SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable.
ABSTRACT The risk of inadequate hand hygiene in food handling settings is exacerbated when water is limited or unavailable, thereby making washing with soap and water difficult. The SaniTwice method involves application of excess alcohol-based hand sanitizer (ABHS), hand "washing" for 15 s, and thorough cleaning with paper towels while hands are still wet, followed by a standard application of ABHS. This study investigated the effectiveness of the SaniTwice methodology as an alternative to hand washing for cleaning and removal of microorganisms. On hands moderately soiled with beef broth containing Escherichia coli (ATCC 11229), washing with a nonantimicrobial hand washing product achieved a 2.86 (±0.64)-log reduction in microbial contamination compared with the baseline, whereas the SaniTwice method with 62 % ethanol (EtOH) gel, 62 % EtOH foam, and 70 % EtOH advanced formula gel achieved reductions of 2.64 ± 0.89, 3.64 ± 0.57, and 4.61 ± 0.33 log units, respectively. When hands were heavily soiled from handling raw hamburger containing E. coli, washing with nonantimicrobial hand washing product and antimicrobial hand washing product achieved reductions of 2.65 ± 0.33 and 2.69 ± 0.32 log units, respectively, whereas SaniTwice with 62 % EtOH foam, 70 % EtOH gel, and 70 % EtOH advanced formula gel achieved reductions of 2.87 ± 0.42, 2.99 ± 0.51, and 3.92 ± 0.65 log units, respectively. These results clearly demonstrate that the in vivo antibacterial efficacy of the SaniTwice regimen with various ABHS is equivalent to or exceeds that of the standard hand washing approach as specified in the U.S. Food and Drug Administration Food Code. Implementation of the SaniTwice regimen in food handling settings with limited water availability should significantly reduce the risk of foodborne infections resulting from inadequate hand hygiene.
- [Show abstract] [Hide abstract]
ABSTRACT: Healthcare worker's (HCW) hands are the commonest vehicle for the transmission of microorganisms from patient to patient and within the healthcare environment. The aims of this study were to evaluate the impact of a multimodal campaign over the type and amount of resident and transient flora and the presence of potential risk factors for hand contamination during routine care. A before-after interventional study was made in medical wards from a tertiary care hospital. Eighty nine samples were analyzed. Samples were cultured immediately before patient contact using a glove-juice method. Data collected included socio-demographic and risk factors for hand contamination. Flora colony-forming units (CFU)/mL loads (log10) were evaluated by comparing median values in the PRE and POST periods. Transient flora was isolated in 67.4% and 46.1% HCW hands in the PRE and POST periods, respectively (p<0.001). Enterobacteriaceae, Pseudomonas spp and MSSA were the predominant contaminants. Resident flora was isolated in 92.1% in pre and in 70.8% in post period (p<0.001); methicillin-resistant coagulase-negative staphylococci log10 count decreased from 1.96 log10 (± 1.2) to 0.89 log10 (± 1.2) (p<0.001). Global flora CFU decreased from 2.77 log10 (± 1.1) to 1.56 log10 (± 1.4) (p<0.001). In the POST period a lower number of rings (p<0.001), shorter fingernail length (p=0.008), shorter time of recent hand hygiene (HH) (p=0.007), and a higher use of alcohol-based hand rub instead of soap (p<0.001) were documented. A HH multimodal strategy reduced the number of risk factors and the level of HCW hand contamination.Journal of Medical Microbiology 01/2013; 62(Pt_4). · 2.27 Impact Factor
Article: Infection control for norovirus[Show abstract] [Hide abstract]
ABSTRACT: Norovirus infections are notoriously difficult to prevent and control due to their low infectious dose, high shedding titer, and environmental stability. The virus can spread through multiple transmission routes of which person-to-person and foodborne are the most important. Recent advances in molecular diagnostics, have helped to establish norovirus as the most common cause of sporadic gastroenteritis and most common cause of outbreaks of acute gastroenteritis across all ages. In this paper, we review the epidemiology and virology of noroviruses as well as prevention and control guidelines with a focus on the principles of disinfection and decontamination; Outbreak management relies on sound infection control principles