Hand sanitizer

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Hand sanitizer
Hand Sanitizer.JPG
A typical hand sanitizer gel
Identifiers
Synonyms hand sanitiser, hand antiseptic,[1] hand disinfectant

Hand sanitizer of the alcohol-based type is preferred to hand washing with soap and water in most situations in the healthcare setting.[2] It is generally more effective at killing microorganisms and better tolerated than soap and water.[3] Hand washing should still be carried out if contamination can be seen or following the use of the toilet.[4] The general use of non-alcohol based versions has no recommendations.[2] Outside the health care setting evidence to support the use of hand sanitizer over hand washing is poor.[5][6] They are available as liquids, gels, and foams.[3]

Alcohol-based versions typically contain some combination of isopropanol, ethanol, or n-propanol. Versions that contain 60 to 95% alcohol are most effective.[3] Care should be taken as they are flammable.[2] Alcohol-based hand sanitizer works against a variety of microorganisms but not spores.[3] Some versions contain compounds such as glycerol to prevent drying of the skin.[3] Non-alcohol based versions may contain benzalkonium chloride or triclosan.[7][8]

Alcohol has been used as an antiseptic at least as early as 1363 with evidence to support its use becoming available in the late 1800s.[9] Alcohol based hand sanitizer has been commonly used in Europe since at least the 1980s.[10] The alcohol based version is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[11] The wholesale cost in the developing world is about 1.40 to 3.70 USD per liter bottle.[12][4]

Uses[edit]

General public[edit]

The CDC Clean Hands campaign instructs the public hand washing. Alcohol- based hand sanitizer is only recommended if soap and water is not available.[13]

When using an alcohol-based hand sanitizer:
  • Apply product to the palm of one hand.
  • Rub hands together.
  • Rub the product over all surfaces of hands and fingers until hands are dry.[13]

The evidence for hand hygiene in school generally is of poor quality.[14]

Health care[edit]

Hand alcohol in a hospital

Alcohol-based hand sanitizer is preferred to hand washing with soap and water in most situations in the healthcare setting.[2] It is generally more effective at killing microorganisms and better tolerated than soap and water.[3] Hand washing should still be carried out if contamination can be seen or following the use of the toilet.[4]

Hand sanitizer that contains at least 60 percent alcohol or contains a "persistent antiseptic" should be used.[15][16] Alcohol rubs kill many different kinds of bacteria, including antibiotic resistant bacteria and TB bacteria. 90% alcohol rubs are highly flammable, but kill many kinds of viruses, including enveloped viruses such as the flu virus, the common cold virus, and HIV, though is notably ineffective against the rabies virus.[17][18][19]

90% alcohol rubs are more effective against viruses than most other form of hand washing.[20] Isopropyl alcohol will kill 99.99 percent or more of all non-spore forming bacteria in less than 30 seconds, both in the laboratory and on human skin.[15][21]

The alcohol in hand sanitizers may not have the 10–15 seconds exposure time required to denature proteins and lyse cells in too low quantities (0.3 mL) or concentrations (below 60%).[22] In environments with high lipids or protein waste (such as food processing), the use of alcohol hand rubs alone may not be sufficient to ensure proper hand hygiene.[22]

For health care settings like hospitals and clinics, optimum alcohol concentration to kill bacteria is 70% to 95%.[23][24] Products with alcohol concentrations as low as 40% are available in American stores, according to researchers at East Tennessee State University.[25]

Alcohol rub sanitizers kill most bacteria, and fungi, and stop some viruses. Alcohol rub sanitizers containing at least 70% alcohol (mainly ethyl alcohol) kill 99.9% of the bacteria on hands 30 seconds after application and 99.99% to 99.999%[note 1] in one minute.[20]

For health care, optimal disinfection requires attention to all exposed surfaces such as around the fingernails, between the fingers, on the back of the thumb, and around the wrist. Hand alcohol should be thoroughly rubbed into the hands and on the lower forearm for a duration of at least 30 seconds and then allowed to air dry.[26]

Use of alcohol-based hand gels dries skin less, leaving more moisture in the epidermis, than hand washing with antiseptic/antimicrobial soap and water.[27][28][29][30]

Safety[edit]

Fire[edit]

