Hand-rub Formulations Research Articles

Local Production of World Health Organization Recommended Hand Rub Formulation and Comparison of its Efficacy with a Commercially Available Alcohol-Based Hand Rub

Objective: To produce a World Health Organization (WHO)-recommended hand rub formulation locally and compare its efficacy with a commercially available Alcohol-based Hand Rub (ABHR) - Sterillium. Methods: A non-randomized comparative study was conducted. Sixty healthcare workers were divided into two groups - Group A (WHO-recommended hand rub) and Group B (Sterillium). WHO-recommended hand rub was prepared according to the specified formula. Each participant from study Group A received three ml of WHO-recommended hand rub formulation, and each study Group B participant received three ml of Sterillium. Bacterial samples of each participant (from both hands) were collected before and 0 after using an ABHR solution. Samples were inoculated on the nutrient agar plates and incubated at 37 C for 24 hours. The total number of bacterial colonies grown on plates inoculated before and after ABHR use was counted and identified by standard microbiology techniques and compared between the two groups. The WHO-recommended hand rub and Sterillium were compared and analyzed using differences in proportion. Results: The overall reduction in bacterial growth was comparable for both the hand rubs, with an average load reduction of log 1.5607 for locally produced hand rub solution and an average load reduction of log 1.609 in the case of Sterillium. Conclusion: Both of the handrubs are comparable in efficacy and are effective against all the bacteria isolated from the palms of HCWs (Coagulase Negative Staphylococcus (CoNS), Micrococcus spp., Acinetobacter spp., Bacillus spp., Pseudomonas spp., and Citrobacter), including Methicillin-Sensitive Staphylococcus aureus

Improvement of the antibacterial and skin-protective performance of alcohol-based sanitizers using hydroglycolic phytocompounds

The Coronavirus disease 2019 (COVID-19) outbreak increased the usage of hand rub disinfectants, resulting in skin damage. The World Health Organization (WHO) proposed hand rubs formulations incorporating glycerine due to its moisturizing effect; nonetheless, glycerine can reduce the antimicrobial activity of alcohol-based hand rubs. Here we demonstrated that incorporating hydroglycolic extract as a substitute for glycerol in hand rub formulations reduces epidermis damage while improving antimicrobial effectiveness. We applied the hydroglycolic extracts from Cucumis sativus L., Fragaria sp. and Calendula officinalis instead of glycerol to modify the formula proposed by the WHO. The antimicrobial activity and the healing skin action were evaluated using the agar diffusion test and a human skin tolerability trial. Furthermore, we assessed the cytotoxicity and wound repair capability of the formulated hydroglycolic extracts against human gingival fibroblasts (HGFs) and the phenotype of murine macrophages. The hand rubs containing Fragaria sp. and C. officinalis hydroglycolic extracts showed improved antimicrobial activity even after six months of fabrication. Moreover, the formulated hand rubs had similar cellular viability behaviour to glycerol. Interestingly, the tolerability and acceptability response were promoted by the C. sativus extract, showing skin protection and increased integrity by up to 14.12%. Our results represent an alternative, ecofriendly and cost-effective option for formulating new potential hand rubs that improve skin protection without compromising the disinfection functionality.

Efficient Inactivation of Monkeypox Virus by World Health Organization‒Recommended Hand Rub Formulations and Alcohols.

Increasing nonzoonotic human monkeypox virus (MPXV) infections urge reevaluation of inactivation strategies. We demonstrate efficient inactivation of MPXV by 2 World Health Organization‒recommended alcohol-based hand rub solutions. When compared with other (re)emerging enveloped viruses, MPXV displayed the greatest stability. Our results support rigorous adherence to use of alcohol-based disinfectants.

