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Ethanol-Based Hand Sanitizing Gel Vapor Causes Positive Alcohol Marker, Ethylglucuronide, and Positive Breathalyzer Gregory E. Skipper, MD, Frieder Wurst, MD, Wolfgang Weinmann, MD, and Michael Liepman, MD Context: Ethylglucuronide (EtG), a minor metabolite of alcohol, is an
Ethylglucuronide (EtG) is a nonoxidative metabolite of ethyl alcohol that has recently gained widespread use in monitor- important new marker that can detect alcohol use for several days or ing alcohol abstinence. Depending on the amount of alcohol more after alcohol itself leaves the body. The test has rapidly gained consumed, EtG can detect alcohol use for several days or more widespread use where alcohol abstinence is desirable (eg, in health after alcohol leaves the body. It has rapidly gained widespread professional monitoring programs, alcohol treatment programs, high use in professional monitoring programs, alcohol treatment schools, criminal justice settings, liver transplant clinics). As with any programs, schools, criminal justice settings, liver transplant new test, it is important to understand its limitations, especially, it turns clinics, and other situations where alcohol abstinence is desir- out, regarding nonbeverage sources of alcohol that can affect EtG able. Shortly after the test became commercially available in the levels. We describe a case and follow-up studies in which ethanol-based United States in 2003, concerns arose regarding "false positive" hand sanitizing gel (EthGel) caused elevated EtG levels for a pharma- tests due to incidental exposure to nonbeverage alcohol. The cist who disputed disciplinary actions by her licensing board.
situation is similar to that of poppy seeds that can cause positive Objective: To document that EthGel causes elevated EtG levels and
tests for morphine. As with any new test, it is important to to identify the route of absorption.
understand its limitations and identify nonbeverage sources of Design, Setting, and Participants: After discovery of the index
alcohol (eg, mouthwash, foods, over-the-counter cough and cold case in 2004, 24 subjects were tested for EtG before and 30 minutes meds) that might cause positive EtG levels.
and 6 hours after exposure to EthGel in 4 groups: controls, skin In 2004, 2 of the authors (G.E.S. and M.L.) were exposure only, vapor exposure only, and both skin and vapor contacted by health professionals who claimed that they exposure. Breathalyzer was used to measure breath alcohol levels.
tested positive in the absence of alcohol consumption, sus- Results: Primarily EthGel caused elevated EtG and breathalyzer
pecting that their positive EtG tests had resulted from fre- from alcohol vapor. For "skin only," "vapor only," and "both" quent use of ethanol-based hand sanitizing gel (EthGel) atwork. One of the health professionals, a pharmacist, was groups the mean EtG levels at 30 minutes were 42 (range 0 to 102) willing to undergo testing and was admitted to an addiction ng/mL, 106 (18 to 328) ng/mL, and 176 (0 to 348) ng/mL, respec- treatment center for a trial exposure to EthGel.
tively. Breathalyzer levels of 0.01 to 0.02 g% persisted for up to 40 EthGels have become ubiquitous in hospitals, homes, to 60 minutes in subjects who had high-EtG levels.
schools, prisons, nursing homes, daycare centers, and even Conclusions: EthGel exposure, particularly inhalation of fumes,
gas stations or grocery stores. The frequent use of EthGel is caused positive EtG levels. Subjects being monitored with EtG strongly encouraged by agencies such as the US Center for testing should be warned to avoid products containing alcohol, Disease Control to prevent the spread of infections.1 A search including fumes from EthGel and similar compounds. Further stud- in the internet showed 14 name brand EthGel products ies should be conducted to better quantitate the amount of ethanol containing 60% or higher content of ethanol. Surprisingly, absorbed from EthGel to determine if frequent use, particularly in little has been reported about potential absorption, abuse, or poorly ventilated areas, might cause toxicity, especially for fetuses, possible toxicity from these products.
where zero tolerance to alcohol is desirable.
Acceptance of the use of EthGels has been remarkable.
One hospital report describes a 4% to 29% increase in the use of Key Words:
EthGel for hand cleansing between 2001 and 2004.2 According (J Addict Med 2009;3: 000–000) to another report, 440,000 uses of the gel were counted in thefirst year of its introduction alone.3 Some nurses, particularlythose in neonatal intensive care units, reported using EthGels upto 50 or more times per shift.4 Numerous studies demonstrate thepopularity5,6 of EthGel use. It is well tolerated7 and leads to From the University of Alabama (GES), Montgomery, AL; Salzburg (FW), Austria; Frieburg (WW), Germany; and Michigan State University (ML), lower infection rates in hospitals,8 extended care facilities,9 and Kalamazoo, MI.
acute care facilities,10 and it has been correlated with decreased Received for publication April 27, 2008; accepted November 25, 2008.