Alcohol gel can catch fire, producing a translucent blue flame. This is due to the flammable alcohol in the gel. Some hand sanitizer gels may not produce this effect due to a high concentration of water or moisturizing agents. There have been some rare instances where alcohol has been implicated in starting fires in the operating room, including a case where alcohol used as an antiseptic pooled under the surgical drapes in an operating room and caused a fire when a cautery instrument was used. Alcohol gel was not implicated. To minimize the risk of fire, alcohol rub users are instructed to rub their hands until dry, which indicates that the flammable alcohol has evaporated.[31] Fire departments suggest refills for the alcohol-based hand sanitizers can be stored with cleaning supplies away from heat sources or open flames.[32][full citation needed]

Skin[edit]

Research shows that alcohol hand sanitizers do not pose any risk by eliminating "good" microorganisms that are naturally present on the skin. The body quickly replenishes the good microbes on the hands, often moving them in from just up the arms where there are fewer harmful microorganisms.[33] However, alcohol may strip the skin of the outer layer of oil, which may have negative effects on barrier function of the skin. A study also shows that disinfecting hands with an antimicrobial detergent results in a greater barrier disruption of skin compared to alcohol solutions, suggesting an increased loss of skin lipids.[34][35]

Ingestion[edit]

The US FDA controls antimicrobial handsoaps and sanitizers as over-the-counter drugs because they are intended for topical anti-microbial use to prevent disease in humans.[36] The FDA requires strict labeling which informs consumers as to proper use of this OTC drug and dangers to avoid, including warning adults not to ingest, not to use in the eyes, to keep out of the reach of children, and to allow children to use only under adult supervision.[37] According to the American Association of Poison Control Centers, there were nearly 12,000 cases of hand sanitizer ingestion in 2006.[38] If ingested, alcohol-based hand sanitizers can cause alcohol poisoning in small children.[39] However, the Centers for Disease Control recommends using hand sanitizer with children to promote good hygiene, under supervision, and furthermore recommends parents pack hand sanitizer for their children when traveling, to avoid their contracting disease from dirty hands.[40] Isopropanol, a moderate health risk, is found in some sanitizers.

There have been cases reported of people drinking the gel (with mixers) in prisons and hospitals to become intoxicated leading to its withdrawal from some establishments.[41]

Non alcohol based[edit]

On April 30, 2015, the FDA announced that they were requesting more scientific data based on the safety of hand sanitizer. Emerging science also suggests that for at least some health care antiseptic active ingredients, systemic exposure (full body exposure as shown by detection of antiseptic ingredients in the blood or urine) is higher than previously thought, and existing data raise potential concerns about the effects of repeated daily human exposure to some antiseptic active ingredients. This would include hand antiseptic products containing alcohol and triclosan.[42]

Chemistry[edit]

Consumer alcohol-based hand sanitizers, and health care hand alcohol or alcohol hand antiseptic agents, are antiseptic products used to avoid transmission of pathogens. These exist in liquid, foam, and easy-flowing gel formulations. The level of alcohol varies between 60% and 95%.

Types[edit]

Alcohol-based hand rubs are extensively used in the hospital environment as an alternative to antiseptic soaps. Hand-rubs in the hospital environment have two applications: hygienic hand rubbing and surgical hand disinfection. Alcohol based hand rubs provide a better skin tolerance as compared to antiseptic soap.[30] Hand rubs also prove to have more effective microbiological properties as compared to antiseptic soaps.

The same ingredients used in over-the-counter hand-rubs are also used in hospital hand-rubs: alcohols such ethanol and isopropanol, sometimes combined with quats (quaternary ammonium cations) such as benzalkonium chloride. Quats are added at levels up to 200 parts per million to increase antimicrobial effectiveness. Although allergy to alcohol-only rubs is rare, fragrances, preservatives and quats can cause contact allergies.[43] These other ingredients do not evaporate like alcohol and accumulate leaving a "sticky" residue until they are removed with soap and water.