Comparative Antimicrobial Efficacy of Current Alcohol-Based Hand Rubs: Formulation, Dose, and Test Methods All Matter

Background: Alcohol-based hand rubs (ABHRs) are the primary form of hand hygiene in healthcare settings globally. Many developed countries, and most US hospitals utilize wall-mounted ABHR dispensers throughout the facility. The adoption of automated touch-free dispensers is increasing. However, data on the efficacy of ABHRs when used at dispensed amounts are limited. The evidence is strong, showing that formulation matters (not just alcohol concentration) and that agent volume impacts efficacy. Objective: We evaluated the efficacy of ABHR foams on human hands using 2 controlled test methods at variable volumes (ie, typical doses and realistic volumes that healthcare personnel could use in patient care practice). Methods: We tested 8 commercially available ABHR products, the WHO hand-rub formulation, (P1–P9) and a nonantibacterial foam handwash control (P10) on human participants at 2 different application frequencies (“1 application” and “10 applications”) using 2 different ASTM test methods (E1174 and E2755). Studies using ASTM-E1174 evaluated 3 different application volumes (0.7 mL, 1.1 mL, and 2.0 mL) of the 10 products, each tested on 12–13 subjects. Studies using ASTM-E2755 evaluated a single 1.1 mL volume for the 9 ABHR products (P1–P9), each on 2–12 subjects. A linear mixed-effects model was fit separately to log reductions with random effects for subject and date, and a fixed effect for product. Results: Four different foam formulations (P1–P4) consistently outperformed all other formulations by the E1174 method, especially with increasing volumes and after 10 product applications (Fig. 1). When tested with E2755, all formulations performed similarly, with only P1 and P2 differentiating after 10 applications (Fig. 2). ABHR efficacy consistently increased with larger application volumes, whereas the handwash control (P10) achieved a similar efficacy (∼2 log reduction) at all volumes. Efficacy for some ABHR formulations increased, whereas others decreased with repeated applications. Alcohol concentration did not correlate with log reduction. Conclusions: Formulation and the product application volume affect the antimicrobial efficacy of ABHR; therefore, those data should be critically assessed by healthcare personnel assessing ABHR product performance. Test methods matter: when E1174 was used, greater differentiation between formulations was observed. This may be due to the larger contamination volume and greater soil load used in E1174.Funding: GOJO Industries, Inc., provided Funding: for this study.Disclosures: James W. Arbogast and David R. Macinga report salary from GOJO Industries.

Inactivation of Severe Acute Respiratory Syndrome Coronavirus 2 by WHO-Recommended Hand Rub Formulations and Alcohols.

Infection control instructions call for use of alcohol-based hand rub solutions to inactivate severe acute respiratory syndrome coronavirus 2. We determined the virucidal activity of World Health Organization–recommended hand rub formulations, at full strength and multiple dilutions, and of the active ingredients. All disinfectants demonstrated efficient virus inactivation.

Improvement of the Efficacy an WHO Alcohol-based Hand Rub Formulation by Reducing Isopropanol Content and Associating Syzygium aromarticum and Piper nigrum Essential Oils

Aim: This work was carried out in order to reduce the isopropanol contain of a World Health Organization (WHO) basic alcohol based hand rub (ABHR) formulation by substituting part of it with ethanol and essential oils.
 Study Design: A quasi-experimental design was used, based on WHO basic formulation modification, antimicrobial assessment followed by a panel test and challenge test of the best formulation.
 Place and Duration of the Study: The study was carried out in different laboratory of the University of Yaoundé 1 during March 2017 to July 2018.
 Methodology: This study was performed by producing different formulations nested from the WHO basic formulation and testing their antimicrobial capacity on selected strains based on the microbial percentage reduction. Following this, the best formulation was compared to two commercial products trough a panel test and later challenged with selected organism (Staphylococcus aureus SR196, Salmonella Typhi 15SA, Escherichia coli ATTC25922 and Pseudomonas aeruginosa PA01) inoculated in the product after different storage periods for one year and the antimicrobial stability assessed on the same strain for the same length of conservation.
 Results: The partial substitution of isopropanol with ethanol and Piper nigrum and Syzygium aromaticum essential oils proved to possess more antimicrobial properties than the original WHO formulation. The best formulation caused a 6 Log cells/ml reduction of the initial population compared to the 4 Log cells/ml of the WHO formulation. The product also proved to maintain its activity for one year and to be able to deactivate possible contaminations by Salmonella Typhi 15SA, Staphylococcus aureus NCTC10652, Escherichia coli ATCC25922, Pseudomonas aeruginosa PA01.
 Conclusion: The present work is a contribution to the improvement of ABHRs and could permit the reduction of hand hygiene associated infections in industries and health care facilities.

