Utilization of Alcohol-based Hand Sanitizers and Associated Health Risks Among Healthcare Professionals Amid COVID-19 Pandemic: A Cross-sectional Study

Background: Alcohol-based hand sanitizer is a crucial and widely used product to avert the rapid spreading of corona-virus disease (COVID-19). However, frequent apply of alcohol-based hand sanitizer mainly at the point-of-care can cause health risks and shortages in and outside the healthcare facilities. The present study was designed to assess the utilization of alcohol-based hand sanitizers and the incidence of associated health risks among health care professionals in COVID-19 pandemic times. Method: A descriptive cross-sectional study was conducted at the Jimma University Medical Center, Ethiopia, between April 01 and June 27, 2020. The collected data were analyzed and described using IBM SPSS Statistics software version 21. Results: Ninety-six health care professionals with 28.69+4.048 years of mean age participated in the study. 95.8% of them practiced alcohol-based hand sanitizers to avert COVID-19 virus transmission in the healthcare setting and community. But they were challenges to practice hand hygiene with alcohol-based hand sanitizers. The common problems were alcohol-based hand sanitizers unavailability 66(68.8%), costly 50(52.1%), and skin damage 8(8.3%). Most of them experienced health risks such as skin dryness 60(62.5%), skin irritation 27(28.1%), ocular irritation 11(11.5%), cough 11(11.5%), and others. These health risks resulted in that 9(9.4%) of them did not practice hand hygiene by alcohol-based hand sanitizers (p-value = 0.999). Conclusion: To prevent COVID-19 virus transmission by alcohol-based hand sanitizers, health care professionals faced different challenges, such as access to alcohol-based hand sanitizers and reported health risks. Therefore, the regulatory and public health bodies should promote local production of alcohol-based hand sanitizers with careful follow-up, and its health risks management plan should gain attention.


Background
The outbreak of the novel and new disease called coronavirus disease (COVID-19) is causing a massive global health crisis. It also affects all sectors. This respiratory illness is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main symptoms explicitly linked to COVID-19 are shortness of breath, cough, fever, chills, and fatigue. In March 2020, the World Health Organization declared this outbreak a pandemic [1][2][3][4][5].
Since its emergence, the COVID-19 virus has been rapidly spreading throughout the world. It transmits from human-to-human primarily through respiratory droplets (>5-10 μm in diameter) and contact routes. Contact transmission occurs when the mucosa of the mouth, nose, or eyes is touched by infected hands. Droplet transmission occurs when a person is in close contact (within 1 m) with someone with COVID-19. It causes the risk of mucosae or conjunctiva exposure to potentially infective respiratory droplets [1,[5][6][7][8].
Till today there is no COVID-19 treatment option in the market. Only vaccine and preventive techniques are of utmost importance to prevent further spread in public and healthcare settings. So, currently, physical distancing, hand hygiene (HH) practices, proper use of all personal protective equipment (masks, goggles, and others) are an integral part of the response to the COVID-19 prevention [1,5].
Appropriate HH practice is the commonly used method to prevent transmission of COVID-19 virus through contaminated hand direct or indirect contact. It can be performed by handwashing using soap and water or using alcohol-based hand sanitizers (ABHSs). If there is visible contamination on the hands, handwashing using soap and water is preferred. Most of the time, if soap and water is not readily available or there is no visible contamination on the hands, the CDC recommends ABHS products in community andhealth care settings [8][9][10][11][12].
The ABHS can exist in liquid, gel, or foam containing 60-95% ethanol or >70% isopropyl alcohol. Relatively, it has a broad microbiological spectrum, time e ciency, better availability at the point of care, and improved skin tolerance. So ABHS is the most effective intervention for HH than handwashing with soap and water [11,13,14].
Health care professionals (HCPs) are at the frontline of combating this highly contagious infectious disease during this COVID-19 pandemic era and have the likelihood of acquiring this disease. So they highly and regularly use ABHSs in the community and at the point-of-care. The frequent or prolonged use of ABHS can facilitate the absorption of it through dermal or inhalation routes. So the frequent or improper use of it may lead to health risks to users and shortages in and outside the healthcare facilities [15][16][17][18][19][20]. Therefore, the regulatory agencies should be concerned about its potential health risks and supply.
Independent studies on the safety of topical ABHS applications are needed. It may be due to industry bias in many studies and a lack of scienti c studies in a resource-limited environment. By conducting the investigations concerning the epidemiology of health risks by topical application of ABHS in a real-life setting, the authors provide at least some scienti c evidence. Therefore the present study aimed to explore the self-reported utilization and incidence of health risks caused by ABHSs among HCPs at Jimma University Medical Center (JUMC), Ethiopia. Study setting, design, and period A hospital-based descriptive cross-sectional study design was conducted between April 01 and June 27, 2020. The study was conducted at JUMC. JUMC is one of the oldest public hospitals, the only teaching, and referral hospital in the southwestern part of Ethiopia. With an 800-bed capacity, it provides service for inpatient, outpatient attendants, emergency cases, and deliveries coming to the hospital from the catchment population of over 15 million people. During the COVID-19 pandemic, JUMC has been giving healthcare services to the communities in this hospital. The number of patients seeking care has been increasing during this pandemic. So, the hospital has been providing COVID-19 prevention materials for its staff.
Study population, sample size, study variables, and sampling method The study populations were HCPs, such as clinical nurses, pharmacists, academicians, medical laboratory technologists, physicians, dental doctors, and midwives working in JUMC during the study period. The HCPs that were on duty during the months of data collection and agreed to participate in the analysis were the study participants. The sample size was only 96 HCPs since data collections were paper-based, and it could be the means of transmission of COVID-19 viruses. It increased the unavailability of study participants on duty and refusal.

