Journal of Apicultural Research

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Defining the standards for medical grade honey

Renée Hermanns, Cristina Mateescu, Andreas Thrasyvoulou, Chrysoula

Tananaki, Frank A.D.T.G. Wagener & Niels A.J. Cremers

To cite this article: Renée Hermanns, Cristina Mateescu, Andreas Thrasyvoulou, Chrysoula
Tananaki, Frank A.D.T.G. Wagener & Niels A.J. Cremers (2019): Defining the standards for
medical grade honey, Journal of Apicultural Research, DOI: 10.1080/00218839.2019.1693713

To link to this article: https://doi.org/10.1080/00218839.2019.1693713

Published online: 27 Nov 2019.

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Journal of Apicultural Research, 2019
https://doi.org/10.1080/00218839.2019.1693713

REVIEW ARTICLE
Defining the standards for medical grade honey
Ren
ee Hermannsa , Cristina Mateescub , Andreas Thrasyvoulouc , Chrysoula Tananakic , Frank A.D.T.G.
Wagenerd and Niels A.J. Cremersa

a
Triticum Exploitatie BV, Maastricht, the Netherlands; bFood Bioresources National Service for Medicinal, Aromatic Plants and Bee
products, National Institute for Research & Development, Bucharest, Romania; cLaboratory of Apiculture-Sericulture, School of Agriculture
and Forestry, Aristotle University of Thessaloniki, Thessaloniki, Greece; dDepartment of Orthodontics and Craniofacial Biology, Radboud
University Medical Center, Nijmegen, the Netherlands

(Received 19 July 2019; accepted 30 October 2019)

Honey has been used since ancient times for the treatment of wounds. The discovery of antibiotics made its use less
appealing, but the development of antibiotic resistance has again increased the interest in honey for its antibacterial
properties. However, attention must be paid to the quality of the honey used for medical application. Honey may con-
tain toxic compounds when plants in honey harvesting areas are treated with herbicides and pesticides or are polluted
with industrial heavy metals, antibiotics, or exposed to environmental pollution. Moreover, bacterial contamination of
honey with, for example, Clostridium endospores has long been disregarded. Honey directly obtained from the bee-
keeper or from the store may not therefore be suitable and it may even be dangerous for use or for wound healing, as
there is no guarantee that it is safe, or it may not be effective because of inappropriate sterilization methods.
Therefore, there is a need for a clear definition of ‘medical grade honey’ (MGH), to guarantee its safety and efficacy for
therapeutic uses. Due to the current lack of strict guidelines to achieve standardized MGH formulations, this article
poses clear standards and criteria, including those related to the collection, possible contamination, sterilization, produc-
tion, storage, physicochemical, legal and safety issues to which MGH should adhere to distinguish itself from regular
honey. We discuss current honey-based wound care products and whether they adhere to the standards of MGH. The
presented guidelines should result in safe MGH formulations that are effective for wound healing.
Keywords: honey; medical grade honey; definition; standards; safety; wound care

Background the medical uses of honey for cleaning and healing of

Prior to modern day non-steroidal anti-inflammatory
drugs (NSAIDs) and antibiotics, small dirty injuries could
have been a death sentence because of uncontrolled
infection. Since antiquity, wounds were treated with the
same sequence of procedures: washing the wound
(cleansing), covering with plasters (topical therapy) and
bandaging the wounds (dressings) (Hsieh et al., 2016).
Many different substances including mud or clay, moldy
bread, meat, plants, and herbs were applied to wounds
to achieve hemostasis and to form a protective barrier
over the wound (Shah, 2011). The ancient Egyptians
would apply honey, Aloe vera, animal fat and lint, as they
believed closing the wound would protect the patient
from the invasion of evil spirits. It is currently known
that honey serves as a natural antibiotic, whereas the
animal fat functioned as a barrier to pathogens and the
lint as an absorbent for wound drainage (Murray,
Hinkle, & Yun, 2008; Sanchez & Burridge, 2007).
Nonetheless, the Egyptians must have been aware of
honey’s healing properties since it was included in most
of the ancient remedies (Eteraf-Oskouei & Najafi, 2013).
The Greek physician, Hippocrates (c. 400 BC) described