Glycerol content within the WHO ethanol-based handrub formulation: balancing tolerability with antimicrobial efficacy

BackgroundThe World Health Organization (WHO) ethanol-based handrub (EBHR) formulation contains 1.45% glycerol as an emollient to protect healthcare workers’ (HCWs) skin against dryness and dermatitis. However, glycerol seems to negatively affect the antimicrobial efficacy of alcohols. In addition, the minimal concentration of glycerol required to protect hands remain unknown. We aim to evaluate the tolerance of HCWs to the WHO EBHR formulation using different concentrations of glycerol in a tropical climate healthcare setting.MethodsWe conducted a cluster-randomized, double-blind, crossover study among 40 HCWs from an intensive care unit of a tertiary-care hospital in Brazil, from June 1st to September 30, 2017. We tested the WHO EBHR original formulation containing 1.45% glycerol against three other concentrations (0, 0.5, and 0.75%). HCWs used one formulation at a time for seven working days during their routine practice and then had their hands evaluated by an external observer using the WHO scale for visual inspection. Participants also used a WHO self-evaluation tool to rate their own skin condition. We used a generalized estimating equations of the logit type to compare differences between the tolerability to different formulations.ResultsAccording to the independent observation, participants had 2.4 times (95%CI: 1.12–5.15) more chance of having a skin condition considered good when they used the 0.5% compared to the 1.45% glycerol formulation. For the self-evaluation scale, participants were likely to have a worst evaluation (OR: 0.23, 95%CI: 0.11–0.49) when they used the preparation without glycerol compared to the WHO standard formulation (1.45%), and there were no differences between the other formulations used.ConclusionIn a tropical climate setting, the WHO-modified EBHR formulation containing 0.5% glycerol led to better ratings of skin tolerance than the original formulation, and, therefore, may offer the best balance between skin tolerance and antimicrobial efficacy.

Tingkat Akseptabilitas dan Tolerabilitas Cairan Pencuci Tangan Formula World Health Organization (WHO) yang Digunakan Mahasiswa Kepaniteraan Klinik Senior di RSUD Arifin Achmad Provinsi Riau

Health Care Associated Infection (HCAI) is one of the leading cause of mortality and morbidity in hospital and otherhealth care facilitiy. Hand hygiene is the main way to reduce incidence of HCAI. World Health Organization (WHO)recommends alcohol-based handrub because it is more acceptable and tolerable than other hand hygiene products.WHO has identified formulations for the local preparation. This was a descriptive study aimed to determine theacceptability and tolerability of WHO recommended handrub formulation. The subjects of the study were 40 seniorclerkships in Arifin Achmad Hospital, Riau Province, from Surgery, Obstetrics and Gynecology, and Internal MedicineDepartment. Each respondent was given WHO-recommended handrub formulation used for three days. On the firstday, the observer distributed handrubs being tested. After 3 days of consecutive use of the product, participantscompleted the questionnaire and the observer evaluate the condition of participants’ hands. We used WHO’squestionnaire to evaluate acceptability and tolerability level. The results of this study showed that WHO-recommendedhandrub formulation had good acceptability for its application, colour, smell, irritation, ease of use, speed of drying,and overall evaluation but had a less rate of acceptability for its textures and drying effect. WHO-recommendedhandrub formulation had good tolerability.