The most common brands of alcohol hand rubs include Aniosgel, Avant, Sterillium, Desderman and Allsept S. All hospital hand rubs must conform to certain regulations like EN 12054 for hygienic treatment and surgical disinfection by hand-rubbing. Products with a claim of "99.99% reduction" or 4Log reduction are ineffective in hospital environment, since the reduction must be more than "99.99%".[20]

The hand sanitizer dosing systems for hospitals are designed to deliver a measured amount of the product for staff. They are dosing pumps screwed onto a bottle or are specially designed dispensers with refill bottles. Dispensers for surgical hand disinfection are usually equipped with elbow controlled mechanism or infrared sensors to avoid any contact with the pump.

Surgical hand disinfection[edit]

Hands must be disinfected before any surgical procedure by hand washing with mild soap and then hand-rubbing with a sanitizer. Surgical disinfection requires a larger dose of the hand-rub and a longer rubbing time than ordinarily. It is usually done in two applications according to specific hand-rubbing techniques, EN1499 (hygienic handwash), and EN 1500 (hygienic hand disinfection) to ensure that antiseptic is applied everywhere on the surface of the hand.[44]

Alcohol-free[edit]

Alcohol-free hand sanitizer

Some hand sanitizer products use agents other than alcohol to kill microorganisms, such as povidone-iodine, benzalkonium chloride or triclosan.[22]

The World Health Organization (WHO) and the CDC recommends "persistent" antiseptics for hand sanitizers. Persistent activity is defined as the prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product. This activity may be demonstrated by sampling a site several minutes or hours after application and demonstrating bacterial antimicrobial effectiveness when compared with a baseline level. This property also has been referred to as "residual activity." Both substantive and nonsubstantive active ingredients can show a persistent effect if they substantially lower the number of bacteria during the wash period.

Laboratory studies have shown lingering benzalkonium chloride may be associated with antibiotic resistance in MRSA[45][46] while no mechanism for resistance to alcohol has ever been described in bacteria.[47] Where alcohol sanitizers utilize 62%, or higher, alcohol by weight, only .1 to .13% of benzalkonium chloride by weight provides equivalent antimicrobial effectiveness.

Triclosan has been shown to accumulate in biosolids in the environment, one of the top seven organic contaminants in waste water according to the National Toxicology Program[48] Triclosan leads to various problems with natural biological systems,[49] and triclosan, when combined with chlorine e.g. from tap water, produces dioxins, a probable carcinogen in humans.[50] However, 90–98% of triclosan in waste water biodegrades by both photolytic or natural biological processes or is removed due to sorption in waste water treatment plants. Numerous studies show that only very small traces are detectable in the effluent water that reaches rivers.[51]

A series of studies show that photodegradation of triclosan produced 2,4-dichlorophenol and 2,8-dichlorodibenzo-p-dioxin (2,8-DCDD). The 2,4-dichlorophenol itself is known to be biodegradable as well as photodegradable.[52][full citation needed] For DCDD, one of the non-toxic compounds of the dioxin family,[53] a conversion rate of 1% has been reported and estimated half-lives suggest that it is photolabile as well.[54][full citation needed] The formation-decay kinetics of DCDD are also reported by Sanchez-Prado et al. (2006) who claim "transformation of triclosan to toxic dioxins has never been shown and is highly unlikely."[55]

Alcohol-free hand sanitizers may be effective immediately while on the skin, but the solutions themselves can become contaminated because alcohol is an in-solution preservative and without it, the alcohol-free solution itself is susceptible to contamination. However, even alcohol-containing hand sanitizers can become contaminated if the alcohol content is not properly controlled or the sanitizer is grossly contaminated with microorganisms during manufacture. In June 2009, alcohol-free Clarcon Antimicrobial Hand Sanitizer was pulled from the US market by the FDA, which found the product contained gross contamination of extremely high levels of various bacteria, including those which can "cause opportunistic infections of the skin and underlying tissues and could result in medical or surgical attention as well as permanent damage". Gross contamination of any hand sanitizer by bacteria during manufacture will result in the failure of the effectiveness of that sanitizer and possible infection of the treatment site with the contaminating organisms.[56]

Society and culture[edit]

Some products claim to kill microorganisms naturally, although these claims are not substantiated in any FDA monograph. All hand sanitizer products require National Drug Code designation in the United States and natural product number designation in Canada.[citation needed]

Notes[edit]

