Soap And Water, Or Hand Sanitiser – Which Is Better?

By Dr Tan Poh Tin | 18 June 2020

Handwashing is more effective than alcohol-based hand disinfectant rubs in reducing the viral contamination of hands.

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There is a bull-run on hand sanitisers. During this Covid season, one supermarket chain, (just its Kuching outlets alone), uses 6-liter hand sanitiser (RM35/l), 10-liter general sanitiser (RM18/l) and 500 (RM1.50) masks per day. This is a mandated excess expenditure of RM1,140 per day!

No wonder shopkeepers are becoming stingy with the dose of sanitiser they squirt on your hands. Some just spray on one hand, barely enough to cover even the palm of that hand. Some use products that feel diluted; one wonders if they really contain at least 60 percent alcohol.

As with handwashing, there is a proper technique when using alcohol-based hand sanitisers. A sufficient amount should be applied to the hands to allow coverage of all surfaces of the hand and fingers. The hands should be rubbed vigorously together (with some friction) until they are dry. Dirty hands soiled with dirt or organic matter should be washed with soap and water, not “dry clean” with sanitiser.

As schools and kindergartens plan to reopen, are there cheaper, more sustainable and safer options than hand sanitisers?

Do we really need to wash so much (taxpayers or Parent Teacher Associations) money down the drain buying hand sanitisers for students and staff?

Or should we be investing in ensuring sufficient handwashing facilities and operational, cleaner and more toilets in schools for the long term?

Can we just advise headmasters to install more stand pipes or hand-wash basins all over the school compound to augment those measly few taps (that always seem to dribble rather than flow) in the universally wet, smelly, “not so clean”, toilets?

Can we invest in or repair sinks and toilets that are blocked and replace slow-filling toilet-flush cisterns that don’t know/care your toilet break is less than 10 minutes and a long queue awaits?

Are there enough taps in the school to allow everyone the 20 seconds that proper hand washing requires? For rural schools dependent on rain or water from river or well – sorry, I hope you will find some way of finding enough water for all this extra washing and have imaginative ways of recycling this to the school garden or to clean your school toilets and drains!

Toilets May Pose Risk for Spreading Covid-19

Gastrointestinal (GI) symptoms were reported in 17.6% of Covid-19 patients in a meta-analysis of 60 publications of 4,243 cases from six countries. (China 53 papers, S. Korea, Vietnam, USA, Singapore, UK). More importantly, GI manifestations may be the only initial symptoms in some patients with Covid-19.

Loss of appetite was the most common (26.8%), followed by diarrhoea (12.5%), nausea/vomiting (10.2%), and abdominal pain or discomfort (9.2%).

Stool samples from 48.6% tested positive for viral RNA. In this study, patients with diarrhoea had a higher prevalence of detectable stool viral RNA on presentation. Even after the respiratory samples turned negative, 70.3% continue to test positive for viral RNA in their stool. This study did not correlate the detection of viral RNA with viral culture or infectivity.

Stool viral RNA was detected as early as Day 3 of illness onset and remained positive in a 78-year-old patient for >33 days from illness onset.

Health care workers are advised to exercise caution while handling faeces or performing endoscopic procedures in patients with Covid-19, even during the recovery phase.

SARS-CoV-2 has been isolated from faeces of infected patients, but faecal-oral spread has not been proven (yet).

We do have available evidence with another coronavirus — SARS (severe acute respiratory syndrome). Researchers looked at the Amoy Gardens apartment complex in Hong Kong, where a large community outbreak of SARS occurred during the 2003 epidemic.

Using airflow dynamics studies, the spread of the virus was tracked from the index case (Case#0) to 187 infected residents of the complex. They reported that the patient’s toilet exhaust fan, which created a negative pressure effect, vented into the apartments above and also to the nearby blocks.

The sewage concentrates of two hospitals receiving patients with SARS in Beijing were also found to have SARS-CoV RNA (2005). Researchers performed cell culture, RT-PCR and gene sequencing to detect and identify the viruses from sewage. No infectious SARS-CoV contamination was found in any of the samples collected, but the nucleic acid of SARS-CoV could be detected in the sewage from the two hospitals before disinfection.

Flushing a toilet creates an aerosolised eruption of viral particles, which can then spread elsewhere within proximity.

We know that toothbrushes left in proximity to the toilet gain germs quite rapidly, mirroring levels observed in the toilet itself. That same thing can occur for cell phones, which most take with them into the bathroom.

However, this mode of transmission has not been well studied as it relates to Covid-19. Researchers collected aerosol samples of three different types (total suspended particle, size segregated and deposition aerosol) in patient areas, medical staff areas of two hospitals (Renmin and Fangcang) and public areas in Wuhan, China during Covid-19 outbreak.