Dose considerations for alcohol-based hand rubs

Manufacturers' recommended dosages for alcohol-based hand rubs are typically determined by measuring product efficacy using a model protocol such as EN1500; however, anecdotal reports and informal observation suggests that in many cases users self-titrate to much lower doses in real-world application. To examine the interdependence of alcohol-based hand-rub volume on in-vivo efficacy using the EN 1500 standard test method, on drying time on users' hands, and on their perceptions of acceptability. Three formulations were studied using EN 1500 and a modification of this method. The modification used volumes ranging from 0.5 to 3.0mL and 30s application. Drying times were recorded and user acceptability was established using a three-point scale (too long, OK, or too short). Dying times were analysed in relation to hand surface area. The drying time for all three products increased as a function of volume. The drying time displayed a positive association with volume and a negative association with hand surface area. The optimum volume for user acceptability was between 1.5 and 2mL, yielding a drying time of between 20 and 30s. Whereas EN 1500 is appropriate for establishing the efficacy of a hygienic hand-rub formulation compared to a benchmark, it does not reflect actual in-use conditions or the likely clinical effectiveness of the product. In particular, it fails to address the need to optimize the volume of application and user acceptability of the product.

Modified World Health Organization Hand Rub Formulations Comply with European Efficacy Requirements for Preoperative Surgical Hand Preparations

The World Health Organization (WHO) has published "Guidelines on Hand Hygiene in Health Care" recommending 2 hand rub formulations based on 80% vol/vol ethanol or 75% vol/vol isopropanol for local production in healthcare settings where commercial products are not available or are too expensive. Previous investigations have shown that neither formulation meets the efficacy requirements of European norm (EN) 12791, which is the most stringent available norm for surgical hand rub preparations. Even when modified with approximately 5% higher alcohol content, the formulations proved to be inferior to the reference of the norm when measured after 3 hours. Because the high glycerol content of the formulations was suspected to negatively influence their efficacy, additional investigations were performed with varying glycerol content. Modified formulations with higher alcohol concentration (mass instead of volume percentage) and lower glycerol concentration (0.725% instead of 1.45%) or without the addition of glycerol were evaluated for their conformity with the efficacy requirements of EN 12791, which demands noninferiority in comparison with a reference hand antisepsis procedure immediately and 3 hours after treatment on volunteers' hands. Randomized Latin-square design. Microbiology laboratory of the Medical University of Vienna, Vienna, Austria. Twenty-five healthy volunteers. Reducing the concentration of glycerol or omitting it completely rendered both WHO formulations noninferior to the reference, both immediately and 3 hours after surgical hand antisepsis. Both WHO-recommended formulations meet the efficacy requirements of EN 12791 by increasing their alcohol concentrations by 5%, prolonging their application to 5 minutes and reducing the glycerol concentration to 0.725%.

Hand hygiene compliance in the critical care setting: A comparative study of 2 different alcohol handrub formulations

Hand hygiene (HH) compliance can be affected by the accessibility of products (alcohol-based products or chlorhexidine) and by the formulations of these products. There are few published studies comparing different alcohol-based hand disinfection formulations. This study was conducted in a 41-bed medical-surgical intensive care unit at a private tertiary care hospital. Over a 16-week period, we assessed HH compliance by direct observation of practice using iPods and measurement of the amount of product used [alcohol and chlorhexidine] in two 4-room pods in which an alcohol gel product was used compared with two other 4-room pods in which an alcohol-based foam formulation was used. A total of 3,895 opportunities for HH were observed, and the overall rate of HH compliance was 36.9%. No statistically significant differences were found in overall HH compliance or alcohol-based HH compliance between the alcohol foam unit and the alcohol gel unit. However, there was a statistically significant difference in chlorhexidine HH compliance between the alcohol foam unit and the alcohol gel unit (7.0% [130 of 1,853] vs 3.8% [77 of 2,042]; P < .01). Alcohol handrub use was greater than chlorhexidine use, but HH compliance was low in both units independent of the alcohol formulation available. The similarity of use of both alcohol formulations suggests that health care workers tend to use whatever product is readily available.

