ROLE OF HAND SANITIZERS IN INFECTION CONTROL AMONG HEALTH CARE WORKERS (HCWs)

1. ROLE OF HAND SANITIZERS IN INFECTION CONTROL AMONG HEALTH CARE WORKERS (HCWs) To be presented by: OKE, MUSHAFAU ADEBAYO SKP PHARMA LTD. 5, Vori Close, off Acme Road, Ogba, Lagos.

2. INTRODUCTION • Hospital-associated infections represent a serious and growing health problem. (Harley et. al., 1985) • The Centers for Disease Control and Prevention (CDC) estimates that approx. 2 million people acquire hospital-associated infections each year and that approx. 90 000 of these patients die as a result of their infections.(Zerr, et. al. 2005) • Healthcare workers carry antibiotic-resistant bacteria, fungi, and viruses on their hands and act as a vector of transmission. ( http://www.med.yale.edu/ynhh/infection/presentations/slide3.html) • The CDC and many other experts promote hand hygiene as the single most important measure in the prevention of hospital-associated infections. (Boyce and Pitter, 2002)

3. Hand Hygiene has 2 major components which are: • Handwashing - removal of microorganisms (germs) with (ordinary) soap and water. • Hand Antisepsis - removal or destruction of microorganisms using an antimicrobial soap or an alcohol-based hand rub. • Despite the evidence and expert opinion supporting hand hygiene, many studies have shown that health care workers perform it approx. 50% of the times they should. (Zerr, et. al. 2005) • Barriers to HCW hand hygiene compliance: • lack of time • skin damage that accompanies frequent washing with soap and water.

4. What are hand sanitizers? • alcohol-containing preparations designed for application to the hands for reducing the number of viable microorganisms on the hands. (CDC, 2002). • They are used for avoiding the transmission of pathogens. • supplements or alternatives to hand washing with soap and water. (FDA, 2009). • Types • Various preparations are available, including gel, foam, and liquid solutions. • Active Ingredients • isopropanol, ethanol, n-propanol, or povidone-iodine.

5. Inactive Ingredients • a thickening agent such as polyacrylic acid for alcohol gels, • humectants such as glycerin for liquid rubs, • propylene glycol, and essential oils of plants. • Antimicrobial Activity • antimicrobial activity of alcohols can be attributed to their ability to denature proteins (Larson and Morson, 1991) and possibly by dissolving membrane lipids (Prescott et. al., 2002). • Alcohol solutions containing 60%–95% alcohol are most effective, • higher concentrations are less potent because proteins are not denatured easily in the absence of water (Larson and Morson, 1991).

6. Alcohol-based hand gels address the barriers to HCW hand hygiene compliance: • they require a fraction of the time for effective hand washing (Mody et. al., 2003) • they are less damaging to the skin than soap and water. (Boyce et. al., 2000) • more effective in killing many microorganisms (Larson et. al., 2001) • Studies have demonstrated increased frequency of hand hygiene and decreased frequency of hospital-associated infections with provision of alcohol hand gels in the context of institution- wide hand hygiene campaigns. (Zerr, et. al., 2005)

7. Spectrum of Activity • Bacteria and Fungi: • germicidal activity against gram-positive and gram-negative vegetative bacteria • multidrug-resistant pathogens (e.g., MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin-resistant Enterococci)) • Mycobacterium tuberculosis, and various fungi (Price (1939, 1938); Sakuragi et. al., 1995; Kampf et. al., 1999.) • very poor activity against bacterial spores, protozoan oocysts, and certain non-enveloped (nonlipophilic) viruses. (Coulthard and Sykes, 1936)

8. Spectrum of Activity (contd.) • Viruses: • herpes simplex virus, human immunodeficiency virus [HIV], influenza virus, respiratory syncytial virus, and vaccinia virus) • Hepatitis B and C are susceptible to 60-70% alcohol. • rotavirus, adenovirus and rhinovirus are susceptible to 60-70% ethanol and 70% isopropanol . • Hepatitis A and some enteroviruses are susceptible to 70-80% ethanol. (Platt and Bucknall, 1985; Krilov and Harkness, 1993; Sattar et al, 2001)