  1. ^ research papers often use "n-log" to mean a reduction of n on a (base 10) logarithmic scale graphing the number of bacteria, thus "5-log" means a reduction by a factor of 105, or 99.999%

Sources[edit]

  1. ^ "Tentative Final Monograph for Health-Care Antiseptic Drug Products; Proposed Rule" (PDF). 74 (56). United States Federal Food and Drug Administration. March 2009: 12613–12617. 
  2. ^ a b c d Bolon, MK (September 2016). "Hand Hygiene: An Update.". Infectious disease clinics of North America. 30 (3): 591–607. doi:10.1016/j.idc.2016.04.007. PMID 27515139. 
  3. ^ a b c d e f Boyce, JM; Pittet, D; Healthcare Infection Control Practices Advisory, Committee.; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task, Force. (25 October 2002). "Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.". MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 51 (RR-16): 1–45, quiz CE1–4. PMID 12418624. 
  4. ^ a b c The selection and use of essential medicines: Twentieth report of the WHO Expert Committee 2015 (including 19th WHO Model List of Essential Medicines and 5th WHO Model List of Essential Medicines for Children). (PDF). WHO. 2015. p. 323. ISBN 9789240694941. Retrieved 8 December 2016. 
  5. ^ de Witt Huberts, J; Greenland, K; Schmidt, WP; Curtis, V (1 July 2016). "Exploring the potential of antimicrobial hand hygiene products in reducing the infectious burden in low-income countries: An integrative review.". American journal of infection control. 44 (7): 764–71. doi:10.1016/j.ajic.2016.01.045. PMID 27061254. 
  6. ^ Meadows, E; Le Saux, N (1 November 2004). "A systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children.". BMC Public Health. 4: 50. doi:10.1186/1471-2458-4-50. PMC 534108Freely accessible. PMID 15518593. 
  7. ^ Long, Bruce W.; Rollins, Jeannean Hall; Smith, Barbara J. (2015). Merrill's Atlas of Radiographic Positioning and Procedures (13 ed.). Elsevier Health Sciences. p. 16. ISBN 9780323319652. 
  8. ^ Baki, Gabriella; Alexander, Kenneth S. (2015). Introduction to Cosmetic Formulation and Technology. John Wiley & Sons. p. 173. ISBN 9781118763780. 
  9. ^ Block, Seymour Stanton (2001). Disinfection, Sterilization, and Preservation. Lippincott Williams & Wilkins. p. 14. ISBN 9780683307405. 
  10. ^ Miller, Chris H.; Palenik, Charles John (2016). Infection Control and Management of Hazardous Materials for the Dental Team (5 ed.). Elsevier Health Sciences. p. 269. ISBN 9780323476577. 
  11. ^ "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Retrieved 8 December 2016. 
  12. ^ "Alcohol, isopropyl". International Drug Price Indicator Guide. Retrieved 8 December 2016. 
  13. ^ a b "Clean Hands Save Lives!". Centers for Disease Control and Prevention. December 11, 2013. 
  14. ^ Willmott, M; Nicholson, A; Busse, H; MacArthur, GJ; Brookes, S; Campbell, R (January 2016). "Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis.". Archives of Disease in Childhood. 101 (1): 42–50. doi:10.1136/archdischild-2015-308875. PMC 4717429Freely accessible. PMID 26471110. 
  15. ^ a b CDC – Handwashing: Clean Hands Save Lives
  16. ^ "Dirty Hands Spread Dangerous Diseases like H1N1 (aka swine flu)". San Jose Mercury News. 25 April 2009. 
  17. ^ Sandora TJ, Shih MC, Goldmann DA (June 2008). "Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention". Pediatrics. 121: e1555–62. doi:10.1542/peds.2007-2597. PMID 18519460. 
  18. ^ Infection Control Campaign brochure Archived January 2, 2009, at the Wayback Machine.
