No one disputes the importance of hand hygiene but there is nothing wrong with old-fashioned soap and water. (Manuel Balce Ceneta, AP)

Sanitisers score hand over fist

Laura Barton
The popularity of saniters has as much to do with health as fashion and the jury is out over their efficacy, writes Laura Barton.

Bakersfield, California, is a large city about 160km north of Los Angeles. Founded on recovered swampland by Colonel Thomas Baker, it is today famed for oil, gas and agriculture, as well as for being the country music capital of the United States’ west coast.

But Bakersfield is also where, in 1966, a student nurse named Lupe Hernandez first dreamed up the idea of a hand sanitiser. She realised that alcohol in a gel could be used to clean hands where there was no access to soap and warm water. Realising the commercial potential of her idea, she called an inventions hotline she had heard about on television and registered a patent.

Forty-six years ago even Hernandez could not have predicted the explosion in popularity that hand sanitiser has experienced in recent times. In the US alone the growth of the market is astounding: valued at $28-million in 2002, it had swollen to $80-million by 2006 and is predicted to be worth $402-million by 2015.

In matters of hygiene, the United Kingdom tends to follow where the US has led. Because I operate on the theory that a little bit of dirt does us good, I do not carry a hand sanitiser, but I recognise that I am increasingly in a minority.

Bottles of antibacterial gel have become an increasingly common sight in Britain and most particularly in London. It has become a handbag must-have, a public transport companion, a desk mate in the office and seemingly invaluable for mothers wiping down sticky toddlers.

Nasties
I see people leaving the tube station and cleansing themselves of whatever nasties they may have picked up from the escalator handrails; I see them in their offices, slicking their hands before they touch their computer keyboards; I see them on their lunch breaks sitting down at café tables and indulging in a quick preprandial hand-gelling.
 
They are women mostly, crisp and well dressed, their hand sanitiser now just another part of their well-run hygiene routine. And even those who have yet to introduce antibacterial gel into their lives with real rigour still seem to carry it, tucking it into their handbags like some kind of posy to ward off the plague.

Since early 2010 even WH Smiths, the ubiquitous high-street news­agent, has stocked small bottles of hand sanitiser perched at the till in its airport, railway and service station stores.

Another chain, Superdrug, reports a 12% increase in sales of hand sanitisers compared with this time last year. And with the northern summer approaching and bringing with it holidays, festivals, picnics and trips to the beach, sales are likely to climb faster. Soap manufacturer Gojo,  maker of the best-selling hand sanitiser brand Purell in the US, calculates that the professional market in the UK is worth about £10-million. Although it does not sell hand gel for the consumer market, its research suggests that it is worth the same.

Hand sanitiser was once the stuff of institutions: hospitals and care homes, for use by the armed forces and, in the US, in large public places such as restaurants and supermarkets, for those concerned about the germ-laden prospect of cutlery and shopping trolley handles. Its transition to essential personal accessory began in the wake of the H1N1 outbreak of 2009 when sales of antibacterial gels and wipes soared in the US. Market research company Nielsen reported that, in the 24 weeks leading up to October that year, sales rose by 71% to $118.4-million, compared with $69.4-million the previous year.

Precautionary squirt
The Walt Disney company installed 60 bulk sanitiser dispensers in the hotel lobbies, park entrances and character meet-and-greet areas of its Florida theme parks. It seemed as if wherever you went and whatever you did, it had to be preceded by a precautionary squirt of sanitiser.

Gojo released Purell, the first commercial antibacterial hand gel, in 1988. In the years since, several public health scares – from severe acute respiratory syndrome and avian flu to swine flu – spurred consumer demand for such products.

Scientific research has delivered a string of ever-horrifying statistics to encourage our anti­bacterial urges, such as the fact that the spread of diarrhoea and gastrointestinal illnesses can be almost halved by practising effective hand hygiene. The British Medical Journal recently reported that a four-year study linked hospitals’ increased use of soap and alcohol hand rub with a drop in the rate of superbug infections.

But the appeal of hand sanitiser has not been solely about hygiene: as sales grew it swiftly became something akin to a fashion accessory as much as a necessity, a way of advertising your cleanliness. A report in the Los Angeles Times during the H1N1 outbreak noted that the growth in hand gels had also spawned a demand in personalised dispensers: “Consumers can go online and order them in fur-trimmed pump bottles or in containers printed with their company names,” it reported.

“Pier 1 Imports is selling holiday-themed sanitisers with scents such as cinnamon and cilantro [coriander], packaged as nicely as perfumes.”

Outbreak of disease
The popularity of hygiene products often spreads this way. “Disgust sensitivity varies in the population in the same way that height varies. Most people are somewhere in the middle, but you find extremes at either end of the spectrum,” said Dr Val Curtis, director of the hygiene centre at the London School of Hygiene and Tropical Medicine. “It’s a particular group of people who use hand sanitiser at first – people who are particularly squeamish about dirt and germs. The marketing challenge is then to spread the usage outside of that group.”