transmission of illness in homes,11 less absenteeism in elemen- Send correspondence and reprint requests to Gregory E. Skipper, MD, 19 S tary schools,12 and fewer upper respiratory illness and absentee- Jackson Street, Montgomery, AL 36104. e-mail: [email protected] ism in university residence halls.13 The only hazard mentioned Copyright 2009 American Society of Addiction MedicineISSN: 1921-0629/09/0302-0001 in the literature from regulatory agencies regarding these prod- J Addict Med • Volume 3, Number 2, June 2009 Skipper et al J Addict Med • Volume 3, Number 2, June 2009 ucts relate to their flammability and fire hazard (Joint Commis- exclusion criteria are age ⬎21 years, body mass index ⬍25, sion and Center for Disease Control).14,15 A recent study de- not pregnant or lactating, had not consumed alcoholic bever- signed to assess possible human toxicity from EthGels ages in the last 5 days, no skin lesions on hands, not sensitive concluded that such an occurrence was highly unlikely.16 Un- to alcohol, and no history of alcoholism or drug addiction).
fortunately, they neglected to test for alcohol markers and did Subjects were divided into 4 groups of 6 each including not specifically examine skin versus inhalation exposure.
controls (unexposed to EthGel), skin only exposure (EthGel Because of the growing use of EtG testing and concerns on hands but inside a plexiglass box), vapor only exposure regarding "false accusations of drinking" the Substance (subjects stood in bathroom with "both vapor and skin" Abuse and Mental Health Services Administration published exposure, but did not touch EthGel themselves), and "both an advisory in 2006 warning against over-reliance on positive vapor/skin" exposure (EthGel on skin with no recommenda- tests as proof of drinking, especially if disciplinary or puni- tion regarding location of hands relative to face, in a 6 ⫻ tive action is being considered.17 10 ⫻ 8, 540 ft3 bathroom, a relatively closed space where It is known that ethanol is not readily absorbed through vapor would be inhaled). All subjects using EthGel applied 2 adult skin18; however, there is a case report of a 1-month old squirts on their hands every 4 minutes for 1 hour. Blood Italian infant who became lethargic and was found to have a alcohol concentrations were measured by an Intoximeter blood alcohol of 0.362 g/dL after application of an umbilical Breathalyzer at baseline, 20, 40, and 60 and at 90 minutes cord stump dressing soaked in methylated alcohol (95% after completion of exposure. Urine samples for EtG were ethanol/5% methanol).19 There is a single report of a subject collected at baseline, 30 minutes, and 6 hours postexposure.
who had a slightly elevated EtG after the use of EthGel.20 All EtG results were from urine and were corrected to Another study showed no significant blood alcohol levels U100Creatinine standard to minimize the effect of variations after use of EthGel.21 One study reported examining the in hydration (U100Creatinine EtG ⫽ 100/urine creatinine ⫻ effect of heavy exposure to EthGel (30 times/hr) and detected urine EtG). All urine samples were tested for urine alcohol alcohol on the breath of 6 of 20 subjects (0.001% to 0.0025%) using an enzymatic test.
at 1 to 2 minutes postexposure and in the serum of 2 subjectsat 5 to 7 minutes postexposure. Another study demonstrated EtG levels as high as 713 ng/mL after 8 uses of EthGel overan 8-hour period.22 However, none of these studies controlled Index Case
for skin versus vapor exposure.23 The pre-exposure EtG at admission to the treatment Even minimal ethanol absorption, especially if recur- program was negative (100 ng/mL cutoff). Postexposure EtG rent, could present a concern for certain individuals. The levels were positive: day 1, 7 PM ⫽ 225 ng/mL, and day 2, 7 Surgeon General's Advisory on Alcohol Use in Pregnancy AM ⫽ 441 ng/mL and 7 PM ⫽ 770 ng/mL.
states "No amount of alcohol can be considered safe during pregnancy."24 However, no warnings have been issued for For this study, the EtG levels obtained from the labo- pregnant women to avoid use or exposure to EthGel.
ratory were at the lower limit of detection. All urine alcoholtests were negative. The control group had negligible EtG levels throughout. All handgel-exposed groups showed sig- nificant intersubject variability. EtG levels in both and vapor-only groups were significantly higher than controls at 30 Determination of EtG was performed by liquid chro- minutes (P ⫽ 0.0044) and at 6 hours (P ⫽ 0.0049) postex- matography-tandem mass spectrometry (LC-ESI-tandem posure (See Charts 1– 4 for details).
MS) method by NW Toxicology. The breathalyzer was an Breathalyzer registered zero in controls and 0.01 in Intoximeter Breathalyzer with lower level of detection at one subject in the skin only group at 20 minutes, otherwise the skin-only group registered zero throughout. All but one Index Case
subject in the vapor-only group registered 0.01 persistingfor 40 minutes postexposure and then returned to zero. One The index case, a pharmacist, was admitted to a secure subject in the both group registered 0.02 and the other 5 residential alcohol treatment program where her possessionswere searched and all potential items containing alcohol(hairspray, etc) were removed. On the first day, she wasinstructed to apply 2 squirts of 62% EthGel to her hands andforearms every hour for 8 hours and on the following dayevery half an hour for 8 hours. Urine for EtG was obtainedbefore beginning testing and at 7 PM and 7 AM for both daysof exposure. Neither blood alcohol nor breathalyzer wastested.