  19. ^ "Hand Hygiene" (PDF). Retrieved 2011-08-31. [dead link]
  20. ^ a b c Rotter M. (1999). "Hand washing and hand disinfection". Hospital epidemiology and infection control. 87. 
  21. ^ Hibbard, John S. (May–June 2005). "Analyses Comparing the Antimicrobial Activity and Safety of Current Antiseptic Agents". J. Infusion Nursing. Infusion Nurses Society. 28 (3): 194–207. doi:10.1097/00129804-200505000-00008. PMID 15912075. 
  22. ^ a b c Boyce John M.; Pittet Didier (October 25, 2002). "Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force". Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 51: 1–44. Retrieved 2010-02-18. 
  23. ^ Kramer, Axel; Rudolph, Peter; Kampf, Gonter; Pittet, Didier (27 April 2002). "Limited efficacy of alcohol-based hand gels". Lancet. 359 (9316): 1489–1490. doi:10.1016/S0140-6736(02)08426-X. PMID 11988252. 
  24. ^ Pietsch, Hanns (2001). "Hand Antiseptics: Rubs Versus Scrubs, Alcoholic Solutions Versus Alcoholic Gels". J. Hospital Infection. Hospital Infection Society. 48 (Supl A): S33–S36. doi:10.1016/S0195-6701(01)90010-6. 
  25. ^ Reynolds, Scott A.; Foster Levy; Elaine S. Walker (March 2006). "Hand Sanitizer Alert". Emerging Infectious Diseases. Centers for Disease Control and Prevention. 12 (3): 527–9. doi:10.3201/eid1203.050955. PMC 3291447Freely accessible. PMID 16710985. Retrieved 2007-02-02. 
  26. ^ Girou, Emmanuelle; Sabrina Layou; Patrick Legrand; Francoise Oppein; Christian Brun-Buisson (August 2002). "Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial". British Medical Journal. 325 (362): 362. doi:10.1136/bmj.325.7360.362. PMC 117885Freely accessible. PMID 12183307. Retrieved 2009-10-16. 
  27. ^ Pedersen, L.K., E. Held, J.D. Johansen, T. Agner (2005). "Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection". British Journal of Dermatology. 153 (6): 1142–1146. doi:10.1111/j.1365-2133.2005.06875.x. 
  28. ^ Pedersen, Kynemund, Elisabeth Held, Jeanne Duus Johansen, Tove Agner (2005). "Short-term effects of alcohol-based disinfectant and detergent on skin irritation". Contact Dermatitis. 52 (2): 82–7. doi:10.1111/j.0105-1873.2005.00504.x. PMID 15725285. 
  29. ^ Boyce, John M. (July 2000). "Using Alcohol for Hand Antisepsis: Dispelling Old Myths". Infection Control and Hospital Epidemiology. The University of Chicago Press. 21 (7): 438–41. doi:10.1086/501784. PMID 10926392. Retrieved 2009-10-16. 
  30. ^ a b Boyce, John M.; Kelliher, Susan; Vallande, Nancy (July 2000). "Skin Irritation and Dryness Associated With Two Hand-Hygiene Regimens: Soap-and-Water Hand Washing Versus Hand Antisepsis With an Alcoholic Hand Gel". Infection Control and Hospital Epidemiology. The University of Chicago Press. 21 (7): 442–8. doi:10.1086/501785. PMID 10926393. Retrieved 2009-10-16. 
  31. ^ "Alcohol-Based Hand-Rubs and Fire Safety". Centers for Disease Control and Prevention. September 15, 2003. Archived from the original on 2007-04-03. Retrieved 2007-04-26. 
  32. ^ Ohio OAC 1301:7-7-3405.5
  33. ^ Aiello, A. E.; Larson, E. L.; Levy, S. B.; et al. (2007). "Consumer antibacterial soaps: effective or just risky?". Clin Infect Dis. 45: S137–47. doi:10.1086/519255. PMID 17683018. 
  34. ^ Löffler, Harald; Günter Kampf (2008). "Hand disinfection: How irritant are alcohols?". Journal of Hospital Infection. 70: 44–8. doi:10.1016/S0195-6701(08)60010-9. PMID 18994681. 
  35. ^ Pedersen, L.K.; E. Held; J.D. Johansen; T. Agner (2005). "Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection". British Journal of Determatology. 153 (6): 1142–1146. doi:10.1111/j.1365-2133.2005.06875.x. 