Corresponding author: E-mail: niels@mesitran.com
sores and ulcers (Ali, Fox, & Finlayson, 2013).
Nowadays, honey is still part of advanced wound
care. In contrast to historical times, there is currently a
lot of environmental pollution with herbicides, pesti-
cides and heavy metals worldwide, as well as plant
derivatives like pyrrolizidine alkaloids and their N-
oxides that can contaminate honey (Al-Waili, Salom, Al-
Ghamdi, & Ansari, 2012; Connolly, 2017; Cramer &
Beuerle, 2012). Therefore, it should be noted that
“medicinal” honey and not regular honey must be used
for wound care purposes. In addition, there is a large
variation in the antimicrobial and wound healing activity
of honey, which is due to spatiotemporal variation in
the origin of the honey. Identification and meeting
standardized criteria will help to guarantee both the
quality and therapeutic potential of medicinal honey.
For example, it is not advised to obtain honey for med-
ical purposes directly from the beekeeper or supermar-
ket, as these honeys are not extensively tested and
there is no guarantee the honey is safe and effective.
However, these concerns are often ignored, and this
demands a formal definition of medical grade honey
(MGH). Although medical remedies containing honey

ß 2019 International Bee Research Association

2 R. Hermanns et al.
Figure 1. Flow diagram MGH.
fall under the regulations for drugs or medical devices,
there is no regulation governing the standards for pure
honey. Therefore, criteria need to be developed and
honey must to comply with these criteria before it can
safely be used as MGH. Next, we will discuss the main
characteristics of honey, followed by the necessary cri-
teria to turn honey into a medical grade product.
Composition of honey
The following definition of honey is given by the Codex
Alimentarius 2001 and the European Honey Directive
(2001): “Honey is the natural sweet substance produced
by honey bees from the nectar of plants or from secre-
tions of living parts of plants or excretions of plant-
sucking insects on the living parts of plants, that bees
collect and transform by combining it with specific sub-
stances of their own and leave in honeycomb to ripen
and mature (European Honey Directive, 2001).
Each time nectar or honeydew is deposited into the
cell, more amylase and invertase are added by the bees
to convert the watery sucrose nectar. The bees evapor-
ate the water by fanning their wings and when the
moisture reaches low levels, they seal the honeycomb
cell with wax. This brings down the water content to
below 18% from its original 70% and ripens the honey,
yielding the classic thick substance (Langstroth, 1922).
The high sugar-to-water ratio makes honey a supersatu-
rated and highly viscous fluid that readily binds water
molecules, giving honey the ability to generate
osmotic pressure.
Honey consists of over 200 components including
enzymes, amino acids, carbohydrates, vitamins, and
organic acids as well as mineral compounds and other
derivatives from the environment in which the nectar
was collected. In this way, heavy metals and other trace
elements can also be deposited, causing great variations
in the composition depending on the location and type
of plant from which the bees collected nectar (Ferreira,
Aires, Barreira, & Estevinho, 2009). Furthermore, the
floral composition from which the honey is produced
determines the type of honey, resulting in countless
sets of honey, depending on their floral or geographical
origin, such as Acacia, Eucalyptus, Clover, Manuka, and
Buckwheat honey. All kinds of honey have different anti-
bacterial and wound healing properties and they vary in
safety and efficacy. This depends on the composition of
honey and the environmental origin and it demands a
definition for MGH, declaring the need for
MGH standards.
What is medical grade honey?
Medical grade honey must fulfill the following criteria:
 is organic and free of contaminants and toxic substances,
 is gamma sterilized under standardized conditions and
free of dangerous microorganisms,
 can be safely implemented in medical therapies,
 follows strict production and storage standards, and
legal and safety regulations,
 complies to the physicochemical criteria that are impor-
tant for the use of honey as a wound care product.
To achieve the criteria for MGH, standards for
honey collection and production need to be tightly fol-
lowed. In Figure 1, a flow diagram is shown summarizing
the minimal criteria to which MGH needs to adhere. In
addition to these MGH standards, medical device stand-
ards must be followed. These criteria are discussed in
the following paragraphs.

