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Review
. 2022 Jul 6;11(1):93.
doi: 10.1186/s13756-022-01134-7.

Ethanol is indispensable for virucidal hand antisepsis: memorandum from the alcohol-based hand rub (ABHR) Task Force, WHO Collaborating Centre on Patient Safety, and the Commission for Hospital Hygiene and Infection Prevention (KRINKO), Robert Koch Institute, Berlin, Germany

Axel Kramer  1   2   3 , Mardjan Arvand  4 , Bärbel Christiansen  5   6 , Stephanie Dancer  7   8 , Maren Eggers  9 , Martin Exner  5   10 , Dieter Müller  11 , Nico T Mutters  5   10 , Ingeborg Schwebke  12 , Didier Pittet  13
Affiliations
Review

Ethanol is indispensable for virucidal hand antisepsis: memorandum from the alcohol-based hand rub (ABHR) Task Force, WHO Collaborating Centre on Patient Safety, and the Commission for Hospital Hygiene and Infection Prevention (KRINKO), Robert Koch Institute, Berlin, Germany

Axel Kramer et al. Antimicrob Resist Infect Control. .

Abstract

Background: The approval of ethanol by the Biocidal Products Regulation has been under evaluation since 2007. This follows concern over alcohol uptake from ethanol-based hand rubs (EBHR). If ethanol is classified as carcinogenic, mutagenic, or reprotoxic by the European Chemicals Agency (ECHA), then this would affect infection prevention and control practices.

Aim: A review was performed to prove that ethanol is toxicological uncritical and indispensable for hand antisepsis because of its unique activity against non-enveloped viruses and thus the resulting lack of alternatives. Therefore, the following main points are analyzed: The effectiveness of ethanol in hand hygiene, the evidence of ethanol at blood/tissue levels through hand hygiene in healthcare, and the evidence of toxicity of different blood/tissue ethanol levels and the non-comparability with alcoholic consumption and industrial exposure.

Results: EBHR are essential for preventing infections caused by non-enveloped viruses, especially in healthcare, nursing homes, food industry and other areas. Propanols are effective against enveloped viruses as opposed to non-enveloped viruses but there are no other alternatives for virucidal hand antisepsis. Long-term ingestion of ethanol in the form of alcoholic beverages can cause tumours. However, lifetime exposure to ethanol from occupational exposure < 500 ppm does not significantly contribute to the cancer risk. Mutagenic effects were observed only at doses within the toxic range in animal studies. While reprotoxicity is linked with abuse of alcoholic beverages, there is no epidemiological evidence for this from EBHR use in healthcare facilities or from products containing ethanol in non-healthcare settings.

Conclusion: The body of evidence shows EBHRs have strong efficacy in killing non-enveloped viruses, whereas 1-propanol and 2-propanol do not kill non-enveloped viruses, that pose significant risk of infection. Ethanol absorbed through the skin during hand hygiene is similar to consumption of beverages with hidden ethanol content (< 0.5% v/v), such as apple juice or kefir. There is no risk of carcinogenicity, mutagenicity or reprotoxicity from repeated use of EBHR. Hence, the WHO Task Force strongly recommend retaining ethanol as an essential constituent in hand rubs for healthcare.

Keywords: Absorption; Biocidal product regulation; Ethanol based hand rub; Hand antisepsis; Inactivation; Memorandum; Non-enveloped viruses; Patient safety; Risk–benefit-assessment; WHO; Worker safety.

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Conflict of interest statement

The authors declare no competing interests.

The authors declare that they have no competing interests. The memorandum was prepared voluntarily without conflicts of interest by the German Commission for Hospital Hygiene and Infection Prevention (Axel Kramer, head of the working group, Mardjan Arvand, Bärbel Christiansen, Stephanie Dancer, Maren Eggers, Martin Exner, Dieter Müller, Niko Mutters, Ingeborg Schwebke) and by the Alcohol Based Hand Rub (ABHR) Task Force of the WHO, Infection Control Programme & WHO Collaborating Centre on Patient Safety, The University of Geneva Hospitals and Faculty of Medicine Geneva, Switzerland (Didier Pittet, head of the task force).

References

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