James W. Arbogast

Improved Inactivation of Nonenveloped Enteric Viruses and Their Surrogates by a Novel Alcohol-Based Hand Sanitizer

ABSTRACT Norovirus is the leading cause of food-related illness in the United States, and contamination of ready-to-eat items by food handlers poses a high risk for disease. This study reports the in vitro (suspension test) and in vivo (fingerpad protocol) assessments of a new ethanol-based hand sanitizer containing a synergistic blend of polyquaternium polymer and organic acid, which is active against viruses of public health importance, including norovirus. When tested in suspension, the test product reduced the infectivity of the nonenveloped viruses human rotavirus (HRV), poliovirus type 1 (PV-1), and the human norovirus (HNV) surrogates feline calicivirus (FCV) F-9 and murine norovirus type 1 (MNV-1) by greater than 3 log10 after a 30-s exposure. In contrast, a benchmark alcohol-based hand sanitizer reduced only HRV by greater than 3 log10 and none of the additional viruses by greater than 1.2 log10 after the same exposure. In fingerpad experiments, the test product produced a 2.48 log10 reduction of MNV-1 after a 30-s exposure, whereas a 75% ethanol control produced a 0.91 log10 reduction. Additionally, the test product reduced the infectivity titers of adenovirus type 5 (ADV-5) and HRV by ≥3.16 log10 and ≥4.32 log10, respectively, by the fingerpad assay within 15 s; and PV-1 was reduced by 2.98 log10 in 30 s by the same method. Based on these results, we conclude that this new ethanol-based hand sanitizer is a promising option for reducing the transmission of enteric viruses, including norovirus, by food handlers and care providers.

Efficacy of commonly used disinfectants for inactivation of human noroviruses and their surrogates.

Human noroviruses (HuNoVs) are the most common cause of acute viral gastroenteritis worldwide and are a leading cause of foodborne disease. Their environmental persistence and purported resistance to disinfection undoubtedly contribute to their success as foodborne disease agents. The purpose of this study was to compare the efficacy of three commonly used disinfectant active ingredients against representative HuNoV strains and cultivable surrogates. Ethanol (50, 70, and 90%), sodium hypochlorite (5, 75, 250, 500, and 1,000 ppm), and a quaternary ammonium compound blend (at 0.1×, 1.0×, and 10× concentrations) were evaluated against two norovirus (NoV) genogroup II strains (GII.2 and GII.4) and two surrogates (feline calicivirus [FCV] and murine norovirus [MNV-1]). Virucidal suspension assays (30-s exposure) were conducted in accordance with ASTM International standard E-1052. Virus inactivation was quantified using reverse transcription quantitative PCR targeting the ORFI-ORFII junction (HuNoV), the RNA polymerase region (MNV-1), or the ORFI region (FCV); infectivity assays were also performed for MNV-1 and FCV. The two HuNoV strains and FCV were relatively resistant to ethanol (<0.5 log inactivation) irrespective of concentration, but MNV-1 was much more susceptible (log inactivation, ∼2.0 log at higher ethanol concentrations). Both HuNoV strains were more resistant to hypochlorite than were either of the animal surrogates, with the human strains requiring ≥500 ppm of hypochlorite to achieve statistically significant reduction (≥3.0 log) in virus concentration. All four viruses were resistant to inactivation (<0.5-log reduction) using the quaternary ammonium compound formulation at all concentrations tested. This study is novel in that it clearly demonstrates the relative ineffectiveness of common active disinfectant ingredients against HuNoV and highlights the fact that the cultivable surrogates do not always mimic HuNoV strains.

Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands.

This study determined whether surrogate organisms can predict activity against Clostridium difficile spores and compared the efficacy of hand hygiene preparations against C. difficile. Our data suggest that surrogate organisms were not predictive of C. difficile spore removal. Four preparations were significantly more effective than tap water at removing C. difficile.

Laboratory evidence of norwalk virus contamination on the hands of infected individuals.

