Seeking Clearer Recommendations for Hand Hygiene in Communities Facing Ebola: A Randomized Trial Investigating the Impact of Six Handwashing Methods on Skin Irritation and Dermatitis

Abstract

To prevent disease transmission, 0.05% chlorine solution is commonly recommended for handwashing in Ebola Treatment Units. In the 2014 West Africa outbreak this recommendation was widely extended to community settings, although many organizations recommend soap and hand sanitizer over chlorine. To evaluate skin irritation caused by frequent handwashing that may increase transmission risk in Ebola-affected communities, we conducted a randomized trial with 91 subjects who washed their hands 10 times a day for 28 days. Subjects used soap and water, sanitizer, or one of four chlorine solutions used by Ebola responders (calcium hypochlorite (HTH), sodium dichloroisocyanurate (NaDCC), and generated or pH-stabilized sodium hypochlorite (NaOCl)). Outcomes were self-reported hand feel, irritation as measured by the Hand Eczema Score Index (HECSI) (range 0–360), signs of transmission risk (e.g., cracking), and dermatitis diagnosis. All groups experienced statistically significant increases in HECSI score. Subjects using sanitizer had the smallest increases, followed by higher pH chlorine solutions (HTH and stabilized NaOCl), and soap and water. The greatest increases were among neutral pH chlorine solutions (NaDCC and generated NaOCl). Signs of irritation related to higher transmission risk were observed most frequently in subjects using soap and least frequently by those using sanitizer or HTH. Despite these irritation increases, all methods represented minor changes in HECSI score. Average HECSI score was only 9.10 at endline (range 1–33) and 4% (4/91) of subjects were diagnosed with dermatitis, one each in four groups. Each handwashing method has benefits and drawbacks: soap is widely available and inexpensive, but requires water and does not inactivate the virus; sanitizer is easy-to use and effective but expensive and unacceptable to many communities, and chlorine is easy-to-use but difficult to produce properly and distribute. Overall, we recommend Ebola responders and communities use whichever handwashing method(s) are most acceptable, available, and sustainable for community handwashing.Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN89815514

Handwashing and Ebola virus disease outbreaks: A randomized comparison of soap, hand sanitizer, and 0.05% chlorine solutions on the inactivation and removal of model organisms Phi6 and E. coli from hands and persistence in rinse water

“…Overall, chlorine may be preferable in some cases because it may confer a benefit of continued disinfection in rinse water after handwashing. In related work, we investigated the safety of these handwashing methods based on their potential to irritate skin and pose a risk for disease transmission, and found no clinically-relevant differences between these same six methods [ 76 ]. Based on our results that validate both the safety and efficacy of all six commonly used handwashing protocols, we recommend Ebola responders and communities facing outbreaks focus on what is most practical and choose the most acceptable and sustainable methods to allow for consistent and thorough handwashing.…”

Determining the Efficacy, Safety and Suitability of Disinfectants to Prevent Emerging Infectious Disease Transmission

“…Safety: Although all groups experienced statistically significant increases in HECSI scores, these increases in irritation were not clinically relevant as the average HECSI score was only 9/360 after 28 days [14]. Subjects using sanitizer had the smallest increases, followed by higher pH chlorine solutions (HTH and stabilized NaOCl) as well as soap and water.…”

“…Safety: To assess safety, a randomized trial with 91 volunteers who washed their hands 10 times a day for 28 days was conducted [14]. Volunteers were assigned and used commercially-available bar soap and water; 70% ethanol hand sanitizer (referred herein as 'sanitizer' and equivalent "alcohol based hand sanitizer, ABHS"); or 0.05% chlorine solution created from HTH, NaDCC, generated NaOCl or stabilized NaOCl for handwashing.…”

COVID-19 salgını sırasında Türk toplumunun sosyal el yıkama bilgi ve tutumunun değerlendirilmesi

“…Wolfe ve ark. [34] Ebola'dan etkilenen toplumlarda bulaşma riskini artırabilecek sık sık yıkamanın neden olduğu cilt tahrişini değerlendirmek için yaptığı çalışmada da el dezenfektanı kullanarak el hijyeni sağlayan grupta dermatit geliştiği ifade edilmiştir. Tüm bu faktörlere ek olarak, şaşırtıcı şekilde çalışmamızda kağıt havlu kullananlarda bez havlu kullananlara göre daha fazla cilt sorunu geliştiği saptandı.…”