains to condition the hands. 4.8.2 Purell does eliminate some good germs while it gets rid of the bad germs. The same is true when washing with soap and water. However, in both cases, the body quickly regenerates the good germs. Because Purell products have no residual antimicrobial activity, the natural flora left in the skin will resurface and repopulate quickly on the skin. Purell is effective against a wide variety of organisms including many common bacteria, viruses and fungi. The product kills germs on contact, but once it has evaporated, the germ-killing action has stopped. Purell products are designed to kill most common germs that may cause illness. It is not a cure for diseases or infections. Purell hand sanitizer is made of active ingredient Ethyl Alcohol 62% and inactive ingredients such as water, isopropyl alcohol, glycerine, carbomer, fragrance, amino methyl propanol, propylene glycol, isopropyl myristate, and tocopheryl acetate. Purell combination 62% ethyl alcohol with a special blend of moisturizers kill germs on hands and leave them feeling soft and refreshed. The alcohol breaks down the germs' cell walls causing them to die. A light layer of moisturizers remains to condition the hands. There is no evidence that organisms adapt and become immune to the active ingredient in Purell products. Many sources indicate that for organisms to become resistant, low levels of the chemical must be available for the organisms to adapt. The alcohol in Purell evaporates completely, leaving no alcohol behind for the organisms to adapt to. Purell leaves no harmful residue. Hands are left feeling soft and refreshed. A small bit of emollient a skin-conditioning agent is left on the hands after use. Once the hands are dry, all the alcohol evaporates 5.0 Conclusion Hand washing is the single most important procedure for preventing the spread of biological contamination. Studies mentioned above have shown that alcohol gel products are effective in eliminating microorganisms, well tolerated with decreased irritation and dermatitis and time saving compared with soap and water. (Kampf G, et al 2005) It kills microorganisms within 15 seconds Also, a number of studies have shown significantly increased compliance with hospital hand disinfection and hand-washing policies, once an alcohol gel solution was available. (Zimakoff J, Kjelsberg AB, 1982) Antibiotics such as the waterless hand cleansers can help people to live longer and healthier lives. (CDC, 2001)It is essential that preventing infection becomes everyone's responsibility. The alcohol-based compounds are more effective than soap and water. (Houben, Evi, 2006) Based upon a number of recent studies, the alcohol-based compounds caused much less skin irritation than soap and water. Many studies have shown that ready-to-use alcohol preparations such as Purell reduce bacterial counts on hands more effectively than soaps and that alcohol is more effective in surgical hand disinfection. (Elaine L Larson, 2005) However, the utility is not only related to its antimicrobial effectiveness, but also to its acceptability by hospital staff. Alcohol preparations can be used at any time and in any situation independently of water and wash basin, require less time to use and cause less skin irritation and dryness than common hand-washing procedures. As an alcohol gel hand sanitizer, Purell kills 99.99% of most common germs in as little as Purell kills 15 seconds without sinks water or towels. Purell gel did not demonstrate a clinically relevant potential for dermal irritation or sensitization, and significantly increased skin hydration after repetitive use, and enhanced compliance with hand hygiene. (Girard R, Amazian K, Fabry J, 2001) Clinical studies mentioned above have shown that a properly formulated alcohol-based hand sanitizer with emollients are better tolerated than soap and water hand washing not drying and irritating the skin. (Boyce J M, 2000) Alcohol by itself can be drying. However, Purell is not drying to the skin because it is formulated with a unique combination of emollients or moisturizers designed to leave hands feeling soft. Purell can be used all day long without drying the skin. It is gentler than soap and water hand washing. This explains why highly effective hand antiseptics are the new trend in hand disinfection. 6.0 Glossary 6.1 Dermal Tolerance: The capacity of the skin to absorb continuously without adverse effect. 6.2 Dermatitis is a term meaning inflammation of the skin. It is usually used to refer to eczema, which is also known as Dermatitis eczema. 6.3 Emollients are substances that soften and soothe the skin 6.4 Humectants or moisturizers are important cosmetic ingredients allowing preventing loss of moisture thereby retaining the skins natural moisture. 6.5 Hydrophilic (water-loving) substances tend to dissolve in water. 6.6 Lypophilic (fat liking) a chemical compound that dissolves in fats, oils, lipids, and non-polar solvents 6.7 Nosocomial infections are those which are a result of treatment in a hospital or hospital-like setting, but secondary to the patient's original condition. Infections are considered nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge. 6.8 Polyacrylic acid is a polymer made from the monomer acrylic acid. These long chains contain thousands of monomer units, and the polymer has some cross-linking between the chains. Many polymers, such as polyethylene and polystyrene used in trash bags, plastic bottles are hydrophobic, meaning they repel water. Polyacrylic acid, however, is very hydrophilic it attracts water. That is because of the carboxylic acid groups in the polymer, which can hydrogen bond to water molecules. 6.9 Surfactant Gel: A soap like compound added to water or some other liquid to increase its wetting properties by reducing the surface tension of the droplets. 7.0 Reference American Academy of Paediatrics A A P (2003) Children in out-of-home child care - General measures. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases, 26th edn. Elk Grove Village: American Academy of Paediatrics, 2003:135-6. American Academy of Paediatrics (2006) Committee on Infectious Diseases and Committee on Practice and Ambulatory Medicine. Infection Control in Physicians' Offices. http://pediatrics.aappublications.org/cgi/content/full/105/6/1361 (February 13, 2006). Bloomfield S F. (2002) Significance of biocide usage and antimicrobial rsistance in domiciliary environments. J Appl Microbiol 2002; 92 Suppl: 144S-57S. Boyce, John M. (2001) "Using Alcohol for Hand Antiseptics." Infection Control and Hospital Epidemiology Boyce J M, Kelliher S, Vallande N Boyce JM, Kelliher S, Vallande N. (2000) Skin irritation and dryness associated with two hand-hygiene regimens: soap and water hand washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000; 21:442-8. Boyce J M, Pittet D (2001) "Draft guidelines for Hand Hygiene in Healthcare Settings", The HIPAC/SHEA/APIC/IDSA Hand Hygiene Task force; and the Healthcare infection control practices advisory committee. Nov. 2001. Boyce J M, Pittet D (2002) Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. 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