By the beginning of 2021, it became apparent that the COVID-19 pandemic would endure well into the New Year. In the medium term, experts predict it is unlikely that COVID-19 will disappear,1 but it will instead become endemic and accepted as a health risk, similarly to flu. However, COVID-19 will require a fundamentally different approach than the usual response to flu.
With flu, public health measures such as hand sanitization, masking, social distancing, contact tracing, quarantining and isolation are usually abandoned once community transmission becomes established. On the other hand, COVID-19 is significantly more lethal than most forms of influenza, and elimination of the disease by vaccination is preferable to the achievement of herd immunity by widespread infection. However, the current form of COVID-19 and its variants will likely continue as a public health concern since the global penetration of this pandemic could make it difficult for vaccines to confer herd immunity ahead of the evolution of variant strains of the virus. This will be exacerbated by the zoonotic characteristic of this virus; that is, it appears to be communicable between human beings and animals.
Moreover, the RNA genome of coronaviruses is the largest among all RNA viruses2 and the frequent recombination of its genetic material results in new strains with altered virulence.3 As coronavirus variants evolve, repeated vaccination will likely be necessary, and public health preventatives such as masking, hand sanitization and physical distancing will need to persist. This is emphasized in a report from McKinsey & Company that concludes populations that adequately and promptly adopt public health preventative measures could achieve a much better economic outcome than countries attempting a “balancing act.4
The rapid geographical spread of viruses is enabled by fast and easy international travel, and this poses the risk of further pandemics. This is the third time, within the last two decades, that an animal coronavirus has cross-infected humans to cause an epidemic, and following COVID-19, it is likely that the global community will be sensitized to the possibility of further devastating pandemics. The perceived continuing uncertainty will encourage proactive preventative measures to protect health and livelihoods, including diplomatic efforts for global cooperation by responsible governments to detect and control emerging diseases, and the implementation of corresponding hygiene measures as the norm for the successful functioning of nations.5 In this context, preventative measures can be expected to continue: respiratory control by masking and social distancing to lower the potential of aerosol transmission, and hand hygiene to limit the transfer of pathogens by contact.6, 7
Importance of Hand Hygiene
As news of the COVID-19 pandemic broke, the importance of hand hygiene was saturation-broadcasted by noted epidemiologists and public health experts. Universal hygiene measures were especially pertinent because infected people can transmit the virus even when they have no, or only mild, symptoms,8, 9 and this can hamper contact tracing and control of the pandemic.
Hand hygiene is a cornerstone of infection prevention10, 11 and its purpose is to minimize the colonization and the transmission of infection among health care workers and the public. Hand hygiene is imperative to prevent transmission of disease via the respiratory route and the fecal-oral route because people habitually touch their faces. Although the need for hand hygiene came to the forefront during the COVID-19 pandemic, its importance extends to many other sources of infection. Before the current pandemic, Linda Homa, the Manager of Clinical Affairs at Ecolab, expressed this poignantly when she stated, “75,000 patients die every year from health care-associated infections and that’s unacceptable. Hand hygiene is the number one way to prevent the transmission of health care-associated infections. We’re spending our time on the things that matter most.”12
Hand hygiene includes hand-washing with soap and water, hand-washing with antiseptic washes, and the use of antiseptic hand rubs, most commonly in the form of alcohol-based hand sanitizers.13 Globally, the vast majority of health care workers is aware of the need for hand hygiene and they are not antipathetic to the use of alcohol-based hand sanitizers. However, these principles of hand hygiene are not always followed due to lack of availability, relatively high cost, forgetfulness and/or the onset of skin or ocular irritation with frequent hand-washing or hand sanitization.14
Antiseptic Rub or Hand-washing?
Consistent with Lister’s 19th century antiseptic regime, soap hand-washing coupled with an alcohol gel sanitizer was shown to be more effective than either agent used alone, and the antiseptic activity persisted for longer.15 Also, the increased reduction of murine norovirus was observed with a wash-sanitizer regimen rather than washing with 70% ethanol alone.16
For the purpose of hand hygiene, the Centers for Disease Control (CDC) and the U.S. Food and Drug Administration (FDA) recommend washing hands with soap and water whenever possible, to remove virtually all types of pathogens. Hand-washing is preferable for soiled hands, as hand sanitizers cannot effectively penetrate the layer of dirt before reaching pathogens on the skin surface. It is important to remove soil from hands before treating them with a hand sanitizer. In fact, hand-washing with soap and water alone has been found to be more effective than alcohol-based rubs for hands soiled with meat.17
Moreover, potentially harmful substances can be washed away but they cannot be removed by leave-on hand sanitizers. However, hand-washing facilities are not readily available at work or public places, and in instances where hand sanitization is needed frequently, the use of alcohol-based antiseptic rubs is an effective and convenient infection-preventive measure.18
In many work settings, alcohol-based hand sanitizers are more versatile, convenient, quick and less irritating than hand-washing with soap and water. However, hand sanitizers work only when formulated properly and used correctly,19, 20 and the choice of container, closure and dispenser is also vital in dispensing the correct amount of the sanitizer for each use.