including hand hygiene, limiting exposure to infectious individuals, and thorough environmental decontamination. Ideally, all infection control recommendations would rely on empirical evidence, but a number of challenges, including the inability to culture norovirus in the laboratory and the challenges of outbreak management in complex environments, has made it difficult to garner clear evidence of efficacy in certain areas of infection control. New experimental data on cultivable surrogates for human norovirus on the environmental survivability and relative resistance to commonly used disinfectants, are providing new insights in further refining disinfection practices. Finally, clinical trials are underway to evaluate the efficacy of vaccines which may shift the current infection control principles to more targeted interventions.This article is protected by copyright. All rights reserved.Clinical Microbiology and Infection 05/2014; · 4.58 Impact Factor
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ABSTRACT: Pathogenic strains of Escherichia coli and human norovirus are the main etiologic agents of foodborne illness resulting from inadequate hand hygiene practices by food service workers. This study was conducted to evaluate the antibacterial and antiviral efficacy of various hand hygiene product regimens under different soil conditions representative of those in food service settings and assess the impact of product formulation on this efficacy. On hands contaminated with chicken broth containing E. coli, representing a moderate soil load, a regimen combining an antimicrobial hand washing product with a 70% ethanol advanced formula (EtOH AF) gel achieved a 5.22-log reduction, whereas a nonantimicrobial hand washing product alone achieved a 3.10log reduction. When hands were heavily soiled from handling ground beef containing E. coli, a wash-sanitize regimen with a 0.5% chloroxylenol antimicrobial hand washing product and the 70% EtOH AF gel achieved a 4.60-log reduction, whereas a wash-sanitize regimen with a 62% EtOH foam achieved a 4.11-log reduction. Sanitizing with the 70% EtOH AF gel alone was more effective than hand washing with a nonantimicrobial product for reducing murine norovirus (MNV), a surrogate for human norovirus, with 2.60- and 1.79-log reductions, respectively. When combined with hand washing, the 70% EtOH AF gel produced a 3.19-log reduction against MNV. A regimen using the SaniTwice protocol with the 70% EtOH AF gel produced a 4.04-log reduction against MNV. These data suggest that although the process of hand washing helped to remove pathogens from the hands, use of a wash-sanitize regimen was even more effective for reducing organisms. Use of a high-efficacy sanitizer as part of a wash-sanitize regimen further increased the efficacy of the regimen. The use of a well-formulated alcohol-based hand rub as part of a wash-sanitize regimen should be considered as a means to reduce risk of infection transmission in food service facilities.Journal of food protection 07/2012; 75(7):1303-9. · 1.80 Impact Factor
SaniTwice: A Novel Approach to Hand Hygiene for Reducing
Bacterial Contamination on Hands When Soap and Water
SARAH L. EDMONDS,1* JAMES MANN,2ROBERT R. MCCORMACK,3DAVID R. MACINGA,1
CHRISTOPHER M. FRICKER,1JAMES W. ARBOGAST,1AND MICHAEL J. DOLAN1
1GOJO Industries, Inc., P.O. Box 991, Akron, Ohio 44309;2Handwashing for Life, 1216 Flamingo Parkway, Libertyville, Illinois 60048;
and3BioScience Laboratories, Inc., 300 North Willson Avenue, Suite 1, Bozeman, Montana 59715, USA
MS 10-220: Received 25 May 2010/Accepted 27 August 2010
The risk of inadequate hand hygiene in food handling settings is exacerbated when water is limited or unavailable, thereby
making washing with soap and water difficult. The SaniTwice method involves application of excess alcohol-based hand sanitizer
(ABHS), hand ‘‘washing’’ for 15 s, and thorough cleaning with paper towels while hands are still wet, followed by a standard
application of ABHS. This study investigated the effectiveness of the SaniTwice methodology as an alternative to hand washing for
cleaning and removal of microorganisms. On hands moderately soiled with beef broth containing Escherichia coli (ATCC 11229),
washing with a nonantimicrobial hand washing product achieved a 2.86 (¡0.64)-log reduction in microbial contamination
compared with the baseline, whereas the SaniTwice method with 62% ethanol (EtOH) gel, 62% EtOH foam, and 70% EtOH
