1. Home and community hygiene and the use of alcohol-based hand sanitizers Sally Bloomfield, BPharm, PhD Chairman and Scientific Advisory Board Member, IFH Hon. Professor, London School of Hygiene and Tropical Medicine

2. The International Scientific Forum on Home Hygiene (IFH) A not-for-profit, non-governmental organization comprising scientists & healthcare professionals Primary objectives: –Promote awareness and understanding of good hygiene practice and its importance in the home - based on scientific evidence Target Audience: –Public health scientists, opinion formers, health professionals, community workers Activities: –Detailed review of scientific literature on home hygiene –Formulate “Guidelines on home hygiene” www.ifh-homehygiene.org

3. The role of home and community hygiene Good hygiene practice is key to reducing infection risks: –even in 21st century where we have access to clean water, sanitation, vaccines, antibiotics etc Good hygiene practice is important: –in the home –in social and workplace settings: child and elderly daycare centers schools, offices theaters, cinemas, cafes, restaurants military establishments travel by rail, air, ship The home forms a continuum with community settings

4. IFH - developing effective policy for home hygiene: In formulating home hygiene policy, the IFH has adopted a risk assessment approach (HACCP) This has come to be known as “targeted hygiene” Infectious disease agents are continually brought into the home: –People: infected or carriers –Food: up to 50% of raw chicken may contain Salmonella or Campylobacter –Pets: up to 39% of dogs may carry Campylobacter, 10-27% may carry Salmonella; cats are also carriers Toilets, basins, wet cloths etc can support growth of microbes and become a source of infectious agents

5. IFH - developing effective policy for home hygiene: Targeted hygiene: –is not about trying to eradicate pathogenic microbes from the home through daily cleaning –means targeting hygiene measures to places and times that matter

6. Targeted home hygiene - importance of hands Since targeted hygiene focuses on preventing spread of germs, major target sites are hands, and hand and food contact surfaces, and cloths - in the kitchen, bathroom and toilet Indications are that the hands are probably the most important agents for disease transmission in the home

7. Handwashing intervention studies Aiello and Larson (2002) evaluated intervention & observational studies, 1980 - 2001, in US, Canada and Australia. Risk reduction: ranged from 21-77%

8. Microbiological studies In recent years a range of microbiological studies have been published, many related specifically to the home & community which indicate: –infectious agents continually brought into these settings –dispersed to hands and other surfaces –survive for significant periods –transfer of pathogens via the hands to the mouth, nose, conjunctiva etc and/or to ready to eat foods in sufficient numbers to cause infections In view of problems of performing clinical trials for prophylactic measures such as home hygiene - it is important that we use these data (e.g in QMRA) for assessing infection risks - and the impact of hygiene practices

9. Targeted home hygiene - Handwashing and risk reduction In situations where there is significant risk of infection, hygiene procedures are used to reduce the risks by eliminating contamination and preventing further spread. For hand hygiene: –generally assumed that contamination can be effectively removed using soap (or detergent) and water. –since this process relies on mechanical release of microbes, to be effective it must be applied in conjunction with rinsing with running water.

10. Targeted home hygiene – Alcohol-based hand sanitizers Because soap and water are not always available –especially in out-of-home settings - schools, daycare centers, social settings, travel etc. There is a need for products that are portable, convenient, waterless, and effective. “No rinse” alcohol-based hand sanitizers (ABHS) meet the need for maintaining hand hygiene when soap and water are not available and when hands are not visibly dirty.

11. Effectiveness of alcohol-based hand sanitizers “No-rinse” hand sanitizers need to be: -active against a broad spectrum of bacteria, viruses and fungi representative of infectious agents commonly found in home and out-of-home settings, and for which there is evidence of infection spread via the hands -fast acting - 30 seconds to one minute -equally or more effective than soap and water Available data on ABHS indicate good efficacy profile: –in vivo (panel tests): reduction of bacteria and viruses on artificially contaminated hands –in vitro: time-kill studies to evaluate spectrum of activity –intervention studies

12. Efficacy of ABHS in reduction of microbes on contaminated hands In vivo testing of alcohol-based hand sanitizers

13. In vitro testing of alcohol-based hand sanitizers *some strains of rhinovirus (e.g. type 16) give log red’n >4.25

14. Intervention studies with alcohol-based hand sanitizers Intervention: HW: handwashing; HE: hygiene education; ABHS: use of ABHS (ethyl or isopropyl alcohol 60-90%); NSR: no significant reduction For infectious illness/symptoms across all studies - median reduction was 22.0% (range 8%-66%) – Personal communication from A. Aiello

15. Safety of alcohol-based hand sanitizers No evidence of alcohol or antibiotic resistance associated with the use of ABHS –non selective action - membrane disruption, coagulation of cell contents –evaporates - leaves no active residue –active against antibiotic resistant strains, e.g. MRSA EPA concludes that aliphatic alcohols not intended for ingestion are of low acute toxicity ABHS formulated with appropriate emollients cause less skin irritation than soap and water in frequent-use situations

16. Conclusions Home hygiene practice is key to reducing the burden of infectious disease in the community Hand hygiene is a key component of good hygiene practice Alcohol-based hand sanitizers provide an effective alternative in situations where soap and water are not available and may encourage compliance Based on their safety and lack of antimicrobial resistance/ cross-resistance, alcohol-based hand sanitizers are appropriate for use in consumer settings Benefit/ risk profile is positive

17. US government & non-governmental organizations recommend use of alcohol-based hand sanitizers when soap and water are not available: Governmental organizations include: Federal Food and Drug Administration Federal Trade Commission U.S. Departments of Education and Labor Centers for Disease Control and Prevention Environmental Protection Agency National Institute of Allergy and Infectious Diseases State Departments of Health, county governments, and public schools U.S. Military branches include: Air Force, Army, Navy Non-governmental groups include: American Red Cross American Association of Occupational Health Nurses American Hospital Association Association for Professionals in Infection Control and Epidemiology Infectious Diseases Society of America Society for Healthcare Epidemiology of America