The shortage of hand sanitizers
The rapid spread of coronavirus (or COVID-19) has people clearing out the shelves of hand sanitizer anywhere in the world, as well as in Indonesia. And if you try to buy it online, good luck -- most of it is out of stock or has the price marked up at physical as well as online retailers.Â
The shortages and buying limits have spurred people to make their own hand sanitizer using recipes from Twitter, Reddit, Pinterest, Youtube, Instagram, countless blogs, and even a pharmacy. But the mere existence of these recipes doesn't mean you should follow them.
Reasons to not make your own hand sanitizer
First, the Centers for Disease Control (CDC) recommends washing your hands over using hand sanitizer, unless you don't have access to soap and water. Second, the Food and Drug Administration (FDA) is aware of people making do-it-yourself (DIY) hand sanitizer at home. However, it doesn't have any "verifiable information on the methods being used to prepare such products and whether they are safe for use on human skin." Lastly, experts have warned that making homemade hand sanitizer is harder than it seems. If you don't get the concentration right, the experts remind you that you'll end up with something that isn't effective or is too harsh and is a waste of ingredients.Â
The key is to get the right ratio of ingredients. The CDC Control recommends using a hand sanitizer that contains at least 60% alcohol, which most store-bought hand sanitizers have. But trying to replicate that on your own can be tricky, Dr. Sally Bloomfield, with the London School of Hygiene and Tropical Medicine, told the Guardian.
In the video below, Dr. Jason Kindrachuk, an assistant professor of Viral Pathogenesis at the University of Manitoba, Canada, explains that you're better using soap than trying to make your own hand sanitizer.
Youtube video URL:
Official hand sanitizer formulas
Both the World Health Organization (WHO) and the FDA have guidelines for making hand rubs (the agencies' term for hand sanitizer, (https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf?ua=1). But, they are designed for medical professionals, not the average consumers. The WHO's official instructions call for denatured alcohol or isopropyl alcohol, glycerol (also known as glycerin), hydrogen peroxide, and sterile water. You must measure the concentration of alcohol in the final product using an alcoholometer to ensure it is effective at killing germs and safe to use.
The recipe also does not recommend including any dyes, essential oils or other fragrances, because they could cause an allergic response -- a lot of DIY recipes call for essential oils to mask the smell of alcohol.
On March 20, 2020, the FDA released its temporary guidelines for pharmacists and other manufacturers to make hand sanitizer. Under its recommendation, you must use pharmacy-grade ingredients, test the alcohol level in the final product, and label the finished formula. The FDA recommends the WHO's formula, and echoes that adding additional active or inactive ingredients (such as aloe vera gel or essential oils) "may impact the quality and potency of the product."Â
The FDA also notes that it is "aware of reports that some consumers are producing hand sanitizers for personal use; the Agency lacks information on the methods being used to prepare such products and whether they are safe for use on human skin." Unless you can follow the instructions outline by the WHO, making your own hand sanitizer just isn't smart for your own safety.
Homemade hand sanitizer recipes
Most of the countless recipes out there use a mix of 91% or 99% isopropyl alcohol (also known as rubbing alcohol) and aloe vera gel, which is necessary to add moisture to your skin because alcohol will dry it out. In these recipes, the typical ratio is two thirds rubbing alcohol to one third of a cup of aloe vera gel.
Even if you follow that recipe, you can still mess it up. Mixing it at home, you can't control how the alcohol gets diluted in the final product. If you don't use enough aloe gel, it will dry out the skin on your hands, which can cause it to crack or bleed (the same is true if you just pour rubbing alcohol on your skin).
But if you don't use enough alcohol, the final product won't be as effective at killing germs as store-bought hand sanitizer -- rendering it basically useless according to some experts. You can also contaminate your batch with bacteria by not using clean mixing tools.
Finally, because of the popularity of these homemade hand sanitizers, the ingredients are now harder to come by. So even if you want to make it, you might not be able to find rubbing alcohol and aloe vera at your local drugstore.
You should avoid recipes that call for vodka or spirits because you need a high proof liquor to get the right concentration of alcohol by volume. That's because most liquor is mixed with water, so if you mix a 80-proof vodka (which is the standard proof) with aloe, you'll have a hand sanitizer that contains less than 40% alcohol. In response to a tweet about someone using Tito's Vodka to make DIY hand sanitizer, the company responded by saying that you shouldn't use its product for that purpose.
So what should you do instead?
Wash your hands. The CDC and WHO both agree that's the best thing you can do right now to protect yourself from getting sick, either from coronavirus or anything else. Wash your hands with soap and water for 20 seconds, many times per day -- after you use the restroom, before and after you eat, prepare food, and in many other scenarios.
Also, avoid touching your face in general, but especially with dirty hands. Most, if not all, things that you touch throughout the day is covered by germs. So, when you unconsciously touch your mucous membranes (lips, nose, eyes), you can spread viruses and bacteria into your own body.
If you want to use other disinfecting products to clean your hands or surfaces, the Environmental Protection Agency released a full list of products that can kill the virus (https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19).
It’s not advisable, but if you're determined to make your own hand sanitizer (and can actually find the ingredients to do so), avoid any recipes that don't use at least 60% alcohol. Otherwise, just wash your damn hands.
Antibiotics misuse
Most people generally understand germs as the culprit of many infectious diseases. It is partly correct, but we need first to realize that microorganisms consist of various organisms, including parasites, bacteria, yeasts, fungi, viruses, etc. Antibiotics are selected and meant to kill only bacteria. Of course, some antibiotics can only kill specific bacteria (narrow-spectrum), while others can kill a wider variety of bacteria, called broad-spectrum antibiotics. The broad-spectrum antibiotics, depending on how they work, may be able to annoy fungi a bit, but not enough to kill them. That's it. No more, no less. Therefore, expecting antibiotics to kill fungi or viruses is too much to ask.