9. Effects on skin • rapidly germicidal when applied to the skin. However, regrowth of the normal skin flora occurs slowly after use (Lilly et. al., 1979). • the drying effect of alcohol on the skin can be reduced or eliminated by adding 1%–3% glycerol or other skin-conditioning agents (Walter, 1965). • Alcohol-based sanitizers vs. ordinary/antimicrobial soaps • an alcohol-based rinse can prevent pathogen transmission more effectively than can handwashing with plain soap and water when the hands of HCWs are heavily contaminated. (Ehrenkranz and Alfonso, 1991)

10. Alcohol-based sanitizers vs. ordinary/antimicrobial soaps (contd.) • alcohol-based products reduced the number of multidrug-resistant pathogens recovered from the hands of HCWs more effectively than did handwashing with plain soap and water (Huang et al, 1994). • alcohol reduced bacterial counts on hands more than washing hands with antimicrobial soaps or detergents (containing hexachlorophene, povidone- iodine, 4% chlorhexidine, or triclosan)(Casewell et al, 1988) • alcohol-based rinses or gels containing emollients caused substantially less skin irritation and dryness than the soaps or antimicrobial detergents tested (Boyce et al, 2000).

11. How to use • Apply enough of the product to the palm of your hand to wet your hands completely. • Rub your hands together, covering all surfaces until they are dry. • around the fingernails, • between the fingers, • on the back of the thumb, • and around the wrist • If your hands are visibly dirty, however, wash with soap and water. [CDC, 2002 and Mayo Clinic, 2009 ]

12. When to Use • For HCW • Before entering a patient’s room • After contact with a patient • After removing gloves (http://www.med.yale.edu/ynhh/infection/presentations/slide15.html ) • Others • Before: • preparing food, eating, treating wounds or giving medicine, touching a sick or injured person, • inserting or removing contact lenses • After • preparing food (especially raw meat or poultry), using the toilet, changing a diaper, touching an animal or animal toys, leashes or waste, blowing your nose, coughing or sneezing into your hands, treating wounds, touching a sick or injured person, handling garbage or something that could be contaminated, such as a cleaning cloth or soiled shoes. [Mayo Clinic, 2009)

13. Religious Concerns • Alcohol is considered haraam, or forbidden, in Islamic tradition • However, some Islamic scholars and The Muslim Council of Britain state that the alcohol in hand sanitizer used as medicine is halal, or permissible [islamonline.net, 2009] • because protection against disease is among the aims that Muslims are commanded to pursue, so it is permissible to touch [islamonline.net, 2009] • the alcohol in hand sanitizer evaporates and is not absorbed significantly through the skin so it cannot cause intoxication.[(http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1803104/ ) ]

14. SKP HAND SANITIZER GEL • Active ingredient: isopropyl alcohol 62% • Other ingredients: • water • glycerine • propylene glycol • fragrance • triethanolamine • carbopol 940 • acetate • isopropyl myristate

15. SKP HAND SANITIZER GEL • Features and Benefits • kills up to 99.9% of common germs that can be transmitted by contaminated hands. • It is easy to use and dries quickly after rubbing for at least 15 seconds. • provides a better skin tolerance and microbial killing strength when compared to antiseptic soaps. • It is a viable alternative to hand washing with soap especially where there is no water or use of water may not be appropriate.

16. SKP HAND SANITIZER GEL • Features and Benefits • First to be registered by NAFDAC in Nigeria • Portable (Different sizes -60ml and 120ml) • Lemon fragrance • Cheaper than imported brands • Made in USA • Availability

17. Available @ • Momrota Pharmacy, Oke Oyi & General, Ilorin. • Ayo Pharmacy, Oke Oyi & Amilegbe, Ilorin. • Mojlat Pharmacy, Lajorin Road, Muritala, Ilorin. • Food & Nut Stores, Taiwo Road, Ilorin. • Martrite Supermarket, GRA, Ilorin (very soon). • Pharmacy outlets and supermarkets in Lagos & Port-Harcourt.

18. We are hopeful that the management and staff of this hospital will adopt SKP Hand Sanitizer Gel in their effort to promote hand hygiene as part of the improved infection control measures.

