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September 13, 2017

Why isn't hand sanitizer more widely used?

'Infrequently Asked Questions' seeks the answer

While it's become more common to spot hand sanitizer for the better part of two decades, it remains a bit of a head-scratcher why it's not more popular in public spaces where hand-washing is encouraged, or even more heavily promoted in stores for home use. 

Is hand sanitizer less effective than soap and water, or is there another reason for why soap and water is still the standard?

Curious, we reached out to Dr. Thomas Fekete, professor of microbiology and immunology at Temple University's Lewis Katz School of Medicine, for an explanation.

Why isn't hand sanitizer more commonly used in the general public? Thinking about restrooms and such, in particular.

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Let's take a step back first and say that in a hospital setting we are all about hand hygiene. We think of the hospital as being a high-risk environment from the perspective of us being exposed to different bacteria and we think one of the major ways bacteria gets on a patient is from the hands of health providers. So, in the hospital, we have a high rate--or, want to have--a high rate of utilization of hand sanitizers. The alternative is hand-washing stations, which are fine, but large and often in inconvenient locations. So, we don't rely on them as much as we used to. We have hand sanitizer in every single room, hallways, etc., as you can imagine.

In a hospital, you're not just trying to get cleanliness, you're trying to eliminate a level of hard-to-treat bacteria that came from one patient and [could transmit] to a second patient. That's the goal of hand sanitizer. The goal isn't to make your hand sterile--that's incidental to preventing infection transmission, right? That's the theory behind that. At home, there aren't the kind of really bad bacteria you'd be worried about, and at a hospital, you have sick patients who are prone to infection. The two things that really drive the use of hand sanitizer in a hospital don't exist at home. There's no need to go to that level at home because there's nothing to prevent. No one is vulnerable to what's being prevented. We don't really encourage that. 

And hand sanitizers aren't always as user-friendly as you'd think. They are invariably residual or sticky, and I think people like to wash their hands when they get home to get the hand sanitizer off their hands. It's the same as we don't use sterilization on our surfaces at home, in the kitchen and in bathrooms regularly, because we don't think it's useful to sterilize because you make bacteria more and more resistant to the sterilizer. And that's not a desirable outcome. We just like to wipe them down. If you're working with raw chicken you may work to greater pains than vegetables. 

So, I think to answer the question, we don't need to use them. 

You made a different point that is interesting: Would it be OK to use them and have access to them in public restrooms where it ends up that there's a line in the restroom for people to use the sink, and then there's no soap and there's the blow dryer blowing in your eyes, etc. I think that would be a reasonable alternative in a public space like that. It's true that sometimes you just don't have everything you need because it's impossible to keep up with soap and towels and all that. To me, that would be reasonable to sanitize in that setting. Not that you need it, per se, but it makes sense if you want to prevent hands from contaminating something you'll touch later and washing isn't a good option.

I do have friends who carry the sanitizer with them all the time and they wipe down surfaces, and I think that's OCD and probably not good because you want a little exposure to stuff in your life. You don't want your world completely sterile. Part of a healthy immune system is coping with normal environmental stress so you don't end up with too delicate an immune system, which leads to allergies and stuff. We want people to be cautious and use the appropriate cleaning, but we don't need to sterilize all the time--it's overkill and probably not even helpful.

So, in hospitals, it's not like in "Grey's Anatomy," where they wash their hands for five minutes?

You see, in Grey's Anatomy, they're not doing it because they are shaking someone's hand, they're doing it because they're going in the operating room to stick their hands in someone's stomach. [Laughs] So yeah, that's fine. In the hospital, the washing of hands is more like a 15-second washing between patients; it's not supposed to be that deep scrub like you see in "Grey's Anatomy." It's meant to be a thorough hand-washing but not manic-obsessed.

I just mean that it's probably less cinematic to show someone squirting Purell on a TV show.

It's not that glamorous. You're right.

Sanitizer with alcohol versus without alcohol: Is one more effective than the other?

I can't give chapter and verse on that and most do have alcohol now, but normally the idea of the sanitizer is you wipe it around and let it dry and the alcohol will mechanically kill bacteria on your hands. Not all bacteria is killed by alcohol; sometimes the bacteria that makes spores can tolerate the high concentration of alcohol and we don't think of it as 100-percent effective, just reasonably effective. If we have people we know have spore-forming bacteria, then we encourage hand washing because we think it may be a good way to dislodge the spores, to wipe and wash them down as opposed to trying to kill them with chemicals that they tolerate surprisingly well.