3.2.2.5: Hand Sanitizers

The use of hand sanitizers by children and adults in child care programs is an appropriate alternative to the use of traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2). ECE programs should provide hand sanitizer containing at least 60% alcohol. Hand sanitizers should be stored up, away, and out of sight of younger children and should be used only with adult supervision for children ages 5 years and younger.
 
Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes (3).
The technique for using hand sanitizers is:

• For visibly dirty hands and soap is not available, rinsing under running water or wiping with a water-saturated towel should be used to remove as much dirt as possible before using a hand sanitizer.
• Apply the product to the palm of one hand (read the label to learn the correct amount);
• Rub hands together; and
• Rub the product over all surfaces of the hands and fingers until hands are dry (4).

Hand sanitizers using an alcohol-based active ingredient must contain 60% to 95% alcohol to be effective in killing most germs including multi-drug resistant pathogens. Child care programs should follow the manufacturer’s instructions for use, check instructions to determine how much product and how long the hand sanitizer needs to remain on the skin surface to be effective.
 
Where alcohol-based hand sanitizer dispensers are used:

1. The maximum individual dispenser fluid capacity should be as follows:
2. 0.32 gal (1.2 L) for dispensers in individual rooms, corridors, and areas open to corridors;
3. 0.53 gal (2.0 L) for dispensers in suites of rooms;
4. Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
5. Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
6. Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
7. Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (5).

When alcohol based hand sanitizers are offered in a child care facility, the facility should encourage parents/guardians to teach their children about their use at home.

RATIONALE

Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (6-8).
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately (5).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (1,3,4). 

COMMENTS

Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).
 
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene.

Some hand sanitizing products contain non-alcohol and “natural” ingredients. The efficacy of non-alcohol containing hand sanitizers is variable and therefore a non-alcohol-based product is not recommended for use.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
5.5.0.5 Storage of Flammable Materials

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
   
3. Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing.html. 
   
4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
   
5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
   

6. American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 148-149, 154, 164

7. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nurs 33:368-72.
8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Handwashing: Clean hands save lives!  http://www.cdc.gov/handwashing/.
9. ADDITIONAL REFERENCE:
    
   American Association of Poison Control Centers. 2016. Hand sanitizer. http://www.aapcc.org/alerts/hand-sanitizer/. 
   

NOTES

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.