advanced formula gel achieved reductions of 2.64 ¡ 0.89, 3.64 ¡ 0.57, and 4.61 ¡ 0.33 log units, respectively. When hands were
heavily soiled from handling raw hamburger containing E. coli, washing with nonantimicrobial hand washing product and
antimicrobial hand washing product achieved reductions of 2.65 ¡ 0.33 and 2.69 ¡ 0.32 log units, respectively, whereas
SaniTwice with 62% EtOH foam, 70% EtOH gel, and 70% EtOH advanced formula gel achieved reductions of 2.87 ¡ 0.42, 2.99
¡ 0.51, and 3.92 ¡ 0.65 log units, respectively. These results clearly demonstrate that the in vivo antibacterial efficacy of the
SaniTwice regimen with various ABHS is equivalent to or exceeds that of the standard hand washing approach as specified in the
U.S. Food and Drug Administration Food Code. Implementation of the SaniTwice regimen in food handling settings with limited
water availability should significantly reduce the risk of foodborne infections resulting from inadequate hand hygiene.
Foodborne diseases are a serious public health concern
(3, 4, 15), but despite preventive efforts there has been little
recent progress in reducing infections caused by foodborne
pathogens (6). Faulty food handling practices, particularly
improper hand washing, contribute significantly to the risk
for foodborne disease (11–13, 19, 25–27, 29). Proper hand
hygiene reduces the risk of transmission of pathogens from
hands to food (7, 20, 21) and is associated with a reduction
in gastrointestinal illness (2, 8, 18). The U.S. Food and Drug
Administration (FDA) Food Code for retail establishments
requires hand washing as a preventive method and provides
specific guidance on proper hand washing procedures (30).
The five-step hand washing procedure outlined in the FDA
Food Code consists of (i) rinsing under warm running water,
(ii) applying the manufacturer-recommended amount of
cleaning compound, (iii) rubbing the hands vigorously, (iv)
rinsing thoroughly under warm running water, and (v)
thoroughly drying the hands with individual paper towels, a
continuous clean towel system, or a heated or pressurized
hand air drying device. According to the Food Code,
alcohol-based hand sanitizers (ABHS) may be used in retail
and food service only after proper hand washing.
ABHS are recommended as an alternative to traditional
hand washing in the health care setting (5). Alcohols are
highly effective against a range of bacterial pathogens, fungi,
enveloped viruses, and certain nonenveloped viruses (2, 10).
Although considered to be ineffective antimicrobial agents in
the presence of visible dirt or proteinaceous material, alcohol-
containingproductsweremoreeffective thanthose containing
triclosan (2, 14) or detergents (17) for removing microorgan-
ismsfromhands contaminatedwithorganic material.Inhealth
have resulted in greater hand hygiene compliance and
reduction in infections (1, 9, 16, 31). Although ABHS are
approved for use in the health care environment, the FDA
does not regard these agents as adequate substitutes for soap
and water in the food service setting (30).
A reliable hand hygiene method is needed for food
service settings in which adequate hand washing facilities
are limited or unavailable. These settings include portable
bars, buffet lines, outdoor events, and catering functions at
which the only available hand hygiene facility often is either
‘‘trickle hand washing’’ (i.e., hand washing done from a
* Author for correspondence. Tel: 330-255-6745; Fax: 330-255-6083:
Journal of Food Protection, Vol. 73, No. 12, 2010, Pages 2296–2300
Copyright G, International Association for Food Protection
portable container of water over a bucket or other type of
basin) or simply the use of a paper towel or damp cloth to
rub the hands. These methods may be inadequate for proper
SaniTwice (a registered trademark with James Mann,
Handwashing for Life, Libertyville, IL) is a two-stage hand
cleansing protocol that is performed using ABHS when
water is not available. In this study, we evaluated the
microbiological efficacy of the SaniTwice method on the
hands of adult human participants. These studies were
designed to assess (i) the antimicrobial efficacy of various
ABHS used with the SaniTwice regimen as compared with
that of a standard hand washing method with soap and water
on soiled hands and (ii) the impact of the active ingredient
and/or formulation of a hand sanitizer on antibacterial
efficacy when used in a SaniTwice regimen.
