Less and less–influence of volume on hand coverage and bactericidal efficacy in hand disinfection

BACKGROUND: Some manufacturers recommend using 1.1 mL per application of alcohol-based handrubs for effective hand disinfection. However, whether this volume is sufficient to cover both hands, as recommended by the World Health Organization, and fulfills current efficacy standards is unknown. This study aimed to determine hand coverage for three handrubs (two gels based on 70% v/v and 85% w/w ethanol and a foam based on 70% v/v ethanol) applied at various volumes. METHODS: Products were tested at product volumes of 1.1 mL, 2 mL, 2.4 mL as well as 1 and 2 pump dispenser pushes; the foam product was tested in addition at foam volumes of 1.1 mL, 2 mL, and 2.4 mL. Products were supplemented with a fluorescent dye and 15 participants applied products using responsible application techniques without any specific steps but the aim of completely covering both hands. Coverage quality was determined under ultraviolet light by two blinded investigators. Efficacy of the three handrubs was determined according to ASTM E 1174-06 and ASTM E 2755-10. For each experiment, the hands of 12 participants were contaminated with Serratia marcescens and the products applied as recommended (1.1 mL for 70% v/v ethanol products; 2 mL for the 85% w/w ethanol product). Log(10)-reduction was calculated. RESULTS: Volumes < 2 mL yielded high rates of incomplete coverage (67%–87%) whereas volumes ≥ 2 mL gave lower rates (13%–53%). Differences in coverage were significant between the five volumes tested for all handrubs (p < 0.001; two-way ANOVA) but not between the three handrubs themselves (p = 0.796). Application of 1.1 mL of 70% v/v ethanol rubs reduced contamination by 1.85 log(10) or 1.60 log(10) (ASTM E 1174-06); this failed the US FDA efficacy requirement of at least 2 log(10). Application of 2 mL of the 85% w/w ethanol rub reduced contamination by 2.06 log(10) (ASTM E 1174-06), fulfilling the US FDA efficacy requirement. Similar results were obtained according to ASTM E 2755-10. CONCLUSIONS: Our data indicated that handrubs based on 70% ethanol (v/v) with a recommended volume of 1.1 mL per application do not ensure complete coverage of both hands and do not achieve current ASTM efficacy standards.