Table 1. Overview regulations honey standards.
EU
Food standards CAC
Regulated by CODEX STAN 12-1981, revised
CODEX 2001
Organic standards EC regulations 834 and 889
Directive 2001/110/EC
Directive 2014/63/EU
Regulated by The Council of the European Union and
local inspection bodies, which follows
DIN EN ISO/IEC 17025
Detection limits for residues of toxic heavy European Food Safety Authority
metals and drugs Regulation EC 1881/2006, which
Regulated by follows the limits in 396/2005, 470/
2009 and 37/2010
Organic origin
Honey is a complex yet delicate substance, whose com-
position is dependent on its environmental origin and it
is further influenced by different collection and produc-
tion modalities. One way to conform to production
standards and to ensure a safe and effective product is
through avoiding pollutants by restricting the colony’s
foraging area, which can extend up to 10 km, to geo-
graphic areas that are far from polluted environments
(Hagler, Mueller, Teuber, Machtley, & Van Deynze,
2011; Pasquet et al., 2008). The same applies to anti-
biotic treatment of the bee colony since, in the long
run, trace amounts can contribute to the global burden
of antibiotic resistance. To produce MGH, raw honey
should at least meet organic food standards and be free
of detectable amounts of pollutants and it should pref-
erably be certified as organic.
A worldwide collection of standards, guidelines, and
codes of practice has been collated by the Revised
Codex Alimentarius Commission (CAC) to create
harmonized international food standards. This and other
regulatory protocols and agencies can be found in
Table 1.
The CAC is a joint intergovernmental body of the
Food and Agriculture Organization of the United Nations
(FAO) and the World Health Organization (WHO) with
188 Member Countries. Their Codex Alimentarius, or
“Food Code” describes the standard for honey in
CODEX STAN 12-1981(Commission, 1981).
In addition to these international food standards,
organic standards have been made stricter by demand-
ing additional requirements to comply with the stand-
ards of organic farming and promote ecological balance
and conserve biodiversity. Beekeepers can obtain
organic certification when they follow such regulations.
For example, Europe has defined the criteria that need
to be fulfilled to obtain European organic certification in
EC regulations 834/2007 and 889/2008. This certifica-
tion is monitored at every stage by local inspection
bodies. Organic production is a comprehensive system
of agricultural management and food production and it
involves caring for the wellbeing of the bees and
Standards for medical grade honey 3
USA
CAC
CODEX STAN 12-1981, revised
CODEX 2001
USDA Organic Seal
The NOP, and EPA (Environmental
Protection Agency)
FDA - Code of Federal Regulations, Title
21, Part 556 and 530.
Section 2107(a)(6) of the Organic Food
Production Act of 1990
respecting what they produce. For example, the hives
used must be made of natural materials and positioned
within a radius of 3 km from areas mainly planted with
organic crops or wild plants. The hives can only be pro-
tected by organic products (wax, propolis, plant oils,
etc.), and sufficient honey and pollen must be left for
the winter, or if the bees do not have reserves, organic
food products must be given. These specifications must
be followed for over one year before the beekeepers
can use the word ‘organic’ on the labels of their prod-
ucts (Association for Organic Agriculture, 2005).
To confirm the honey was collected in an organic
environment, specific testing in a qualified laboratory is
necessary to guarantee that the MGH is free of pollu-
tants, using specific set limits and accredited protocols
and ISO certifications according to DIN EN ISO/IEC
17025. Honey must be free of detectable levels of her-
bicides, pesticides, antibiotics (full range of sulfonamides,
trimethoprim, streptomycin, and tetracyclines), and
heavy metals that are toxic even at low levels (arsenic,
lead, and cadmium). The levels of iron and zinc must
not exceed the maximum levels set for comparable
foodstuffs and must lie within the range of the naturally
occurring range for honey (Bogdanov, 2006; MAFF,
1995). The examined parameters of the honey must
correspond to the limit of quantification and the legal
regulations according to EC 1881/2006, 396/2005, 470/
2009, and 37/2010.
Sterilization
The collection of honey in an organic environment is
not enough to ensure the absence of all potential pollu-
tants. Many different bacteria, yeasts and moulds can be
present in honey (Olaitan, Adeleke, & Ola, 2007).
Microorganisms may influence the quality and safety of
the honey (Snowdon & Cliver, 1996). Clostridium botu-
linum is a bacterium ubiquitous to products from
nature. The endospores of this microorganism have
been revealed to different degrees in honey from over
the world, ranging from 5% to 64% (Grenda et al.,
2018; Nakano, Okabe, Hashimoto, & Sakaguchi, 1990).
While harmless when confronted by healthy persons
4 R. Hermanns et al.
and persons with an intact immune system, these bac-
teria can cause a life-threatening condition in immuno-
compromised individuals. In infants under the age of
1 year, honey is the primary cause of botulism since
their intestinal immune system is still underdeveloped,
making them vulnerable to pathogen proliferation after
ingestion, resulting in the release of the dangerous tox-