A robust droplet digital polymerase chain reaction (ddPCR) method was employed to quantitate the viral SARS-CoV-2 RNA genome and determine aerosol RNA concentration.

The ICU, CCU and general patient rooms inside Renmin, patient hall inside Fangcang had undetectable or low airborne SARS-CoV-2 concentration, but deposition samples inside ICU and air sample in Fangcang patient toilet tested positive. They found that although the intensive care units were good at containing the spread of the virus outside of the patients’ rooms, there was a high concentration of the virus in the air samples taken from the patients’ toilets.

Room ventilation, open space, proper use and disinfection of toilet can effectively limit aerosol transmission of SARS-CoV-2. Toilet lids should be closed before used toilets are flushed to minimise the volcanic dispersion of faecal and germs aerosols.

Proper Handwashing With Soap And Running Water Is Better Than Hand Sanitisers Thinly Applied Or Rationed In Timing And Amount

While antibacterial gels can quickly reduce the number of germs on your hands, they do not eliminate all types of viruses, e.g. Norovirus, or bacteria e.g. C difficile. Alcohol-based sanitisers (>60% alcohol) are highly effective at killing bacteria and viruses, but only if there is direct contact of alcohol with the microorganisms and enough contact time.

If there is a lot of dirt on the hands, the antibacterial hand gel may not reach the microorganisms under the dirt. The gel will not remove the dirt.

An antibacterial hand gel can substitute for handwashing only when there is no organic material (e.g. dirt or mucus) on one’s hands. If you can see or feel some dirt on your (or your kids’) hands, it is best to wash with soap and water. Soap can help break down organic material and running water will rinse the dirt and germs away.

A Japanese study found that ethanol-based hand rubs took eight times longer to inactivate influenza A viruses (IAV) in mucus than in saline. However when the mucus is completely dried, IAV can be killed within 30 seconds.

Infectious IAV can remain on the hands and fingers, even after using ethanol-based disinfectant hand rub, thereby increasing the risk of IAV transmission. In the health care setting, if there is insufficient time before treating the next patient (i.e. if the infectious mucus is not completely dry), medical staff should be aware that effectiveness of hand rubs is reduced.

Antiseptic handwashing is effective against both dry and non-dry infectious mucus (preschool teachers and parents helping kids with flu to clean snotty noses, please take note of this!)

A good practice is not to use hand sanitisers in the place of proper hand washing in the bathroom/toilet, kitchen, or for children after the playground, school, home or toilet, or before and after meals.

Old-fashioned soap is as good as antibacterial ones. CDC studies have shown that there is no added benefit to using antibacterial soap over regular soap. However do consider using liquid soap (and dispensers) rather than solid pieces of soap, because the latter (sitting in wet open containers) will pick up germs from users and is less hygienic.

Lanolin containing soaps may cause some children/adults with eczema to develop contact dermatitis (“washer-woman” dermatitis). Such individuals may have to bring their own soaps!!

Washing the virus off with water alone might work. But soapy water is better at loosening the strong, glue-like interactions between the skin, virus, and dirt. Soap, like alcohol (>60% concentration), damages the protective viral lipid membrane, and kills it.

Take Home Message

  1. Numerous studies have shown that sanitiser is not more effective than soap and water in stopping the spread of colds, flu and other respiratory diseases.
  2. Alcohol-based hand sanitisers is preferred compared to alcohol-free sanitisers: the alcohol in the sanitiser serves as a preservative, it’s less likely to be contaminated.
  3. Alcohol-based sanitisers – beware of accidental or self poisoning.
  4. For health care or nursing home settings, the CDC recommends the use of alcohol-based hand rubs for the decontamination of hands between each patient contact (of non-soiling type) and the use of liquid soap and water for cleaning visibly contaminated or soiled hands. The availability of bedside alcohol-based solutions have increased compliance with hand hygiene among Health Care Workers.

It’s an opportune time to audit toilets in Malaysian schools.

If we want to teach our kids to respect the next user and flush after use, the flush cistern must fill up quickly between users.

The flush must flush and not splash faecal water all over your shoes as the toilet bowl is blocked. If the flush handle is broken, there must be a bucket and access to a tap so flushing can be manual.

If we want kids to wash their hands, the sink and taps have to be reachable and there must be water, not little dribbles like a baby’s pee.

This investment is not just good for Covid-19, but for all the other foodborne illnesses e.g. polio, cholera, typhoid, acute gastroenteritis, worms and parasites.

Clean hands and clean toilets should become a habit and a Malaysian way of life.

A fusion opinion from a Sarawakian public health specialist, paediatrician, ex-associate professor, disaster relief and medical volunteer, passionate about helping people learn.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
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