The patients may feel the alleviation of symptoms due to antibiotic administration. Such relief may be due to diminished bacterial population responsible for secondary infection, so the body can focus on combating the primary viral infection. This relief hence may encourage the widespread usage of antibiotics, with or without prescription. Consequently, an antibiotic prescription for common cold or influenza is commonly practiced by some general practitioners (GP). In some countries, it is not even impossible to get an antibiotic at the pharmacy without a prescription. Such misconduct may solve the patient's problem in the short term, but it would carry wider long-term impacts.
One of the long-term impacts that we have started to bear is the development and spread of antibiotic-resistant bacteria (van Belkum, Bachmann et al. 2019). Following antibiotic treatment, bacteria carrying a resistant factor may stay alive. Within the body, they can pass on the resistant factors to other commensal bacteria living in our gut microbial system (Jernberg, Löfmark et al. 2010). After cessation of antibiotic treatment, some resistant strains can persist in the human host (Jernberg, Löfmark et al. 2010) before passing the factors back to the pathogens (Bengtsson-Palme, Kristiansson et al. 2017). Or, these resistant bacteria can also escape and pass on the resistant genes to other bacteria in the environment, especially in the antibiotic-containing environment, e.g., due to antibiotic misuse in human and in animal husbandry or livestock production (Bengtsson-Palme, Kristiansson et al. 2017). Later, this factor may find its way back to the commensal or pathogenic bacteria (Bengtsson-Palme, Kristiansson et al. 2017), building up the antibiotic-resistant microbial community.
As a result, most pathogenic bacteria are now resistant to many antibiotics (Nathan and Cars 2014). At this moment, drug resistance, including bacterial infection, malaria, HIV/AIDS, and tuberculosis, are held accountable for at least 700,000 annual deaths globally (Commission 2016). This number is estimated to reach 10 million by 2050 (Commission 2016). This resistance imposes threats for the declining effectivity of antibiotic treatment and the rising cost of treatment in the future (Jernberg, Löfmark et al. 2010). WHO, among many other key organizations in health, has announced antibiotic resistance as a significant problem that can wipe away the progress of modern medicine, calling an immediate action plan to combat this issue (Nathan and Cars 2014).
As the efforts involve many stakeholders, the general public should participate in bearing the same concern and solving the problem. As part of society, we can restrict the inappropriate use of antibiotics (Nathan and Cars 2014) by stopping the purchase of antibiotics over the counter and asking the GP to prescribe antibiotics only under the utmost necessity. The pharmacy should remain committed to selling antibiotics only under prescription despite the potential financial loss (Erku and Aberra 2018), hence making sure that antibiotic treatment is only available through prescription (van Belkum, Bachmann et al. 2019). Meanwhile, the patients can focus on improving the immune system and train it to combat the pathogenic bacteria without relying on the antibiotics. Without antibiotic administration, the gut microbiota will persist well and restore the balance quickly after the disease, which would strengthen the defense mechanism for the next attack.
Other than reducing antibiotic administration in humans, the usage of antibiotics in other fields, including in the agriculture and animal husbandry, also needs to stop, as this practice may leak the antimicrobial substances to the environment (Commission 2016). Improving access to clean water and sanitation facility takes the next concern. A review on Antimicrobial Resistance Commission has predicted a 60% potential reduction of antibiotic treatment on diarrhoeal cases related to water and sanitation (Commission 2016). Therefore, improving the quality of water and sanitation, incorporating hygiene practices in our daily life, besides keeping a healthy lifestyle, hold the key to reduce the need for antibiotics and suppress the spread of antibiotic-resistant bacteria, as well as improve the overall health status.
Conclusion
As preventive actions play an essential role in health, we tried to raise awareness on some common misconceptions and mistakes around the basic hygiene and health practices. At the same time, access to a proper toilet as well as clean water for drinking, sanitation, and hygiene should be a fundamental need for everyone. Although behaviour change is not an easy task, we hope that everyone understands the importance of these hygiene practices and turns them into habits. Finally, we hope that these small changes will keep us healthy and help other stakeholders to take the required actions for continuous improvement.
S.A.D Team
References
Bengtsson-Palme, J., E. Kristiansson and D. G. J. Larsson (2017). "Environmental factors influencing the development and spread of antibiotic resistance." FEMS Microbiology Reviews 42(1).
Commission, R. o. A. R. (2016). The review on antimicrobial resistance Tackling drug-resistant infections globally: final report and recommendation. J. O'Neill. United Kingdom.
Erku, D. A. and S. Y. Aberra (2018). "Non-prescribed sale of antibiotics for acute childhood diarrhea and upper respiratory tract infection in community pharmacies: a 2 phase mixed-methods study." Antimicrobial Resistance & Infection Control 7(1): 92.
Jernberg, C., S. Löfmark, C. Edlund and J. K. Jansson (2010). "Long-term impacts of antibiotic exposure on the human intestinal microbiota." Microbiology 156(11): 3216-3223.
Nathan, C. and O. Cars (2014). "Antibiotic Resistance — Problems, Progress, and Prospects." New England Journal of Medicine 371(19): 1761-1763.
van Belkum, A., T. T. Bachmann, G. Lüdke, J. G. Lisby, G. Kahlmeter, A. Mohess, K. Becker, J. P. Hays, N. Woodford, K. Mitsakakis, J. Moran-Gilad, J. Vila, H. Peter, J. H. Rex, W. M. Dunne, J. A. M. R. R. D. T. W. G. o. A. R. the and T. Rapid Diagnostic (2019). "Developmental roadmap for antimicrobial susceptibility testing systems." Nature Reviews Microbiology17(1): 51-62.