MATERIALS AND METHODS
Test products. All test products in this study were
manufactured by GOJO Industries (Akron, OH). Two hand
washing products were evaluated: a nonantimicrobial product
(GOJO Luxury Foam Handwash) and an antimicrobial product
(MICRELL Antibacterial Foam Handwash, 0.5% chloroxylenol
active). Four ABHS also were evaluated: a 62% ethanol (EtOH)
gel (PURELL Instant Hand Sanitizer Food Code Compliant), a
62% EtOH foam (PURELL Instant Hand Sanitizer Foam), a 70%
EtOH gel (PURELL 70 Instant Hand Sanitizer), and a 70% EtOH
Advanced Formula (AF) gel (PURELL Instant Hand Sanitizer
Advanced Formula VF481).
Overall study design. Three studies were conducted by
BioScience Laboratories (Bozeman, MT) to determine the in vivo
antimicrobial efficacy of various test product configurations under
conditions of moderate or heavy soil. The order of use of each
product was determined randomly. A two-step testing sequence
was used for all products. Each volunteer completed the baseline
cycle, where hands were contaminated with moderate or heavy soil
(as described below) containing Escherichia coli (ATCC 11229),
and samples were collected for baseline bacterial counts. Following
the baseline sampling, participants completed a 30-s nonmedicated
soap wash followed by the product evaluation cycle, which
consisted of a contamination procedure, application of the test
product, and subsequent hand sampling. Between uses of different
test products, participants decontaminated their hands with a 1-min
70% EtOH rinse, air drying, and a 30-s nonmedicated soap wash.
A minimum of 20 min elapsed before the next testing sequence
began. Baseline and postapplication samples were evaluated for the
presence of E. coli. Testing was performed according to the FDA
health care personnel hand washing product evaluation method
(28) and modified as described previously (22).
The study was approved by the Gallatin Institutional Review,
an independent review board unaffiliated with BioScience
Laboratories, and was conducted in compliance with Good Clinical
Practice and Good Laboratory Practice regulations. All participants
provided written informed consent.
Participants. The study enrolled healthy adults with two
hands. All participants were free of dermal allergies or skin
disorders on the hands or forearms.
Preparation of inoculum. E. coli was used to test the
efficacy of the test procedures. A 2-liter flask was filled with
1,000 ml of tryptic soy broth: 30.0 g of dehydrated tryptic soy
broth medium (BD, Franklin Lakes, NJ) added to 1 liter of
deionized water, heated, and sterilized for a final pH of 7.3 ¡ 0.20.
The broth was inoculated with 1.0 ml of a 24-h culture of E. coli
grown from a cryogenic stock culture. The flask was incubated for
24 h, and the suspension was used for challenge.
Hand contamination procedures. For the moderate soil
study, a 24-h culture of E. coli was suspended in beef broth
(Swanson low sodium beef broth, Campbell Soup Company,
Camden, NJ) at 1 | 109CFU/ml. Three aliquots of 1.5 ml were
transferred into each participant’s cupped hands. Each aliquot was
distributed over the entire front and back surfaces of the hands up
to the wrists during a 20-s period and allowed to air dry for 30 s
after the first and second aliquots and for 90 s after the third
aliquot. After samples were collected for baseline bacterial counts
and hands were decontaminated with a 30-s wash with non-
medicated soap, a second cycle of contamination was initiated.
After the 90-s final drying step, participants applied the randomly
assigned test product.