Eligibility criteria
The volunteer HCPs who served at a health institute for a minimum of one year and working in JUMC during the study period were eligible to participate in the study.

Data collection tools and procedures
Data collections were done with pretested, structured, and self-administered questionnaires. The questionnaire included questions prepared to evaluate the HCPs' demographics, HH practice, availability, use, and health risks of ABHSs. It was developed by using various standard references [8,11,15,35] The data collectors were four trained, healthcare professionals. The training was given to data collectors on the research objectives and the contents of the checklist for data collection. Data collection was done by self-administered questionnaires to the respondents at their working area. Then the questionnaire was immediately collected after being lled out.

Data quality assurance and analysis
A pretest was performed, using expert opinion before data collection. Then actual data was collected using a standard questionnaire and a regular check for clarity, completeness, and validity individually and coded. The collected data was entered and analyzed using IBM Statistical Package for Social Sciences (SPSS) version 21. The level of signi cance was set at 5% (p< 0.05).

Ethics approval
The Jimma University Institutional Review Board issued ethical approval before the commencement of the study. The Institutional Review Board reviewed the document, waived the requirement for written formal consent documents, and allowed investigators to obtain verbal informed consent. The data collectors then clari ed all relevant details (purpose, risks, bene ts, alternatives to participation, etc.) for study participants before the administration of the questionnaire and allowed them to ask questions. Then a verbal agreement was obtained from the volunteers, and data collected. The collected data were kept con dential. The data was only available to the principal investigator and coauthor.

Availability of alcohol-based hand sanitizers
According to the present study, due to the reported substandard ABHSs products in the market, getting the product with approved quality was becoming a major problem. The respondents mostly purchased from pharmacy 50 (52.1%), shop 11 (11.5%), another area 1, and obtained from their institution 34 (35.4%).