ins (Abdulla et al., 2012; Hoarau et al., 2012; Joseph,
Khoo, & Lee, 2017; Lopez-Laso et al., 2014; Sobel,
2005; WHO, 2018b).
Hence, the MGH end product must be sterile and
any bacterial endospores of Clostridium botulinum,
Clostridium tetani and other unwanted microorganisms
must be eliminated to remove the risk of botulism and
other morbidities. To disclose safe use and consump-
tion, gamma irradiation is the standard procedure for
sterilizing all medical devices and food products (Chou,
Skornicki, & Cohen, 2018). While different methods of
sterilization can be applied to kill bacteria effectively,
almost all of these procedures also inactivate the
enzymes and components that grant honey its anti-
microbial and pro-healing activity. For this reason,
honey bought in a grocery store often loses its wound
care stimulating characteristics, as this honey is most
likely to be heat sterilized. Gamma irradiation, on the
other hand, achieves product sterilization while preserv-
ing honey’s pro-healing and antibacterial efficacy (Gupta
& Reybroeck, 2014; Molan, 1992; Molan & Allen, 1996;
Postmes, van den Bogaard, & Hazen, 1993). According
to ISO 11137, specific regulations and protocols for
sterilization must be followed when applying gamma
irradiation; the level of irradiation should not be too
low, as endospores may survive, or too high to prevent
alteration of honey’s beneficial properties (Postmes, van
den Bogaard, & Hazen, 1995).
Next to gamma irradiation, the only other proven
sterilization technique that maintains honey’s bioactivity
is ozonation. By bubbling ozone gas through liquids in
an ozone-resistant container, bacterial residues and
endospores are effectively neutralized (Vestergard,
1994). In the food and meat industry, ozonated water is
often used to wash fruit and vegetables to remove fer-
tilizers, mycotoxins, Clostridium perfringens, E. coli, and
Salmonella (Castillo, Mckenzie, Lucia, & Acuff, 2003;
Crowe, Bushway, Bushway, Davis-Dentici, & Hazen,
2007; Crowe, Bushway, Bushway, & Hazen, 2006; Kim,
Yousef, & Dave, 1999; Novak & Yuan, 2004; Young,
Zhu, & Zhou, 2006). Currently, the method of ozone
sterilization of honey and honey-based wound care
preparations is patented under WO 2008/049578. This
is reflected in the market as all other MGH prepara-
tions are sterilized by gamma irradiation. However,
according to the patent, microorganisms are not com-
pletely eliminated by this method, but only reduced in
number from, on average, 250-1000 colony-forming
units (CFU) per g in raw, unheated biological honey to
100 CFU/g or less after ozone treatment (Vandeputte,
2008). Therefore, ozone treatment is inferior to gamma
irradiation. Regardless of market trends, honey-based
medical preparations should always be sterilized without
risking the decay of honey’s bioactive components to
provide augmentation of the wound healing trajectory
and the best possible protection for immunocomprom-
ised patients.
Although bacteria are killed by sterilization, endotox-
ins can be released into the honey as a result, such as
LPS, subsequently causing an inflammatory pyrogenic
response. The amount of released toxins correlates
with the number of endospores and therefore it is
important during the selection of honey that the honey
contains a low number of microorganisms. We propose
establishing strict microbiological criteria for bacteria at
a maximal limit of 10 CFU/g honey and a maximum limit
for fungi and moulds of 10 CFU/g honey should also
be maintained.
Clinical implementation
The term ‘medical grade honey’ has been generally
adopted by the scientific and medical community. Even
so, some studies that have included honey other than
commercially available MGH products lack the descrip-
tion of using a sterilized and standardized MGH.
Unclear terminology can raise confusion and for this
should be scrutinized. For example, if a case were to
refer to ‘medicated honey’ as the culprit of botulism in
an infant (Joseph et al., 2017). However, it remains
unclear whether the applied product was a standardized
MGH or if therapeutic agents were added to regular
honey which was then applied. Since botulism occurred,
it can be safe to say that the honey was, in fact, neither
medical grade nor properly processed, yet the author’s
use of terminology does not help in distinguishing
the error.
Once the honey is irradiated, it is suitable for med-
ical application and could be called medical grade honey
(MGH), providing the honey still presents bio-activity
(Molan & Allen, 1996; Postmes et al., 1995).
The levels of bioactivity differ among the vast variety
of available honey, and it has been reported that the
antibacterial activity of different honey sources can vary
a 100-fold (Lusby, Coombes, & Wilkinson, 2005; Mandal
& Mandal, 2011). Thus, many monofloral kinds of honey
from trees and plants such as lime, acacia, elm, thyme,
buckwheat, and manuka and polyfloral wildflower or
jungle honey have been the subject of studies in the
fields of wound healing, oncology, and immunology. The
mechanisms by which honey conveys its antioxidant and
anti-inflammatory action are well-documented and they
have been found to be related to its phenolic compo-
nents which are found in high levels in monofloral
honey, such as manuka and buckwheat, as well as poly-
floral jungle honeys like tualang honey (Ahmed &
Othman, 2013; Alvarez-Suarez, Gonz
alez- Param
as,
Santos-Buelga, & Battino, 2010; Alvarez-Suarez, Tulipani,