ABSTRACT Human norovirus (NoV) outbreak investigations suggest that the hands of infected individuals play an important role in NoV transmission. However, there is no experimental evidence documenting the likelihood and degree of NoV contamination on hands. As part of a clinical trial designed to evaluate the efficacy of high-pressure processing for Norwalk virus (NV) inactivation in oysters, 159 hand rinse samples were collected from 6 infected and 6 uninfected subjects. NV was concentrated from the samples by polyethylene glycol precipitation, followed by RNA extraction using an automated guanidinium isothiocyanate-silica method. NV RNA was detected and quantified using multiple NV-specific reverse transcription-quantitative PCR (RT-qPCR) assays. A total of 25.4% (18/71) of the hand rinse samples collected from 6 infected volunteers were presumptively positive for NV, with an average of 3.86 log10 genomic equivalent copies (GEC) per hand. Dot blot hybridization of PCR products obtained using a different primer set, and DNA sequencing of selected amplicons, provided further confirmation of the presence of NV in the hand rinses. NV contamination was also detected in two hand rinse samples obtained from one uninfected subject. These findings provide definitive evidence of NV contamination on the hands of infected subjects observed under controlled clinical research conditions. Such data support the need for better hand hygiene strategies to prevent NoV transmission.

Alcohol-Based Instant Hand Sanitizer Use in Military Settings: A Prospective Cohort Study of Army Basic Trainees

We investigated the impact of a customized alcohol-based instant hand sanitizer hand-hygiene regimen in an Army basic training setting. The entire population at the U.S. Army Field Artillery Training Center, Fort Sill, Oklahoma, participated in the 13-week prospective cohort study between January 18, 2005 and April 18, 2005. Two training battalions were randomly assigned to the control group, one to the primary intervention group (customized Purell Instant Hand Sanitizer regimen, education, reinforcement) and one to the secondary intervention group (customized Purell Instant Hand Sanitizer regimen). When compared to the control group, intervention groups experienced 40% less respiratory illness (p < 0.001), 48% less gastrointestinal illness (p < 0.02), 44% less lost training time (p < 0.001), and 31% fewer health care encounters (p < 0.001). These findings suggest that this intervention is capable of significantly reducing illness in this setting and has the potential to help reduce absenteeism in the military workforce as a whole.

Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs: Formulation matters

BACKGROUND Use of alcohol-based hand rubs (ABHRs) effectively reduces transmission of pathogenic microorganisms. However, the impact of alcohol concentration and format on product efficacy is currently being debated. METHODS Two novel ABHR formulations containing 70% ethanol were evaluated according to American Society for Testing and Materials E1174 (Health Care Personnel Handwash [HCPHW]) and European Norm (EN) 1500 global standards. Additionally, using E1174, the efficacy of these formulations was compared head-to-head against 7 representative commercially available ABHRs and 2 World Health Organization recommended formulations containing alcohol concentrations of 60% to 90%. RESULTS The novel ABHR formulations met efficacy requirements for both HCPHW and EN 1500 when tested at application volumes typically used in these methods. Moreover, these formulations met HCPHW requirements when tested at a more realistic 2-mL product application. In contrast, the commercial ABHRs and World Health Organization formulations failed to meet HCPHW requirements using a 2-mL application. Importantly, product performance did not correlate with alcohol concentration. CONCLUSION Product formulation can greatly influence the overall antimicrobial efficacy of ABHRs and is a more important factor than alcohol concentration alone. Two novel ABHRs based on 70% ethanol have been formulated to meet global efficacy standards when tested at volumes more representative of normal product use in health care environments.

Bacterial Hand Contamination and Transfer after Use of Contaminated Bulk-Soap-Refillable Dispensers

ABSTRACT Bulk-soap-refillable dispensers are prone to extrinsic bacterial contamination, and recent studies demonstrated that approximately one in four dispensers in public restrooms are contaminated. The purpose of this study was to quantify bacterial hand contamination and transfer after use of contaminated soap under controlled laboratory and in-use conditions in a community setting. Under laboratory conditions using liquid soap experimentally contaminated with 7.51 log10 CFU/ml of Serratia marcescens, an average of 5.28 log10 CFU remained on each hand after washing, and 2.23 log10 CFU was transferred to an agar surface. In an elementary-school-based field study, Gram-negative bacteria on the hands of students and staff increased by 1.42 log10 CFU per hand (26-fold) after washing with soap from contaminated bulk-soap-refillable dispensers. In contrast, washing with soap from dispensers with sealed refills significantly reduced bacteria on hands by 0.30 log10 CFU per hand (2-fold). Additionally, the mean number of Gram-negative bacteria transferred to surfaces after washing with soap from dispensers with sealed-soap refills (0.06 log10 CFU) was significantly lower than the mean number after washing with contaminated bulk-soap-refillable dispensers (0.74 log10 CFU; P < 0.01). Finally, significantly higher levels of Gram-negative bacteria were recovered from students (2.82 log10 CFU per hand) than were recovered from staff (2.22 log10 CFU per hand) after washing with contaminated bulk soap (P < 0.01). These results demonstrate that washing with contaminated soap from bulk-soap-refillable dispensers can increase the number of opportunistic pathogens on the hands and may play a role in the transmission of bacteria in public settings.