World Health Organization-recommended hand-rub formulations do not meet European efficacy requirements for surgical hand disinfection in five minutes

The World Health Organization (WHO) has recommended two hand-rub formulations for local production based on 80% ethanol or 75% isopropanol (both v/v). We have looked at their efficacy according to EN 12791. Twenty-six subjects treated their hands with the reference procedure (n-propanol, 60%) for 3 min or with one of the two formulations for 1.5, 3 or 5 min (Latin square design). Post-values (immediate effect) were taken from one hand, the other hand was gloved for 3 h. After the glove had been taken off, the second post-value was taken (3 h effect). The mean log(10) reduction of each hand rub at all three application times was compared to Hodges and Lehmann's reference procedure for non-inferiority. In the first block the reference procedure reduced bacterial load by 2.43 log(10) (immediate effect) and 2.22 log(10) (3 h effect). The efficacy of the ethanol-based formulation (e.g. immediate efficacy of 1.41 log(10) at 5 min) was inferior to the reference procedure at all application times [lower 95% confidence interval (CI): less than -0.75]. In the second block the reference procedure reduced bacterial load by 2.72 log(10) (immediate effect) and 2.26 log(10) (3 h effect). The efficacy of the isopropanol-based formulation (e.g. immediate efficacy of 2.05 log(10) at 5 min) was also inferior to the reference procedure at all application times (lower 95% CI: less than -0.75). Both WHO-recommended hand-rub formulations failed to meet the EN 12791 efficacy requirements for surgical hand disinfection within 5 min. A higher concentration of the active ingredients may improve the efficacy.

Double-Blind, Randomized, Crossover Trial of 3 Hand Rub Formulations: Fast-Track Evaluation of Tolerability and Acceptability

To compare healthcare workers' skin tolerance for and acceptance of 3 alcohol-based hand rub formulations. Double-blind, randomized, crossover clinical trial. Intensive care unit in a university hospital. Thirty-eight healthcare workers (HCWs). A total of 3 alcohol-based hand rub formulations (hereafter, formulations A, B, and C) were used in random order for 3-5 consecutive working days during regular nursing shifts. Formulations A and B contained the same emollient, and formulations B and C contained the same alcohol at the same concentration. Use of each test formulation was separated by a "washout" period of at least 2 days. A visual assessment of skin integrity by a blinded observer using a standard 6-item scale was conducted before and after the use of each formulation. Univariate and multivariate analyses were used for the assessment of risk factors for skin alteration, and product acceptability was assessed by use of a customized questionnaire after the use of each formulation. Thirty-eight HCWs used each of 3 formulations for a median of 3 days (range, 3-5 days). The mean amount of product used daily (+/-SD) was 54.9+/-23.5 mL (median, 50.9 mL). Both subjective and objective evaluation of skin conditions after use showed lower HCW tolerance for product C. Male sex (odds ratio [OR], 3.17 [95% confidence interval {CI}, 1.1-8.8]), fair or very fair skin (OR, 3.01 [95% CI, 1.1-7.9]), skin alteration before hand rub use (OR, 3.73 [95% CI, 1.7-8.1]), and use of formulation C (OR, 8.79 [95% CI, 2.7-28.4]) were independently associated with skin alteration. This protocol permits a fast-track comparison of HCWs' skin tolerance for different alcohol-based hand rub formulations that are used in healthcare settings. The emollient in formulation C may account for its inferior performance.

Hand hygiene: improved standards and practice for hospital care.

To review the most recently published literature on hand hygiene practices in healthcare settings. Adherence with recommendations for hand hygiene remains low, but key factors of noncompliance have been identified and corrective actions proposed. Current guidelines recommend the use of alcohol-based handrub formulations as the new standard of care, thus requiring a system change in most hospitals. In addition, healthcare worker education and motivation are obviously important to modify hand hygiene behavior and must be part of multimodal strategies to enhance compliance in hospitals. Compliance improvement is associated with reduced infection rates and resistance spread. Handrub application according to recommended practices is an alternative to conventional surgical handscrubbing with antiseptic soap and water for surgical hand preparation. System change must be addressed in most hospitals where alcohol-based handrubbing has not become a standard of care. Strategies to improve hand hygiene compliance must be multimodal and include staff education and motivation, the use of performance indicators, and hospital management support. Successful campaigns will result in reduced infection rates, antimicrobial resistance spread, and enhance patient safety.