From the Department of Unintended Consequences

This morning, one of our infection preventionists came into my office with a bottle of our alcohol-based hand rub and a salt shaker. She poured gel into a plastic cup, dumped a couple teaspoons of salt into it, and voila! The emollients immediately precipitated out, leaving behind a solution that I assume must have been about 120 proof (no, we didn’t drink it….).

This little science experiment was performed as a result of reports we’ve received from another healthcare facility in our region that is having problems with hand rub ingestion using this method of emollient removal—a method that is now available on the interwebs for all to see. Others have reported problems related to hand rub ingestion, and I’ve read many of those reports—however, I was unaware of how easily one could render a disgusting gel into a potable alcohol solution. Here is an interesting report and description of one such use in a prison population, from a Clinical Toxicology meeting in 2006:

Hand Sanitizer Abuse

Roche KM, Barko IR, McDonagh J, Bayer MJ, Sangalli B. Connecticut Poison Control Center, UCONN Health Center, Farmington, CT, USA; Hartford Hospital, Hartford, CT, USA.

Background: Hand sanitizers are often gel-like emulsions, containing high concentrations (>60%) of ethanol. We became aware of correctional facility (CF) inmates using table salt (NaCl) to “break” these emulsions, to generate consumable ethanol. Therefore, a potential for abuse of these products by inmates and others exists. We sought to recreate this procedure and analyzed the resultant liquid for its alcohol concentration. We also surveyed the medical staff and corrections officers (staff) of the state's eighteen correctional facilities to assess their awareness of this practice. Methods: A) Following the method used by CF inmates, four ounces of hand sanitizer was added to a clean cotton sock that was placed over a glass graduated beaker. One teaspoon of NaCl was sprinkled on the gel-like material and within seconds a cloudy liquid filtered into the beaker. The resultant liquid was sent to an independent lab for alcohol analysis using a gas chromatography headspace technique. B) A telephone survey queried the CF staff of each facility (correctional officer (CO) supervisor and nurse) as to: 1) their awareness of this practice in their facility; 2) product availability to inmates, and 3) the value of this information towards changing their institution's policy regarding product availability. Results: A) Laboratory analysis revealed that the submitted liquid contained: ethanol 69.9% v/v; Isopropyl 2.1% v/v. B) Survey Results: 94% (17/18) of the CF staff were not aware of the potential abuse of these products. Inmates had direct access to product in 22% (4/18) of CFs. In one CF, product was removed from the cell blocks as a result of our survey. In 100% (18/18) of CFs, product is used in all medical areas as well as carried by correction officers. Discussion: CF staff found this information both enlightening and beneficial. Surveyed nurses planned on notifying their supervisors and the CO supervisors relayed that they would notify their staff. Conclusion: We discovered the potential for abuse of hand sanitizers in a number of state correctional facilities. More importantly we educated CF staff on the need to control product accessibility to inmates.

What does this mean for prevention? Besides keeping easily accessible products off units where abuse potential is high, education of staff should include awareness of the abuse potential, so that hand rub ingestion is considered when circumstances suggest it as a possibility (e.g. unexplained mental status changes, combined with higher than average product utilization!).

New studies on alcohol-based hand sanitizers

There are two new studies on the use of alcohol for hand hygiene. Antimicrobial Agents and Chemotherapy has a study from the University of Virginia in which volunteers had their hands inoculated with rhinovirus followed by hand hygiene. Water alone removed the virus from 12% of study subjects, soap and water was 31% effective, and alcohol was 81-87% effective.

In the second study, just released by BMC Infectious Disease, researchers found that with the use of alcohol foam, the larger the volume applied, the longer it takes to dry. Makes sense. But the investigators found that the volume of alcohol that would dry by 30 seconds was only slightly better than water alone in removing E. coli that had been inoculated onto the hands. So more is better; a little dab won't do ya.