19. Other SKP Pharma Products

20. REFERENCES • Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol. 1985;121:159–167 • Zerr, DM, Garrison, MM, Allpress, AL, Heath, J and Christakis, DA. (2005). Infection control policies and hospital-associated infections among surgical patients: variability and associations in a multicenter pediatric setting. PEDIATRICS Vol. 115 No. 4 • (http://www.med.yale.edu/ynhh/infection/presentations/slide3.html) accessed 04/08/2011. • Boyce J, Pittet D, Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep. 2002;51(RR-16):1–56. • Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR- 16):[inclusive page numbers]. • "Tentative Final Monograph for Health-Care Antiseptic Drug Products; Proposed Rule" (http:/ / www. fda. gov/ OHRMS/ DOCKETS/ ac/ 05/ briefing/ 2005-4184B1_01_16-FDA-TAB15. pdf). Federal Register 21 CFR Parts 333 and 369 (United States Federal Government) 74 (56): 12613–12617. March 2009. • Larson EL, Morton HE. Alcohols [Chapter 11]. In: Block SS, ed. Disinfection, • sterilization and preservation. 4th ed. Philadelphia, PA: Lea and Febiger, 1991:642-54. • Prescott, l.M., Harley, J and Klein, D.A. (2002). Microbiology. 5th ed. The McGraw-Hill Companies. P. 147. • Mody L, McNeil SA, Sun R, Bradley SF, Kauffman CA. Introduction of a waterless alcohol-based hand rub in a long-term-care facility. Infect Control Hosp Epidemiol. 2003;24:165–171. • Boyce JM, Kelliher S, Vallande N. 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;21:442–448. • Larson EL, Aiello AE, Bastyr J, et al. Assessment of two hand hygiene regimens for intensive care unit personnel. Crit Care Med. 2001;29: 944–951. • Price PB. Ethyl alcohol as a germicide. Arch Surg 1939;38:528–42. • Sakuragi T, Yanagisawa K, Dan K. Bactericidal activity of skin disinfectants on methicillin-resistant Staphylococcus aureus. Anesth Analg 1995;81:555–8. • Kampf G, Höfer M, Wendt C. Efficacy of hand disinfectants against vancomycin-resistant enterococci in vitro. J Hosp Infect 1999;42: 143–50. • Coulthard CE, Sykes G. The germicidal effect of alcohol with special reference to its action on bacterial spores. Pharmaceutical Journal 1936;137:79–81. • Platt J, Bucknall RA. The disinfection of respiratory syncytial virus by isopropanol and a chlorhexidine-detergent handwash. J Hosp Infect 1985;6:89–94. • Krilov LR, Harkness SH. Inactivation of respiratory syncytial virus by detergents and disinfectants. Pediatr Infect Dis 1993;12:582–4. • Sattar SA, Tetro J, Springthorpe VS, Giulivi A. Preventing the spread of hepatitis B and C viruses: where are germicides relavant? Am J Infect Control 2001;29:187–97. • Lilly HA, Lowbury EJL, Wilkins MD, Zaggy A. Delayed antimicrobial effects of skin disinfection by alcohol. J Hyg (Lond) 1979;82: 497–500. • Walter CW. Editorial: disinfection of hands. Am J Surg 1965;109:691–3. • Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol 1991;12:654–62. • Huang Y, Oie S, Kamiya A. Comparative effectiveness of hand-cleansing agents for removing methicillin-resistant Staphylococcus aureus from experimentally contaminated fingertips. Am J Infect Control 1994;22:224–7. • Casewell MW, Law MM, Desai N. A laboratory model for testing agents for hygienic hand disinfection: handwashing and chlorhexidine for the removal of klebsiella. J Hosp Infect 1988;12:163–75. • Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water handwashing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000;21:442–8. • "Mayo Clinic staff" (Oct. 16, 2009). "Hand washing: Do's and don'ts, How to use an alcohol-based hand sanitizer" (http:/ / www. mayoclinic. com/ health/ hand-washing/ HQ00407). Mayo Clinic. • http://www.med.yale.edu/ynhh/infection/presentations/slide15.html accessed 04/08/2011. • "Using Alcohol-Based Hand Sanitizers as a Protection from Swine Flu" (http:/ / www. islamonline. net/ servlet/ Satellite?pagename=IslamOnline-English-Ask_Scholar/ FatwaE/ FatwaEAskTheScholar& cid=1251021359062). IslamOnline.net. March, 2009. • "Can Alcohol-Based Hand-Rub Solutions Cause You To Lose Your Driver's License? Comparative Cutaneous Absorption of Various Alcohols" (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1803104/ ). Antimicrob Agents Chemother (American Society for Microbiology). March 2007. . Retrieved 2009-10-16.