  36. ^ Daniel S. Wagner, Manager of Regulatory Compliance, ISSA (2000). "GENERAL GUIDE TO CHEMICAL CLEANING PRODUCT REGULATION" (PDF). International Sanitary Supply Association, Inc. 
  37. ^ Judith E. Foulke (May 1994). "Decoding the Cosmetic Label". FDA Consumer magazine. U.S. Food and Drug Administration. 
  38. ^ "Paging Dr. Gupta, Hand sanitizer risks". CNN. June 21, 2007. 
  39. ^ "Hand Sanitizers Could Be A Dangerous Poison To Unsupervised Children". NBC News Channel. Retrieved 2007-07-15. 
  40. ^ "International Travel with Infants and Young Children". Travelers' Health – Yellow Book. Centers for Disease Control. 8. March 2009. 
  41. ^ "Prisoner 'drunk on swine flu gel'". BBC news online. 2009-09-24. 
  42. ^ "FDA issues proposed rule to address data gaps for certain active ingredients in health care antiseptics". U.S. Food and Drug Administration. 2015-04-30. 
  43. ^ de Groot AC (1987). "Contact allergy to cosmetics: causative ingredients". Contact Dermatitis. 17 (1): 26–34. doi:10.1111/j.1600-0536.1987.tb02640.x. PMID 3652687. 
  44. ^ Kampf G, Ostermeyer C (Apr 2003). "Inter-laboratory reproducibility of the hand disinfection reference procedure of EN 1500". J Hosp Infect. 53 (4): 304–6. doi:10.1053/jhin.2002.1357. PMID 12660128. 
  45. ^ Akimitsu, N; Hamamoto, H; Inoue, RI; Shoji, M; Akamine, A; Takemori, KI; Hamasaki, N; Sekimizu, K (1999). "Increase in Resistance of Methicillin-Resistant Staphylococcus aureus to β-Lactams Caused by Mutations Conferring Resistance to Benzalkonium Chloride, a Disinfectant Widely Used in Hospitals". Antimicrobial Agents and Chemotherapy. American Society for Microbiology. 43 (12): 3042–3043. PMC 89614Freely accessible. PMID 10651623. 
  46. ^ "Antibacterial Household Products: Cause for Concern". Centers for Disease Control and Prevention. Retrieved 2001-06-01. 
  47. ^ Dix, Kathy (December 1, 2002). "CDC's Endorsement of Alcohol Hand Rubs Launches New Era in Hand Hygiene". Infection Control Today. 
  48. ^ "Hand NTP Research Concept: Triclosan" (PDF). National Toxicology Project. Retrieved 2008-11-20. 
  49. ^ McMurry LM, Oethinger M, Levy SB (1998). "Triclosan targets lipid synthesis". Nature. 394 (6693): 531–2. doi:10.1038/28970. PMID 9707111. 
  50. ^ "Environmental Emergence of Triclosan" (PDF). Santa Clara Basin Watershed Management Initiative. Retrieved 2006-01-01. 
  51. ^ Heidler, Jochen; Halden, Rolf U. (March 2007). "Mass balance assessment of triclosan removal during conventional sewage treatment". Chemosphere. Elsevier B.V. 66 (2): 362–9. doi:10.1016/j.chemosphere.2006.04.066. PMID 16766013. Retrieved 2010-01-25. 
  52. ^ European Commission 2000
  53. ^ Wisk, Joseph D.; Cooper, Keith R. (1990). "Comparison of the toxicity of several polychlorinated dibenzo-p-dioxins and 2,3,7,8-tetrachlorodibenzofuran in embryos of the Japanese medaka (Oryzias latipes)". Chemosphere. 20 (3–4): 361–377. doi:10.1016/0045-6535(90)90067-4. 
  54. ^ Aranami et al. 2007
  55. ^ Sanchez-Prado, Lucia; Llompart, Maria; Lores, Marta; García-Jares, Carmen; Bayona, Josep M.; Cela, Rafael (2006). "Monitoring the photochemical degradation of triclosan in wastewater by UV light and sunlight using solid-phase microextraction". Chemosphere. Elsevier B.V. 65 (8): 1338–47. doi:10.1016/j.chemosphere.2006.04.025. PMID 16735047. 
  56. ^ "Consumers Warned Not to Use Clarcon Skin Products". U.S. Food and Drug Administration. June 15, 2009. Retrieved 2009-06-15. 

External links[edit]