For the heavy soil study, 5.0-ml aliquots of the challenge
suspension of E. coli were transferred to 4-oz (113-g) portions of
sterile 90% lean ground beef and distributed evenly with gloved
hands to achieve contamination levels of approximately 5.0 | 108
CFU per portion. Each participant then kneaded the inoculated raw
hamburger for 2 min. Hands were air dried for 90 s and then
sampled for baseline counts. After a 30-s decontamination with
nonmedicated soap, the cycle was repeated, and the test product
Test article or product application and SaniTwice
procedure. The hand washing procedure used for the nonantimi-
crobial and antimicrobial hand washing products was consistent
with Food Code specifications. Table 1 shows the stepwise
product application procedures for all test configurations.
Bacterial recovery and microbial enumeration. Within
1 min after contamination for baseline evaluation or after product
application, powder-free sterile latex gloves were placed on each
participant’s hands and secured above the wrist, and 75 ml of
sterile stripping fluid (0.4 g of KH2PO4, 10.1 g of Na2HPO4, and
1.0 g of isooctylphenoxypolyethoxyethanol in 1 liter of distilled
water, pH adjusted to 7.8) was transferred into each glove.
Following a 60-s massage of the hands through the gloves, a 5.0-ml
of Butterfield’s phosphate buffer solution with product neutralizers.
Each aliquot was serially diluted in neutralizing solution, and
appropriate dilutions were plated in duplicate onto MacConkey agar
plates (BD; 50.0 g of dehydrated medium added to 1 liter of
deionized water, heated, and sterilized; final pH, 7.1 ¡ 0.2) and
incubated for 24 to 48 h at 30uC. Colonies were counted and data
were recorded using the computerized Q-COUNT plate-counting
systems (Advanced Instruments, Inc., Norwood, MA).
Data analysis and statistical considerations. The estimated
log transformed number of viable microorganisms recovered from
each hand (the R value) was determined using the formula R ~
log(75 | Ci| 10D| 2), where 75 is the amount (in milliliters) of
stripping solution instilled into each glove, Ciis the arithmetic
average colony count of the two plate counts at a particular
dilution, D is the dilution factor, and 2 is the neutralization dilution.
Descriptive statistics and confidence intervals were calculated
using the 0.05 level of significance for type I (alpha) error.
Statistical calculations of means and standard deviations were
J. Food Prot., Vol. 73, No. 12SANITWICE: A NOVEL HAND HYGIENE SOLUTION
generated for the log recovery data from baseline samples,
postproduct application samples, and the log differences between
baseline and postapplication samples. Product comparisons were
made using a one-way analysis of variance with post hoc analysis
(Bonferroni’s multiple comparison test) using the 0.05 level of
significance for alpha error.
Reduction in microbial contamination of moderate-
ly soiled hands. Two studies were conducted to evaluate
microbial count reductions on hands that had been
contaminated by handling beef broth containing E. coli.
Reductions from baseline produced by the five test product
configurations in these two studies are shown in Figure 1.
All SaniTwice regimens were equivalent to or better than
the Food Code hand washing protocol. Reductions from
baseline ranged from 2.64 ¡ 0.89 log CFU/ml for
SaniTwice with the 62% EtOH gel to 4.61 ¡ 0.33 log
CFU/ml for SaniTwice with the 70% EtOH AF gel.
SaniTwice using the 62% EtOH gel was equivalent to
the nonantimicrobial Food Code hand washing protocol.
However, SaniTwice using the 62% EtOH foam (3.64 ¡
0.57-log reduction) was more effective than SaniTwice with
the 62% EtOH gel and the Food Code hand washing
protocol (P , 0.05).
The 70% EtOH AF gel was the most effective
sanitizing product. When used independently, it was
significantly more effective (4.44 ¡ 0.47-log reduction)
than SaniTwice with 62% EtOH foam or 62% EtOH gel or
the nonantimicrobial hand washing product (P , 0.05 for
all comparisons). Although the log reduction data suggest
that SaniTwice with 70% EtOH AF gel (4.61 ¡ 0.33-log
reduction) was equivalent to the 70% EtOH AF gel used
independently, this lack of differentiation was most likely
due to the limitations of the assay. The 4.61-log reduction
was at the limit of detection for all participants using 70%
EtOH AF gel with SaniTwice but for only half the
participants using 70% EtOH AF gel alone. Therefore, the
log reductions produced by the 70% EtOH AF gel after
either a single sanitization or the SaniTwice regimen are
likely underestimated, and the log reductions in both cases
would likely be higher if the limits of detection were lower.