et al., 2010; Khalil, Alam, Moniruzzaman, Sulaiman, &
Gan, 2011; Moniruzzaman, Amrah Sulaiman, & Gan,
2017; Pasini, Gardini, Marcazzan, & Caboni, 2013;
Porcza, Simms, & Chopra, 2016; Sergiel, Pohl, &
Biesaga, 2014; van den Berg et al., 2008). Hence,
research has been conducted on tualang honey, to
account for its immune function and anti-tumor activity
(Fukuda et al., 2011). Aside from their phenolic con-
tents, animal studies and in vitro assays revealed
increased efficacy in wound healing of acacia and buck-
wheat honey, in contrast to manuka, as demonstrated
by the activation of keratinocyte re-epithelialization
(Abd Ghafar, Ker-Woon, Hui, Mohd Yusof, & Wan
Ngah, 2016; Ker-Woon, Abd Ghafar, Kien Hui, & Mohd
Yusof, 2014; Moniruzzaman et al., 2017; Ranzato,
Martinotti, & Burlando, 2013; Sergiel et al., 2014).
Making honey ‘medical grade’ - production and
storage regulations & safety
Honey for consumption must comply with several Food
Standards, such as the Global Standard for Food Safety,
and the International Food Standard (IFS) certifications.
However, higher quality standards are needed for honey
in medical use, and additional guidelines and restrictions
can further guarantee its safety for medical purposes,
such as the Organic Certification and country-dependent
certifications (for example, the British BRC, French FCD,
Dutch EKO, and Italian ANCC, ANCD and
Federdistribuzione), that follow stricter protocols
(Postmes et al., 1993). Beyond these pre-manufacturing
parameters focusing on the honey, a standardized prepar-
ation of MGH also extends to the handling, production,
and storage of MGH. Improper manufacture and storage
conditions, such as exposure to heat or light, can affect
the physicochemical properties, and subsequently, result
in reduced or loss of antimicrobial and wound healing
properties (Mandal & Mandal, 2011). It is therefore
important to follow the production and storage guide-
lines strictly, in accordance with good manufacturing
practice principles. MGH falls within the scope for med-
ical devices, more specifically, Class 2 b medical devices
and the EN ISO 13485 certification is therefore manda-
tory and needs to be confirmed by specifically notified
bodies. To comply with the EU legislation of the
European Medicine Agency (EMA) and the American
Food and Drug Administration (FDA), it is important to
strictly follow their guidelines for obtaining the CE and
FDA quality certification marks MDD 93/42/EEC and
21CFR820, respectively. In addition, the requirements of
EN ISO14971 provide manufacturers with a framework
for risk analysis, evaluation, control, and management,
and they specify a procedure for review and monitoring
during production and post-production (International
Organization for Standardization, 2007).
Several physicochemical factors can be examined to
check for the decay of the product during production,
storage and handling, e.g., measuring the concentration
Standards for medical grade honey 5
of 5-hydroxymethyl furfuraldehyde (HMF), which
increases following overheating, storage in poor condi-
tions or as honey ages. In Directive 110/2001, the
European Union describes the maximum value for HMF,
which in general should not exceed 40 mg/kg.
Exceptions for this are Baker’s honey and honey of
tropical origin, for which the HMF value should not
exceed 80 mg/kg; however, these honey types may be
less appropriate for the use in wound care products.
Physicochemical criteria and antibacterial
properties of honey as a wound care product
Honey contains more than 200 different compounds, of
which the greater part are sugars, predominantly fruc-
tose and glucose, as well as enzymes, minerals, vitamins,
and solid particles derived from the honey collection
such as pollen, and phenolic compounds, which give rise
to honey’s anti-inflammatory capacities (Ahmed &
Othman, 2013; Alvarez-Suarez, Gonz
alez- Param
as,
et al., 2010, Alvarez-Suarez, Tulipani, et al., 2010; van
den Berg et al., 2008). Furthermore, honey contains dif-
ferent volatile substances such as ketones, esters, alde-
hydes, hydrocarbons, alcohols and sulfur compounds
that are deposited in honey following collection from
different floral sources, the transformation from plant
compounds or production by bees or during honey
processing and storage (Kruz
ık, Gr
egrov
a, Rajchl, &
 ızkov
a, 2017). Research shows how these volatile
C