A study was subsequently carried out, after Institutional Review Board approval, on 24 volunteer subjects (inclusion/ Effect of handgel on EtG—Skin-only group.
2009 American Society of Addiction Medicine J Addict Med • Volume 3, Number 2, June 2009 Effects of Ethanol-Based Hand Sanitizing Gel Vapor Effect of handgel on EtG—Vapor-only group.
Grouped mead data—Effect of handgel on EtG.
registered 0.01 that persisted for 40 minutes, otherwise all6 subjects in the both group registered 0.01 persisting for The highest EtG value noted from EthGel exposure in our 60 minutes before returning to zero by 90 minutes.
study was 770 ng/mL in the index case, achieved after EthGeluse every 30 minutes for 8 hours. EtG levels seem to vary widely between subjects with similar exposure even when con-trolled for dilution, suggesting that some individuals either In 2004, when the index case was discovered, EtG testing absorb more ethanol or produce more EtG. It is not known was new, used only by a few professional monitoring programs whether actively avoiding inhalation of vapor from EthGel (ie, in the United Sates. As concerns over possible false-positive holding hands away from the face) can prevent positive tests.
results were raised, it became increasingly important to under- This might be the case since most absorption seems to be from stand the effect of different sources of alcohol exposure. This inhalation rather than skin absorption.
became especially important because laboratories had asserted,in marketing materials, indisputable reliability of a positive EtG as a proof of drinking.
After documentation of findings in the index case, we Use of EthGel, in accordance with product literature proceeded to verify this phenomenon in other subjects to deter- causes positive urine EtG levels, primarily from inhalation of mine whether absorption was from inhalation of vapor or vapor. Further investigation is warranted to assess the poten- through skin. It is known that vapor of alcohol can cause tial public health hazard of frequent or prolonged use of elevated ethanol levels. In many animal studies, use of alcohol EthGels, as occurs in some professions (eg, nurses in neonatal vapor has been the preferred route of administration, because of intensive care units), especially if exposure involves pregnant the difficulty of orally administering alcohol to animals. In women, where repeated small exposures could threaten fetal addition, a device for aerosolizing alcohol has been recently health and development.
marketed for use in bars.25 What has not been known is that use Although the maximum achievable levels of EtG from of EthGel, according to recommendations, produces enough EthGel exposure is unknown, the highest recorded level was ambient vapor to trigger positive tests for EtG.
770 ng/mL in this study. It will likely prove difficult to This study demonstrated that the breathing EthGel vapor establish a clear cutoff that distinguishes between drinking caused positive EtG tests and elevation of breathalyzer levels for and incidental exposure to alcohol due to the plethora of up to 60 minutes. The significantly elevated alcohol markers in products containing alcohol and the multiple and highly urine after exposure to EthGel vapor are of particular concern to varied exposures they could produce.
individuals in monitoring programs where positive readings In consideration of the above, it is recommended that EtG could result in sanctions such as loss or suspension of profes- can be primarily used as a screening tool for recent drinking.
sional license, loss of child custody, return to jail, or uninsur- When used properly the test remains useful and fair. In our experience, up to half of all positive EtG tests are associated withthe patient's admission of drinking. However, if the patientdenies drinking when confronted, one or more of the followingcan be considered: (1) continue observation and close monitor-ing; (2) obtain further intensive evaluation from an addictionmedicine provider (potentially involving in-depth history andthe questioning of collateral sources of information about thepatient's drinking); (3) corroborate further drinking episodes byadding an additional "confirmatory" method of alcohol usedetection, such as wearing a transcutaneous alcohol sensingdevice, recently shown to be accurate27; and/or (4) in safetysensitive situations consider administering disulfiram for en-hanced prevention of drinking behavior.
Although all laboratory tests have potential for false- Effect of handgel on EtG—Both skin and vapor positives and many drug tests the potential for "incidental exposure" (ie, poppy seeds, hemp oil, coca tea) the presence 2009 American Society of Addiction Medicine Skipper et al J Addict Med • Volume 3, Number 2, June 2009 of ethyl alcohol in so many products presents a dilemma.
Although EtG testing remains a valuable tool for early Patients being monitored using EtG should be warned to detection and deterrence of drinking, it is important to be avoid incidental alcohol exposure and should be provided a cautious by acknowledging its limitations, especially in fo- list of products to avoid.28 Because of the multitude of rensic settings where a positive test can have serious conse- products containing alcohol, it is unrealistic, however, to quences. Further naturalistic studies in larger populations are expect monitoring program participants to completely avoid needed to better understand the reliability of EtG and similar all incidental exposure to alcohol.
tests and produce better guidelines for their proper use.
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2009 American Society of Addiction Medicine

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