Reduction in microbial contamination of heavily
soiled hands. Figure 2 shows microbial count reductions
produced by test product configurations on hands that had
been contaminated by handling ground beef containing E.
coli. All SaniTwice regimens tested were equivalent to or
better than the Food Code hand washing protocol, indicating
that under conditions of heavy soil, the SaniTwice procedure
is as effective as hand washing. The performance of the
antimicrobial hand washing product was equivalent to that of
the nonantimicrobial hand washing product in this heavy soil
challenge, with log reductions of 2.69 ¡ 0.32 and 2.65 ¡
0.33, respectively. SaniTwice with the 70% EtOH AF gel
outperformed all other sanitizer configurations tested and was
superior to hand washing for reduction of organisms on
heavily soiledhands (P , 0.05 forcomparisons of SaniTwice
with 70% EtOH AF gel versus each of the other procedures).
TABLE 1. Test product application proceduresa
Food Code–compliant procedure for
hand washing products SaniTwicebprocedure for ABHSProcedure for 70% EtOH AF gel
1Wet hands with water at 40uC Dispense ,3 ml of product into cupped
Rub vigorously over hands for 15 s
to simulate washing
Clean thoroughly with two paper towels
Dispense additional ,1.5 ml of product
Rub hands together until dry
Dispense ,1.5 ml of product into
Rub hands together until dry2Apply ,1.5 ml of product
Lather for 15 s
Rinse with water for 10 s
Pat dry with two paper towels
aAll application procedures were initiated within 10 s of completing the 90-s drying step.
bSaniTwice is a registered trademark with James Mann (Handwashing for Life, Libertyville, IL).
FIGURE 1. Log reduction from baseline for microbial contam-
ination of hands moderately soiled with contaminated beef broth
after application of test products. Error bars represent standard
deviation. Data are from two separate studies. In study 1 (n ~ 11),
nonantimicrobial hand washing product and SaniTwice with 62%
EtOH gel were compared. In study 2 (n ~ 12), the conditions
evaluated were nonantimicrobial hand washing product, Sani-
Twice with 62% EtOH foam, 70% EtOH AF gel without
SaniTwice, and SaniTwice with 70% EtOH AF gel. Results for
nonantimicrobial hand washing product represent pooled data
from both studies. * P , 0.05 for SaniTwice with 62% EtOH foam
versus nonantimicrobial hand washing product or SaniTwice with
62% EtOH gel. ** P , 0.05 for 70% EtOH AF gel or for
SaniTwice with 70% AF gel versus nonantimicrobial hand
washing product, SaniTwice with 62% EtOH gel, or SaniTwice
with 62% EtOH foam.
EDMONDS ET AL.J. Food Prot., Vol. 73, No. 12
Two ABHS used with SaniTwice under both moderate
and heavy soil conditions produced greater log reductions in
the moderate soil condition. Mean log reductions using
SaniTwice (moderate versus heavy soil) were 3.64 versus
2.87 for 62% EtOH foam and 4.61 versus 3.92 for 70%
EtOH AF gel.
The SaniTwice method for hand disinfection was
equivalent or superior to hand washing with soap and water
for reducing viable bacteria on hands in the presence of
representative food soils. Although the raw hamburger was
a more difficult soil to penetrate, as demonstrated by
approximately 1.0-log lower reductions compared with
challenge by contaminated beef broth, the SaniTwice
method with ABHS was equivalent to hand washing even
under this worst-case simulation, underscoring the efficacy
of this new method and indicating a potentially greater
margin of safety.
The ABHS products used in this study exhibited a
range of antimicrobial efficacy, suggesting that product
formulation and the concentration of active ingredient may
play a role in the observed efficacy. The impact of
formulation was indicated by the significantly higher
efficacy of the 62% EtOH foam compared with the 62%
EtOH gel when challenged with moderate soil. This
difference may be due to the additional foaming surfactants
in the foam formulation, which may aid in lifting and
removing bacteria and soil from the hands during the
SaniTwice procedure. In addition, SaniTwice with the 70%
EtOH AF gel was superior to SaniTwice with the 70%
EtOH gel and 62% EtOH foam under heavy soil conditions.