components directly influence the flavor of honey and
how they can be used to determine its botanical source
(Bicchi, Belliardo, & Frattini, 1983; Bouseta, Scheirman,
& Collin, 1996; Graddon, Morrison, & Smith, 1979;
Radovic et al., 2001). Thus, depending on the location
where honey is collected, the regional environment and
plant origin determine the exact composition, consist-
ency, color, flavor, and aroma (European Honey
Directive, 2001).
Before being sold on the market, MGH needs to
meet several composition criteria to guarantee the qual-
ity of the honey as described by the European Union
(Directive 110/2001) and as listed in Table 2, below
(European Honey Directive, 2001).
When brought into contact with water, honey’s
supersaturated nature employs an effect of osmosis.
Furthermore, the conversion of large amounts of sugar
into gluconic acid lends honey a lowset pH ranging
between 3.2 and 4.5 which is enough to inhibit the pro-
liferation of bacteria that usually thrive in more alkaline
conditions such as are often seen in chronic wounds
(Allen, Molan, & Reid, 1991; Pridal AMZaLU, 2002).
Leveen et al. (1973) showed that topical acidification
improves healing through the increased release of oxy-
gen from hemoglobin into the wound environment,
which can be exploited by the regenerating tissues
(Leveen et al., 1973). During the formation of gluconic
acid, the antiseptic hydrogen peroxide is produced as a
by-product (Kleppe, 1966). Next to peroxide-dependent
6 R. Hermanns et al.
Table 2. Criteria to guarantee the quality of the honey.
Component General requirement
Fructose and glucose content blossom honey: 60 g/100 g
honeydew honey: 45 g/100 g
Sucrose content 5 g/100 g
Moisture content 18%
Water-insoluble content 0.1 g/100 g
Electrical conductivity blossom honey: 0.8 mS/cm honeydew
honey: 0.8 mS/cm
Free acid 50 milli-equivalents acid/1000 g
Diastase activity 8 (Schade scale)
HMF 40 mg/kg
activity, manuka honey exerts antimicrobial activity in a
“non-peroxide dependent” manner by the dehydration
of dihydroxyacetone (DHA) to methylglyoxal when
honey is produced from nectar (Adams, Manley-Harris,
& Molan, 2009). The amount of methylglyoxal depends
on its precursor molecule. That is present in the plants
and increases as the reaction continues as honey is
stored. The presence of methylglyoxal reduces the per-
oxide-dependent activity of honey as methylglyoxal has
been found to inhibit glucose oxidase thus lowering the
concentration of H2O2 (Majtan, Bohova, Prochazka, &
Klaudiny, 2013).
While manuka honey is being sold as a therapeutic
agent worldwide, current studies show other monoflo-
ral, and polyfloral kinds of honey perform equally well,
if not better than manuka honey against a wide spec-
trum of the pathogens often encountered in wounds
(Grego et al., 2016; Lusby et al., 2005; Majtan et al.,
2013; Sherlock et al., 2010). When compared to
manuka honey, Grego et al. present the increased bac-
teriostatic and bactericidal activity of honeydew, chest-
nut, and polyfloral honey against Gram-positive bacteria
and E. coli ESBL (Grego et al., 2016). Similarly, Kus et al.
have described the higher antibacterial activity of buck-
wheat, cornflower, thyme, and tansy phacelia honey
