Exploring Current CDC Recommendations: The Myth About Alcohol-Based Sanitizers

Below is perhaps one of the better-written reports that causes one to wonder what the CDC is really thinking..or who is "influencing" them.

But then again, if you're a company with a four-letter name that begins with "G" is followed by an "O", then a "J", and ending in "O", you should rejoice now that the Supreme Court has lifted the ceiling on the amount of money that you can spend to improperly influence politicians and hence, regulators into drinking your potion!

For everyone else, the following is actually a good read, prepared by a distributor of alcohol-free hand sanitizer products. We won't mention their name, as we've found that by mentioning the names of other distributors and respective manufacturers of non-alcohol sanitizers, they've found themselves on the receiving end of court orders and persecutions by government regulators--all, we suspect, after the company noted above, exerted its influence.. (a corporate strategy that company is notorious for..)

Sanitizing hands and eliminating the transfer of bacteria and germs, in a medical
or dental setting, are of the utmost importance in the prevention of infection in a
hygienic environment. In order to better understand how bacteria quickly multiply,
a review of the rapid nature of bacterial contamination is necessary by
understanding important facts given by the Department of Health (MN):
• Viruses can be transferred from dry smooth surfaces up to 20 minutes after
being contaminated.
• E. coli, salmonella, and other bacteria can live up to two hours on surfaces
like doorknobs, keyboards, and tables.
• Bacteria double every 20 minutes. Five bacteria in a sandwich at noon will
total over 10 million by 7p.m. After three days, with no bacteria dying, there
would be enough to cover the earth.
A Basic Understanding of the CDC's recommendations:
In 2002, the Centers for Disease Control advised the use of alcohol-based hand
rubs as necessary in a non-surgical medical environment. The CDC made this
recommendation based on eliminating infections in a medical environment.
Medical professionals were encouraged to use such antibacterial alcohol-based
agents, on unsoiled hands, as a replacement for washing hands with soap and
water. Unsoiled hands are considered those that are not visibly soiled or have not
come into contact with bodily fluids, which could cause the subsequent spread of
infection. The following suggestion was given about the appropriate use of alcohol-
based hand sanitizers outside of medical facilities, in the general public, and inside
a medical facility:
• Sanitization appropriate outside of a medical facility: The use of soap
and water, when lathered for up to 15 seconds, scrubs bacteria spores and
literally washes them down the drain.
• Sanitization appropriate inside a medical facility: The use of a "mild
detergent containing antiseptic" (CDC), or the use of alcohol based hand
sanitizers containing 60 % – 95 % ethanol or isopropanol when hands are
not visibly soiled.



The Spread of Infection in Medical Environments:
The majority of medical facilities today, have rigid government and private
standards. These standards make the containment of both bacteria and infection
the utmost priority. However, even with the most stringent efforts, medical settings
cannot control every negative outcome when working with illness and infection.
The following are a few examples (via private research), in which bacteria and
illness is spread in a medical setting:
• Invasive surgical treatment which exposes the body to other outside
bacteria
• Medical professionals constantly work in and around biohazards which
spread bacteria in the air, causing more infections
• The patients seeking treatment in medical facilities have an already
weakened immunity and can contract infection more easily
• The possibility of transmitting disease from one contagious patient to
another
• Time constraints placed on medical professionals in a small, sometimes
confined setting
The Purpose of Alcohol-Based Hand Sanitizers:
In an effort to eliminate such occurrences in medical settings from occurring, hand
washing over the last 100 years has become standard protocol in the elimination
of bacteria and subsequent infection. Alcohol is the standard sanitizing agent used
by the majority of hospitals to prevent infection from occurring in a hospital setting.
Alcohol is cheap and widespread in its uses, especially in medical facilities. The
CDC made recommendations in 2002, citing the use of alcohol-based hand rubs
as effective in fighting bacteria and infection.
Thus, the CDC defined hand sanitation that included the use of alcohol-based rubs
to replace the traditional method of soap and water. The objective of moving
forward with the use of alcohol-based rubs had several objectives. Primarily, the
use of alcohol-based sanitizers was an effort to decrease time constraints placed
on a system that is already lacking enough medical staff to care for patients. The
CDC estimated that this practice alone (alcohol sanitizer use) saved staff over an
hour a day.


