To the Editor:
The use of alcohol-based hand sanitizers is the currently recommended procedure for the control of infection in health care settings. The American College of Obstetricians advises that “women should avoid alcohol entirely while pregnant or trying to conceive.” Is the use of alcohol-based hand sanitizers by pregnant health care workers a risk to their unborn fetuses?
A review of the literature revealed that few studies have been done to measure blood alcohol concentrations after the use of these alcohol-based hand sanitizers. Miller et al1 had 5 volunteers (all men) apply hand sanitizer (62% ethanol) 50 times over a 4-hour period, and found all blood alcohol concentrations to be below 5 mg/dL.
Kramer et al2 had 12 volunteers (six men and six women) use three different hand sanitizers (95%, 85%, and 55% ethanol) for a Basic Hand Hygiene application regimen. The volunteers applied 4 mL of hand sanitizer for 30 seconds each time, 20 times over the course of 30 minutes, with 1-minute breaks between applications. They then measured blood alcohol levels immediately after the last applications, and at intervals up to and including 90 minutes after the last application. This group reports peak blood alcohol levels to occur 30 minutes after the last application. They report levels from 0.69 to 2.1 mg/dL for the different strengths of alcohol-based hand sanitizers.
Although the Centers for Disease Control and Prevention reports averages of five to 30 hand rubs/health care worker/shift,3 Dr Michele Walsh (MD, Director, Division of Neonatology, Case Western Reserve University, Rainbow Babies’ and Children's Hospital, personal communication, August 2011) estimates that a health care worker in the neonatal intensive care unit at Case Western Reserve's Rainbow Babies' and Children's Hospital often uses a hand sanitizer as many as 100 times over an 8-hour shift. Using Kramer et al's2 data and Walsh's maximum-use information, a predicted blood alcohol level for a real-life intensive care unit health care worker using alcohol rubs even at the 95% ethanol composition to sanitize hands would be 0.65 mg/dL.
Bessonneau et al4 published a mathematical model to predict inhalation exposure to ethanol from an alcohol-based hand sanitizer. They postulated a health care worker uses an alcohol-based sanitizer 30 times in an 8-hour shift. Assuming no room air exchanges, they calculated an inhalation exposure of 5500 mg/m3/8-hour shift, which is above the Occupational Safety and Health Administration permissible exposure limit and National Institute for Occupational Safety and Health recommended exposure limit of 1900 mg/m3.5 This would translate to an exposure of 687.5 mg/m3/h, and with a standard ventilation factor of six exchanges per hour, the projected worker exposure would be 114.58 mg/m3/h.
The excessive use of alcohol during pregnancy is well documented to cause fetal alcohol syndrome, and more recent studies are showing that lower levels of alcohol during pregnancy may also result in adverse effects on the developing neurologic system of the fetus.
Bearer et al6 studied the effect of ethanol on normal neurological development using animal models, and have found adverse effects at a concentration as low as 4.6 mg/dL, although a no observed adverse effect level was not identified.
Sood et al,7 in a study at an urban university-based maternity clinic, screened women at their first prenatal visit for alcohol use. They stratified these women into none; <0.3 oz; and >0.3 floz absolute alcohol a day. Six years later, they contacted and tested the children's behavior using the Achenbach Child Behavior Checklist. They found that the odds ratio of scoring in the range for delinquent behavior was 3.2 in children with any exposure to alcohol. Further statistical tests suggested that “adverse effects of prenatal alcohol exposure on child behavior at age 6 to 7 years are evident even at low levels of exposure.”
As to available alternatives, Larsen et al8 compared the effect of two hand hygiene regimens, a traditional antiseptic hand wash and an alcohol-based hand sanitizer in two neonatal intensive care units. They found that infection rates and microbial counts on nurses’ hands were equivalent, although they acknowledge that “other practices such as frequency and quality of hand hygiene are likely to be as important as product in reducing risk of cross-transmission.”
In conclusion, the blood alcohol levels found in Kramer et al's2 study for all strengths of alcohol-based hand sanitizers are all well below the 4.6 mg/dL level found to cause adverse neurologic developmental effects in laboratory animals, and Bessonneau et al's4 study does not suggest a significant inhalation exposure to health care workers. These data are reassuring that exposure to alcohol-based hand sanitizers would, at most, lead to very low blood alcohol levels; yet, no, NOAEL (no observed adverse effect level) of fetal alcohol has been identified. We suggest therefore that if an additional risk reduction is desired by pregnant health care workers, work practices should be modified to allow the use of soap and water as a substitute for the alcohol-based hand sanitizer.
Virginia Evans, MD
Chief Resident, University of Illinois
School of Public Health Occupational
Peter Orris, MD, MPH, FACP, FACOEM
Professor and Chief of Service
University of Illinois Medical Center
1. Miller MA, Rosin A, Levsky ME, Patel MM, Gregory TJ, Crystal CS. Does the clinical use of ethanol-based hand sanitizer elevate blood alcohol levels? A prospective study. Am J Emerg Med. 2006;24:815–817.
2. Kramer A, Below H, Bieber N, et al. Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans. BMC Infect Dis. 2007;7:117.
3. Boyce JM, Pittet D. Guideline for hand hygiene in health care settings. MMWR October 25, 2002/51(RR16);1–44.
4. Bessonneau V, Clément M, Thomas O. Can intensive use of alcohol-based hand rubs lead to passive alcoholization? Int J Environ Res Public Health. 2010;7:3038–3050.
5. Centers for Disease Control and Prevention. NIOSH Pocket Guide to Chemical Hazards. Atlanta, GA: Centers for Disease Control and Prevention; 2010. http://www.cdc.gov/niosh/npg/default.html
6. Bearer CF, Swick AR, O’Riordan MA, Cheng G. Ethanol inhibits L1-mediated neurite outgrowth in postnatal rat cerebellar granule cells. J Biolog Chemistry. 274:13264–13270. http://www.jbc.org/content/274/19/13264.long
7. Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Dose-response effect. Pediatrics. 2001;108:e34. http://pediatrics.aappublications.org/content/108/2/e34.full.pdf±html
8. Larsen EL, Cimiotti J, Haas J, et al. Effect of antiseptic handwashing vs alcohol sanitizer on health care–associated infections in neonatal intensive care units. Arch Pediatr Adolesc Med. 2005;159:377–383.