when compared to manuka honey (Kus, Szweda,
Jerkovic, & Tuberoso, 2016).
Early scientific research of manuka honey may have
hyped the use of this specific honey type for honey-
based wound dressings, but the growing number of new
studies using other honey types – including studies pro-
viding comparison data on manuka – should be sufficient
to stimulate the diversification of MGH-based wound
healing products.
Criteria for the biological activity should be estab-
lished to guarantee its efficacy during wound healing.
For example, to assure the antimicrobial activity, a min-
imum amount of methylglyoxal or hydrogen peroxide
needs to be present in manuka or other types of honey.
Exceptions
false acacia, alfalfa, firewood Banksia,
French honeysuckle, red gum,
leatherwood, citrus spp.: 10 g/100 g
lavender, borage: 15 g/100 g
Calluna, erica (23%)
pressed honey: 0.5 g/100 g
strawberry tree, bell heather, eucalyptus,
lime tree, tea tree, ling heather,
manuka or jelly bush.
Honey with natural low enzyme content
(e.g., citrus honey) and HMF content
15 mg/kg: 3 (Schade scale)
Fresh and unheated honey: 15 mg/kg
Honeys of tropical origin: 80 mg/kg
However, this may also be influenced by the dilution of
the honey, as it has been demonstrated that 30-50%
dilutions of honey yields the highest hydrogen peroxide
concentrations (Bang, Buntting, & Molan, 2003). In add-
ition, since the antimicrobial properties of honey rest
on multiple mechanisms, other factors should also be
taken into account making it more complex. Another
option would be that the antimicrobial activity of each
honey batch needs to be tested against common micro-
organisms and must be effective at a certain dilution.
For the biological activity on wound healing, other fac-
tors may be more important, such as the amount of
phenols, the anti-oxidative and anti-inflammatory action
and its effects on cell proliferation, differentiation
and migration.
MGH in wound care
In times of rising antibiotic resistance, health care can
benefit from novel antimicrobial agents that have limited
risk to develop resistance (WHO, 2018a). Since the
antimicrobial effects of honey are based on multiple
physicochemical properties and different constituents,
there is a limited risk of the development of antimicro-
bial resistance against honey formulations and that
explains the resurgence of this ancient remedy in health
care (Maddocks & Jenkins, 2013). Generally, it is stated
that the variety in antibacterial activity among different
kinds of honey is a result of the different concentrations
of hydrogen peroxide or methylglyoxal, the concentra-
tion of honey used and the type of bacteria involved
(Mandal & Mandal, 2011). Hence, a greater concentra-
tion of honey should result in a more versatile antibac-
terial agent (Badawy, Shafii, Tharwat, & Kamal, 2004).
Variation in antimicrobial activity may exist between
honey types, but it may also differ between bacterial
isolates as bacteria differ in susceptibility towards the
different killing mechanisms of honey (Alvarez-Suarez,
Gasparrini, Forbes-Hernandez, Mazzoni, & Giampieri,
2014; Boateng & Diunase, 2015; Kwakman, Te Velde,
 Standards for medical grade honey 7