An outbreak of disease would encourage such use outside the initial squeamish group, Curtis said. “When you have a sense of high contamination in a population, it moves people into the next category. It’s no coincidence that during the swine flu epidemic there was an increase in clinical concentration of obsessive-compulsive disorder.”

But Curtis warned against a marketing campaign that increased our sense of contamination. “It’s not good for mental health,” she said. Instead, the most effective way to get people to practise good hygiene or  use a specific product was to increase the sense of disgust. “The most powerful marketing tactic is the power of social norm,” Curtis said. “In studies we conducted in the bathrooms of service stations, we found that the best message to convince people to wash their hands was moral. We put up signs saying: ‘Is the person next to you washing their hands?’”

Thanks to the heightened fear of contamination experienced during recent flu epidemics, there is now a value judgment attached to carrying and using an antibacterial gel. “Purity is associated with goodness,” Curtis said. “Cleanliness and godliness do go together. People start to feel ashamed of not having clean hands, because the message is that you are not protecting others from your germs.”

But the appeal of hand sanitisers does not stop there. It also, as some teenagers have realised, offers alternative uses: earlier this year it was reported that teens were drinking hand sanitisers as a way of getting drunk. After all, ethanol-based gels can contain more than 60% ethanol, meaning they are 120 proof. Tequila, by comparison, is about 70 to 80 proof and a great deal harder to buy if you are below the legal drinking age. A CNN survey of poison control centres in the US found that last year there were 622 calls involving teens and hand sanitisers (77% involved oral consumption). In the first quarter of this year, there had already been 203 calls.

Multidrug-resistant organisms
But aside from their moral, aesthetic, convenient and intoxicating appeal, the benefits offered by hand sanitisers may not be quite the magical cure-all we think them to be.
Dr Ron Cutler, senior lecturer at Queen Mary, University of London and an expert in infection control, has noted hand sanitisers’ growing popularity with interest. “You see a lot of people, especially young ladies, tend to use it on the tube and on the train, and I see students here using gels and wipes,” he said.

“What has happened with society is that we’re seeing multidrug-resistant organisms that seem to be more common than they ever were before. And it’s been shown several times that when these superbugs get out, they do tend to grow like never before. People are concerned about that, so you get an increase in the number of people buying hygiene products.”

In such a climate, it is both enticing and reassuring to see your hand sanitiser of choice emblazoned with proof of its efficacy, each promising to obliterate an impressively high percentage of germs. But Cutler tempers such enthusiasm. “These sanitisers state that they kill 99.9% of germs, but the difficulty is that the data was done on inanimate surfaces and they don’t replicate what happens on the human hand,” he said.

The hand was different because “you have flora on your hand that lives there and interacts with other bugs on your hand”. And these percentages might not actually be so impressive. “My take, as a bacteriologist, is that 99.9% is nothing when you consider that organisms live in communities of billions – that 0.1% can mean a lot of bacteria,” Cutler said.

A little bewilderingly, some studies suggest that hand sanitisers may even be detrimental to our health. Hand-sanitising gels work by removing the top layer of oil from our hands, taking with it some of the good bacteria on our skin. They can also dry the skin, which is why many manufacturers have begun to add moisturising ingredients to counteract the effect of the alcohol.

Inactivate sanitisers
Questions have also been raised about triclosan, an ingredient in many hand sanitisers, liquid soaps, shaving gels and dishwashing liquids. The US Food and Drug Administration has said that research shows “valid concerns” about triclosan, including whether it can disrupt the body’s endocrine system and create bacteria that are resistant to antibiotics.

Furthermore, Cutler said, hand gels could be affected by the type of grubbiness they encounter. “Put simply, dirt, particularly some faecal proteins, can sometimes inactivate sanitisers,” he said.

And on top of all this, are hand sanitisers not just a little bit wasteful – all that plastic, all that manufacturing energy when, in many cases, we could just use soap and water to clean our hands?

In fact, many studies have shown that sanitiser is no more effective than soap and water in stopping the spread of colds, flu and other respiratory diseases.

“People think they’re more effective than water because you don’t see adverts for soap and water saying the percentage of germs they kill,” Cutler said. “But the Food and Drug Administration doesn’t recommend hand sanitiser in place of soap and water.”

Smaller risks
Curtis agreed. “Hand gel is desirable but it’s not absolutely essential,” she said. It might be compared with bottled water – preferable in a world of consumer choice and convenience but, in a country where infection and disease were small compared with developing nations, far from vital. “We live in a world where we have much fewer risks and so we start to worry about smaller risks,” Curtis said.

“But we can just use normal soap and water.”

This is not to downplay the importance of clean hands. Curtis and Cutler are involved with Global Handwashing Day, an initiative that seeks to raise awareness about the importance of washing hands in reducing the spread of infection.
 
“There is nothing wrong with washing your hands,” Cutler said. “I’d be the first to say that. And, in fighting epidemics, hygiene and hand hygiene is a solution. But I don’t think hand sanitisers are an alternative to washing hands.” – © Guardian News & Media 2012

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