The CDC also made such recommendations in an attempt to decrease the
percentage of non-compliance by medical professionals. The purpose was to
eliminate the spread of bacteria with alcohol-based hand sanitizers in a timely
and effective manner. Bacteria eliminated by the use of alcohol-based sanitizing
agents include, but are not limited too: streptococcus, salmonella,
staphylococcus, E. coli, and shigella.
Alcohol-Based Hand Sanitizers Ineffectiveness:
In order to be most effective, alcohol-based hand sanitizers must completely
cover the surface of the hand and dry completely. When considering the limited
time of health care professionals, rarely is it possible to move from one patient to
the next and allow complete coverage of the given product. In addition, many
professionals do not give an ample amount of time for disinfection to take place
(>10 seconds). However, it is more likely that portions of the skin have not been
touched by the sanitizing solutions, leaving areas on hands prone to existing
bacteria.

The result, with certain types of alcohol-based sanitizers, is their tendency to
crumble off after repeated use. This, caused by build-up after multiple and
consistent use. In a busy area of the hospital (e.g., Emergency Care), one may not
have the time to cleanse hands to eliminate such debris. According to the 2nd
edition of Hospital Epidemiology and Infection Control, "[...such buildup from
alcohol based sanitizers, in gel form, leave hands soiled and with possible viruses,
bacteria, fungi, and parasites]".

Reviewing the CDC's Recommendation 6 Years Later:
According to the Healthcare Infection Control Practices Advisory Committee, the
broader context of hand sanitization is educating the medical community on
adhering to hand sanitizing in an effort to prevent higher rates of infection. More
specifically, the committee believes inclusive factors are those which educate the
medical community on "knowledge concerning the appropriateness, efficacy, and
understanding of the use of hand hygiene and skin care protection agents"
(Healthcare Infection Control Practices Advisory Committee).
The recommendation made by the CDC has only been replaced one time in the
last 13 years. The last recommendation, made prior to 2002, was in 1985. While
advances, in the medical world continue to progress at lightening speed, this
advice can be considered somewhat archaic. A culture that looks for newer and
better procedures and treatments necessitates looking for better alternatives, to
the use of alcohol based sanitizers, in overcoming a lack of education about the
necessity of better alternatives.


Benzalkonium Chloride as an Alternative to Alcohol-Based Hand Sanitizers:
Benzalkonium chloride has a long history in the medical and pharmaceutical
community. It is known as extremely effective in the long term elimination of
bacteria without evaporation. The compound is extremely effective against "gram-
positive bacteria in concentrations as low as 0.00050/0 and against gram negative
bacteria as low as 0.0330/0. Its specific uses are as antibacterial hand
rubs and moist towel lets, as well as preoperative preparation of skin, surgeons
skin and arm soak, treatment of wounds, preservation of contact lens solution, and
irrigations of the eye, body cavities, bladder, and urethra." (www.tufts.edu)
Benzalkonium chloride has been used in the medical field for decades and was
originally used prior to surgery. It is under the umbrella of quaternary ammonium
compounds (a.k.a., "Quats") and is excellent in the fight against bacteria
specifically inhibiting the growth of bacteria and it's multiplying affect. The
sanitizing agent has parallel uses to alcohol, without its drying affects, and lacks the evaporative nature of alcohol, staying on hands approximately 30 -90 minutes longer (www.tufts.edu). Current estimates report even a greater bacteria kill time,
upwards of 3-4 hours after application.