Self-reported experienced health risks of alcohol-based hand sanitizers
As HCPs are the frequent users of ABHSs, especially after the outbreak of COVID-19, the prevalence of health risks of ABHSs was examined. (Table 3)  During the COVID-19 incidence, the enormous demand for and consumption of ABHSs created major challenges to get and use ABHSs for HH as a primary prevention technique [27,28]. In accordance with the results of the present study, ABHS unavailability, cost, forgetting, and skin damage were the main reasons for not performing HH by ABHSs. Especially the unavailability of ABHSs was the main reason for not performing HH by ABHSs in the community and healthcare settings. Binary logistic regression analysis indicated that the ABHSs unavailability contributes more than four times to not practicing ABHSs (AOR 4.118; 95% CI 0.878-19.318; P= 0.073). The nding in this study was in line with other studies conducted in the Central Gondar Zone in ve public primary hospitals (2019) [29]. Despite allowed local production of ABHS by the WHO [8], substantial shortages should be due to regular use of ABHS such as at the ve-moments in the clinical setting.
The safety of improper and frequent usage of ABHS should regain attention because of their ever-increasing use as the main HH agent for COVID-19 prevention worldwide [32]. According to the ndings of the present study, 79 (82.3%) study participants were experienced different health risks. Skin dryness, skin irritation, and ocular irritation were commonly reported (Table 3). These ndings have supported the ndings reported from studies conducted by G. Kampf, H Lo er (2003) [32], Lachenmeier DW (2008) [30], Santos C (2017) [31], Jairoun AA (2020) [28] and A. Mahmood et al (2020) [20]. These ndings indicated that these risks were associated with the frequency and improper use of ABHS or lack of emollients in the product.
The nding of the present study reported skin dryness and skin irritation as the most health risks experienced. It should be due to topicalapplication of ABHSs, and the most prone organ for adverse effects appears to be the skin, which comes into direct contact with the agent. However, there is no statistically signi cant association between experienced health risks and types of ABHS used. (Table 4) These skin risks can be improved by locally preparing and supplying or using ABHSs containing appropriate emollients according to the WHO guideline. The use of emollients in facilitating skin barrier regeneration is widely accepted even by affected individuals [32,33]. So, the HCPs should use moisturizers containing ABHSs to increase compliance, maintain healthcare quality, and skin safety during the ght against COVID-19.
According to the present study, 9 (9.4%) of respondents who experienced health risks do not practice HH by ABHS due to experienced risks (pvalue = 0.999). The association between experienced health risks and not practicing ABHS for HH was insigni cant. It should be due to the users' belief that, relative to other HH maintaining measures, ABHSs are most effective (advantages outweigh its risks), better tolerated, and often associated with better acceptability. These results corroborate the ndings reported by different studies [15,34,35,36].

Strength and limitation of the study
The present study provided evidence to support the development and implementation of an action plan for preventing ABHSs health risks and proper use of standard products. Furthermore, the data can be used for further study by the scienti c communities. A limitation of this study can be noted that the number of study participants was not adequate to distinguish statistically signi cant results. Besides this, the questions were self-evaluation and most susceptible to bias. In real-life scenarios, what the study participants respond cab be different from what they practice.

Conclusion
ABHSs were used by most HCPs to minimize transmission of COVID-19 to staff, between staff, between staff and patients/visitors, and in the community. They prefer ABHSs due to it is most effective, easily available, provided by their health facility, and other reasons. They mostly purchased ABHSs from pharmacies and shops. During the COVID-19 pandemic time, HCPs were getting challenges to get ABHSs and practice it as primary COVID-19 prevention technique due to the unavailability of ABHSs, costly, forgetting, skin damage, unpleasant taste, and others to practice HH by ABHSs. ABHSs enormous demand and regular use are leading to substantial shortages in the supply and an increase in its cost.
As HCPs are frequent users of ABHSs, HCPs experienced different health risks; mainly like skin dryness, skin irritation, ocular irritation, cough, and others. Therefore, while its bene ts outweigh its health risks, the range of harm caused to the skin by ABHS cannot and should not be overlooked.

Recommendation
Currently, ABHSs are heavily consumed in the community and healthcare settings to ensure adequate patient care and HCPs safety. Therefore, the present study recommends that the shortage of ABHSs can lead to fraudulent production and sales of poor quality and even dangerous products. Therefore, the regulatory and public health bodies' effort to ensure the availability and quality of ABHSs to meet the demand during this pandemic time was needed. Additionally, the prevalence of health risks should be investigated, and the management plan should gain attention. So, the ndings of the present study can be used by interested researchers and other interested bodies to have a better outlook for understanding the issues.

Operational de nition
Hand hygiene: removal or killing of transient microorganisms from the hands Health care professional: a person who is quali ed and allowed by regulatory bodies to provide a healthcare service to clients (patient) Health risk: an adverse event due to a speci c condition

Declarations
Ethics approval and consent to participate: Formal verbal consent was obtained from Jimma University Institutional Review Board. During the study period, all study participants were asked for voluntarily participation in the study using formal verbal consent.
Competing interest: No potential con ict of interest Consent for publication: The authors declared they agree to publish the manuscript.
Authors' contributions: Both authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave nal approval of the version to be published; and agree to be accountable for all aspects of the work.