The 70% EtOH AF gel, whether tested as a single
application or with the SaniTwice method, was superior to
hand washing and to the 62% EtOH gel or foam under
moderate soil conditions. The 4.44-log reduction with a
single use of the 70% EtOH AF gel demonstrates its high
antimicrobial efficacy, which is further enhanced when used
with the SaniTwice method. The 70% EtOH AF gel
contains a patent-pending blend of ingredients that enhance
the activity of the alcohol and likely contribute to the high
efficacy observed in this study. The SaniTwice procedure
gives the benefit of skin cleansing and soil removal, which
is not obtained with single use of a product. The efficacy of
ABHS used with SaniTwice against nonenveloped enteric
viruses, which are more difficult to eradicate, remains to be
In support of previous findings (23), the findings in this
study indicate that the decontamination efficacy was similar
for the antimicrobial and nonantimicrobial hand washing
products under heavy soil conditions, suggesting that the
cleansing properties of the surfactants in these soaps and the
mechanical action of hand washing may be the primary
contributors to efficacy rather than the antimicrobial activity
of any constituent of the formulations. It is expected that
with heavy hand soiling, the surfactant effect drives
efficacy, and typical antibacterial constituents will have
little additional effect.
In this study, SaniTwice was an effective hand hygiene
regimen at least equivalent to hand washing with soap and
water for reducing microbial contamination, even under
worst case conditions of high bacterial load and heavy food
soils. The current FDA Food Code allows use of ABHS
only on hands that have been cleaned according to the
recommended hand washing protocol (30). However, other
than substitution of an ABHS for soap and water, the
SaniTwice protocol mirrors the FDA-specified hand wash-
ing sequence. SaniTwice is at least as effective as hand
washing when used with standard-efficacy ABHS; when
used with a high-efficacy ABHS, the SaniTwice protocol is
superior to washing with soap and water. The Food Code
provides few specific recommendations for achieving good
hand hygiene when water (or other hand washing supplies
and equipment) is unavailable or limited. The Food Code
(Section 2-301.16) severely restricts hand sanitizers by
allowing use only after proper hand washing or in situations
in which no direct contact with food occurs (30).
A potential solution to this gap in food safety practices
is SaniTwice. The SaniTwice studies described here provide
convincing scientific rationale for including the SaniTwice
approach in the Food Code as an alternative method of hand
hygiene when standard hand washing is impractical. The
simplicity and ease of use of the SaniTwice method, which
requires only a supply of ABHS and paper towels, should
allow this protocol to be applied to various food service
settings and other areas in which hand hygiene is needed but
safe water is unavailable or in short supply.
The findings in the present study support and extend
those from previous studies; ABHS used alone or in
combination with hand washing can be effective for
decontaminating hands in the presence of organic soils
(17, 23, 24). A well-formulated ABHS in conjunction with
FIGURE 2. Log reduction from baseline for microbial contam-
ination of hands heavily soiled with contaminated uncooked
hamburger after application of test products and protocols. Error
bars represent standard deviation. Data are from study 3 (n ~
15), in which five test configurations were evaluated. * P , 0.05
for SaniTwice with 70% AF gel versus nonantimicrobial hand
washing product, antimicrobial hand washing product, SaniTwice
with 62% EtOH foam, or SaniTwice with 70% EtOH gel.
J. Food Prot., Vol. 73, No. 12SANITWICE: A NOVEL HAND HYGIENE SOLUTION
the SaniTwice regimen can have high efficacy, even in the
presence of high organic load. Therefore, a reevaluation of
the longstanding paradigm defining the use of ABHS in the
presence of organic soils in both food handling and health
care environments is warranted.
Lakshmi Kamath and Meher Dustoor assisted in the preparation of
this manuscript for publication.
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