Quest for a Realistic In Vivo Test Method for Antimicrobial Hand-Rub Agents: Introduction of a Low-Volume Hand Contamination Procedure

ABSTRACT A novel method has been developed for the evaluation of alcohol-based hand rubs (ABHR) that employs a hand contamination procedure that more closely simulates the in-use conditions of ABHR. Hands of human subjects were contaminated with 0.2 ml of a concentrated suspension of Serratia marcescens (ATCC 14756) to achieve baseline contamination between 8 and 9 log10 CFU/hand while allowing product to be applied to dry hands with minimal soil load. Evaluation of 1.5 ml of an ABHR gel containing 62% ethanol produced log10 reductions of 2.66 ± 0.96, 2.40 ± 0.50, 2.41 ± 0.61, and 2.33 ± 0.49 (means ± standard deviations) after 1, 3, 7, and 10 successive contamination/product application cycles. In a study comparing this low-volume contamination (LVC) method to ASTM E1174, product dry times were more realistic and log10 reductions achieved by the ABHR were significantly greater when LVC was employed (P < 0.05). These results indicate that a novel low-volume hand contamination procedure, which more closely represents ABHR use conditions, provides more realistic estimates of in-use ABHR efficacies. Based on the LVC method, log10 reductions produced by ABHR were strongly dependent on the test product application volume (P < 0.0001) but were not influenced by the alcohol concentration when it was within the range of 62 to 85% (P = 0.378).

Efficacy of novel alcohol-based hand rub products at typical in-use volumes.

In vivo efficacies of 2 alcohol-based hand rub (ABHR) products (gel and foam) were evaluated at a volume of 1.1 mL. Both met US Food and Drug Administration log(10) reduction requirements after a single application and 10 consecutive applications. This is the first study to identify ABHR formulations capable of meeting efficacy requirements with a single-dispenser actuation.

Ability of Hand Hygiene Interventions Using Alcohol-Based Hand Sanitizers and Soap To Reduce Microbial Load on Farmworker Hands Soiled during Harvest.

Effective hand hygiene is essential to prevent the spread of pathogens on produce farms and reduce foodborne illness. The U.S. Food and Drug Administration Food Safety Modernization Act Proposed Rule for Produce Safety recommends the use of soap and running water for hand hygiene of produce handlers. The use of alcohol-based hand sanitizer (ABHS) may be an effective alternative hygiene intervention where access to water is limited. There are no published data on the efficacy of either soap or ABHS-based interventions to reduce microbial contamination in agricultural settings. The goal of this study was to assess the ability of two soap-based (traditional or pumice) and two ABHS-based (label-use or two-step) hygiene interventions to reduce microbes (coliforms, Escherichia coli, and Enterococcus spp.) and soil (absorbance of hand rinsate at 600 nm [A600]) on farmworker hands after harvesting produce, compared with the results for a no-hand-hygiene control. With no hand hygiene, farmworker hands were soiled (median A600, 0.48) and had high concentrations of coliforms (geometric mean, 3.4 log CFU per hand) and Enterococcus spp. (geometric mean, 5.3 log CFU per hand) after 1 to 2 h of harvesting tomatoes. Differences in microbial loads in comparison to the loads in the control group varied by indicator organism and hygiene intervention (0 to 2.3 log CFU per hand). All interventions yielded lower concentrations of Enterococcus spp. and E. coli (P < 0.05), but not of coliforms, than were found in the control group. The two-step ABHS intervention led to significantly lower concentrations of coliforms and Enterococcus spp. than the pumice soap and label-use ABHS interventions (P < 0.05) and was the only intervention to yield significantly fewer samples with E. coli than were found in the control group (P < 0.05). All interventions removed soil from hands (P < 0.05), soap-based interventions more so than ABHS-based interventions (P < 0.05). ABHS-based interventions were equally as effective as hand washing with soap at reducing indicator organisms on farmworker hands. Based on these results, ABHS is an efficacious hand hygiene solution for produce handlers, even on soiled hands.