As common bacteria and infections, in parts of the world, become increasingly
difficult to identify the necessity of an antibacterial agent with staying power is an absolute necessity. This becomes a dangerous situation when considering that
"unidentified infectious agents" can cause incurable diseases, such as HIV and
hepatitis C. This information coupled with the CDC's efforts to lower infections
from bacterial exposure is a powder keg waiting to explode. Research indicates
that changing bacteria are from a variety of sources, which include, but are not
limited to the following:
• Rapid population growth, combined with increased poverty
• Expansion of the population into 'remote areas'
• Environmental degradation
• Improved transportation, leading to easier spread of disease
• Inadequate or deteriorating public health infrastructure
• Widespread, and often inappropriate, availability and use of antibiotics
• Poor disease control and disease prevention


Switching from Alcohol-Based Hand Sanitizers to Benzalkonium Chloride-Based
Sanitizers:

Benzalkonium chloride based sanitizers have quickly become a popular alternative
in K-12 schools as a replacement to traditional alcohol-based
sanitizers because of its ability to kill staph. Infections like staph are
commonplace in locations like school gyms and locker rooms where multiple
users have exposure to the same equipment. In addition to eliminating multiple
strains of staph (including MRSA), the sanitizing agent is effective in the
elimination of Hepatitis A and Hepatitis B, HIV, herpes, salmonella, E. coli, as well as many other infectious agents.

Containing the spread of bacteria with this product (benzalkonium chloride) will
increase the likelihood that attempts to prevent infection will be successful in
medical, school, and social facilities.

Furthermore, the rates of staph infection are higher in patients with differing
ailments. Dry and cracked hands, which can be caused by alcohol-based
sanitizers, have higher rates of staph infection. Diabetics and individuals receiving dialysis for kidney failure also "are likely to have areas of intact skin colonized with S. aureus," according to the CDC.

Looking more closely at benzalkonium chloride as an antibacterial agent, this
quaternary ammonium compound can be viewed as a successor/replacement
standard alcohol-based sanitizers. In fact, The American College of Toxicology
describes it as "safely used as an antimicrobial at concentrations of up to 0.10/0".
(www.ncbi.nlm.nih.gov/pumed)

Ending the CDC's "Alcohol Recommendation":

Again, the most recent (2002) recommendation by the CDC for hand hygiene does
not take into account the advances in the arena of hand hygiene. Nor does it
adequately evaluate the efficacy of other hand sanitizing agents, like
benzalkonium chloride. The fact remains -alcohol-based sanitizers are cheap to
produce and manufacture despite their many short comings.
Additionally, only twice in the last 13 years has the CDC made recommendations
for alcohol-based sanitizers. However, since these recommendations, hundreds of
Westerners continue to deal with the discomfort, dangers, and potential lethality of alcohol sanitizers. Furthermore, current studies find that alcohol sanitizers are now providing a false sense of protection, as most adults and health care professionals fail to sanitize their hands correctly (below).


The above cited report supports the long held belief that many health care
professionals perceive a persistent effect with alcohol-based hand sanitizers.
Statistics back these recent findings, as well. However, this is not the case.
Alcohol sanitizers evaporate quickly and do not protect for significant durations of time.

To compound the issue, a notable study in 2000 reported that less than half
(48%) of health care workers in hospitals adhered to the CDC's recommended
hand hygiene regimen (Pittet D, Lancet 2000:356;1307-1312.). This includes
inadequate hand washing times, or the lack thereof.

Moreover, a study conducted in 1997 showed that the median wash time for health
professionals in a clinical setting was 4.7 -5.3 seconds (J Clin Nursing 1997;6:55-
67). There is little evidence to show an improvement in these times today.
According to the CDC, times under 15 -20 seconds are ineffective at reducing the
risk and spread of bacterial and viral infection(s).

As opposed to alcohol-based sanitizers, benzalkonium chloride lotions last for
hours and possess persistent and potent germicida1 activity. They have been
shown to be 99.99% effective against a broad spectrum of harmful bacteria in
clinical studies.