In the United States, hand sanitizers are regulated as OTC drugs and in the Final Rule for Antiseptic Hand-Rubs, the FDA allows only three active ingredients to be used for hand sanitizers.64 The three ingredients are ethyl alcohol, isopropanol and benzalkonium chloride. Note that these ingredients are not “approved” by the FDA. Rather, they are classified as Category III and have been allowed as eligible actives during the time in which data is being generated to determine if they could be recognized as “Generally Safe and Effective” for use as antiseptic rubs.
- Charumilind, S., Craven, M., Lamb, J., Sabow, A. and Willson, M. (2021, Jan). When will the COVID-19 pandemic end? Available at: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/when-will-the-covid-19-pandemic-end#
- Lai, M.M. and Cavanagh, D. (1997). The molecular biology of coronaviruses. Adv Virus Res 48 1-100.
- Graham, R.L. and Baric, R.S. (2010). Recombination, reservoirs, and the modular spike: Mechanisms of coronavirus cross-species transmission. J Virol 84 3134-3146.
- Charumilind, S., Greenberg, E., Lamb, J. and Singhal, S. (2020, Aug). COVID-19: Saving thousands of lives and trillions in livelihoods. Available at https://ecambiomed.com/wp-content/uploads/2020/08/McKinsey-Company-COVID-19-Saving-thousands-of-lives-and-trillions-in-livelihoods-vF.pdf
- Skeggs, D. (2021, Feb). The Covid-19 pandemic: Lessons for our future. Available at: https://bit.ly/3vsotky
- Chu, D.K., Akl, E.A., Duda, S., Solo, K., Yaacoub, S. and Schünemann, H.J. (2020, Jun 27). Physical distancing, face masks and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Lancet. 395(10242) 1973-1987.
- Rachana, A.R., Davalagi, S., Kusum, M.S. and Malatesh, U. (2020). Effectiveness of non-pharmacological interventions in containment of COVID-19 pandemic. Intl J Health Systems and Implementation Res 4(3) 5-21.
- Lai, C.C., Shih, T.P., Ko, W.C., Tang, H.J. and Hsueh, P.R. (2020). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents, 55(3)1 05924.
- World Health Organization (2020, Mar 29). Modes of transmission of the virus causing COVID-19: Implications for IPC precaution recommendations. Available at: https://bit.ly/3eFPr1o
- Mehtar, S. and Bearman, G. (2018). Guide to Infection Control in the Hospital. Int Soc Infect Dis
- Sharma, R.P., Dutta S., Kumar, T., Singh, S. and Sharma, A. (2020, Sep-Oct). Role of alcohol based hand rubs (ABHR) in the COVID-19 Era: A concise review. Available at: https://globalresearchonline.net/journalcontents/v64-1/32.pdf
- American Cleaning Institute. (Accessed 2021, Apr 28). Preventing the transmission of infections in hospitals. Available at: https://www.cleaninginstitute.org/sustainable-cleaning/covid-19-report/preventing-transmission-infections-hospitals
- Gold, N.A. and Avva, U. (2020). Alcohol sanitizer. Available at https://www.ncbi.nlm.nih.gov/books/NBK513254/
- Assefa, D., Melaku, T., Bayisa, B. and Alemu, S. (2021). Knowledge, attitude and self-reported performance and challenges of hand hygiene using alcohol-based hand sanitizers among healthcare workers during COVID-19 pandemic at a Tertiary Hospital: A cross-sectional study. Available at: https://doi.org/10.2147/IDR.S291690
- Paulson, D.S., et al. (1999). A close look at alcohol gel as an antimicrobial sanitizing agent. Amer J Infection Control 27 332-8.
- Edmonds, S.L., et al. (2012). Hand hygiene regimens for the reduction of risk in food service environments. J Food Protection 75 1303-9.
- Charbonneau, D.L., et al. (2000). A method of assessing the efficacy of hand sanitizers: Use of real soil encountered in the food service industry. J Food Protection 63 495-501.
- CDC (2019). Show me the science–When and how to use hand sanitizer in community settings. Available at https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html
- Edmonds, S.I., Macinga, S.L., Mays-Suko, D.R., Duley, P., Rutter, C., Jarvis, J. and Arbogast, W.R. (2012). Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs: Formulation matters. Amer J Infection Control 40 521-5.
- Hadaway, A. (2020). Hand-washing: Clean hands save lives. Consum Health Internet 24 43-49
- FDA (2020, Apr 1). U.S. Food and Drug Administration, Code of Federal Regulations, Title 21, Volume 4. Available at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=211&showFR=1