Finally, a report issued June 8th, 2008, again, contradicts CDC recommendations.
This time, regarding antimicrobial-impregnated wipes (Le., towelettes). In 2004,
the CDC stated that such wipes "may be considered as an alternative to washing
hands." The following article shows that not only are towelettes/wipes not effective at cleansing hands, they may also be spreading harmful and potentially life-threatening bacteria (below).


(Associated Press)
Published: Wednesday, Jan. 30,2008
OMAHA, Neb. -Doctors and nurses on the go often skip soap and water in favor of an
alcohol-based hand gel, thinking the quick-acting goo will kill bacteria on their hands and curb the spread of infection.
It turns out that's not enough. In a Nebraska hospital, medical workers nearly doubled their use of the alcohol-based gel, but their generally cleaner hands had no bearing on the rate of infections among patients.
The doctor who studied the problem pointed to many villains: Rings and fingernails that are too long and hard to clean, poor handling of catheters and treatment areas that aren't sanitized.

"Hand hygiene is still important, but it's not a panacea," said Dr. Mark Rupp, an
infectious disease specialist at the University of Nebraska Medical Center. He led the study at the adjoining Nebraska Medical Center.

The results of his study appear to contradict hospital guidelines from the Centers
for Disease Control and Prevention that say better hand hygiene -through frequent washing or use of [alcohol-based] hand gels -has been shown to cut the
spread of hospital infections.

The spread of infection-causing germs in U.S. hospitals is a huge health problem,
accounting for an estimated 1.7 million infections and 99,000 deaths each year, according to the CDC. These include drug-resistant staph, urinary tract infections and ventilator-associated pneumonia, among others.
He suggested hand gels be combined with other measures, such as better cleaning of
hospital units, proper insertion and maintenance of catheters, and doctors prescribing antibiotics only when necessary so more drug-resistant bacteria don't pop up. He also said hospital workers shouldn't wear rings and should trim their fingernails even more than the CDC, recommendation of no longer than a quarter of an inch. Rupp said bacteria showed up when nails extended just beyond the fingertip [...]

(Reuters)
Published: Tuesday, June 3, 2008
Antibacterial wipes can spread superbugs: study
LONDON (Reuters) -Disinfectant wipes routinely used in hospitals may actually spread drug-resistant bacteria rather than kill the dangerous infections, British researchers said on Tuesday.
While the wipes killed some bacteria, a study of two hospitals showed they did not get them all and could transfer the so-called superbugs to other surfaces, Gareth Williams, a microbiologist at Cardiff University, said.
The findings presented at the American Society of Microbiology's General Meeting in
Boston focused on bacteria that included methicillin-resistant Staphylococcus aureus, or MRSA.

"What we have found is there is a high risk," Williams, who led the study, said by
telephone. "We need to give guidance to the staff on how to use the wipes because we found there is a possibility of cross transfer."

MRSA infections can range from boils to more severe infections of the bloodstream,
lungs and surgical Most cases are associated with hospitals, nursing homes or other
health care facilities. The superbug can cause life-threatening and disfiguring infections and can often only be treated with expensive, intravenous antibiotics.
Experts have been saying for years that poor hospital practices spread dangerous bacteria, and yet many studies have shown that health care workers, including doctors and nurses, often fail to even wash their hands as directed.

The findings from a study of intensive care units at two Welsh hospitals suggest that even cleaning with antin1icrobial wipes n1ay not be enough depending on how staff use them. The researchers found that many health care workers cleaned multiple surfaces near patients, such as bed rails, monitors and tables with a single wipe and risked sweeping the infections around rather than cleaning them up.
"We found that the most effective way to prevent the risk of MRSA spread in hospital wards is to ensure the wipe is used only once on one surface," Williams said.


References:
Antibacterial agents, July 1, 2008,
http://www.tufts.edu/med/apua/Qo;026A1Q%26A_antibacterials.html#1
Benzalkonium Chloride, July 1, 2008,
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Centers for Disease Control, Guideline for Hand Hygiene in Health-Care
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