Table 3. Overview of MGH-based formulations currently available on the wound care market.
Sterilization
Product name Manufacturer Honey type MGH % method Certification Supplements
Medihoney Derma Sciences Manuka 80% Gamma irradiation FDA & CE
Activon Advancis Manuka 100% Gamma irradiation FDA & CE
Manuka Fill Links Medical Manuka 100% Gamma irradiation FDA & CE
Products Inc.
Mesitran Triticum Organic honey 40 and 48% Gamma irradiation FDA & CE Vitamin C, vitamin
E, zinc oxide,
essential oils
Revamil Bfactory Polyfloral 100% Gamma irradiation CE
Health
Products
Surgihoney Matoke Any honey 100% Gamma irradiation CE
Holdings
Limited
Vivamel Tosama Chestnut 100% Gamma irradiation CE
Principelle IF Principelle Dark buckwheat n/a Gamma irradiation CE Minerals, trace
elements,
and oxides
Melladerm Plus SanoMed Polyfloral 45% Ozonation CE Vitamin C, vitamin
Manufacturing E,
glucose oxidase

de Boer, Vandenbroucke-Grauls, & Zaat, 2011). Many
studies have compared the antimicrobial activity of
manuka honey with other natural honey, and it is evi-
dent that manuka honey is not superior. In contrast,
the antibacterial properties of the diverse honey types
produced worldwide have been reported to be similar
or superior compared to manuka honey and they may
have distinct advantages over manuka honey
(Anthimidou & Mossialos, 2013; Mandal & Mandal, 2011;
Stagos et al., 2018). Despite these findings, many of the
products available worldwide are based on 80% to
100% manuka honey solutions (Table 3).
There are a number of things that stand out when
looking at Table 3.
Most of the products that are approved by the FDA
use manuka honey. As discussed before, this popularity
probably proceeds from early honey research focusing
on manuka honey. Other honey types have been
described to be similar, or more biologically active, than
manuka, which supports the use of other kinds of
honey. Due to its popularity, the price of manuka has
risen sharply in recent decades and it will probably
increase further in the near future as demand continues
to outpace increases in supply (Spence, 2018). The
honey yield in 2016 per hive in New Zealand dropped
36% from 29.1 kg/hive to 18.7 kg/hive. Despite an
increase of 16% in beehives in 2017, the production of
manuka honey dropped by a further 4% (Ministry for
Primary Industries, 2018). These decreases in honey
production are mainly attributed to poor weather: dry
and hot summers, windy weather, and increased risk of
fires (Ministry for Primary Industries, 2018). Instead of
collecting honey, bees have switched to collecting water
for cooling, which costs a lot of energy for the bees
and affects their health (Brugman, 2014; Ministry for
Primary Industries, 2018). In contrast, extremely cool
and wet weather as experienced during autumn and
winter brings other challenges and reduces crop quality
(Ministry for Primary Industries, 2018). The increased
demand in manuka together with the decreased avail-
ability will probably further inflate its price.
While all presented products have received the
Conformit
e Europ
eenne (CE) mark, only four of them
are FDA approved. Acquisition of the FDA approval is a
costly procedure yet it proves its worth by informing
the general public that the benefits of the product out-
weigh the known risks for the intended use.
Some of the described MGH products have add-
itional ingredients, such as lanolin, polyethylene or poly-
propylene glycol, added to their formulation. These
ingredients may help with the application of the MGH,
as there are difficulties described with pure honey prod-
ucts, that are hard to apply and can drip from the
wounds in warm environments.
To assure the best possible MGH-based wound care
products, the honey should adhere to organic standards
(CAS 8028- 66-8) and be present in an amount of 30 -
50% w/w or at least 20- 60% w/w to guarantee efficacy
as a wound healing product. Furthermore, the compos-
ition preferably includes substances that improve the
applicability of the honey, such as hypoallergenic lanolin
(CAS 8006-54-0) and one or more components chosen
from the group of PEG (CAS 57-55-6), PEG 4000 (CAS
25322-68-3). Moreover, supplementation with additional
ingredients that enhance the antimicrobial and pro-
healing activity should be considered, such as ascorbic
acid (CAS 50-81-7), Vitamin A, Vitamin D, Vitamin E,
and Omega 3.
All the products listed in Table 3 are sterilized with
gamma irradiation, except for one using ozonation.
Although both sterilization methods may maintain hon-
ey’s bioactivity, gamma irradiation can be considered as
8 R. Hermanns et al.
the golden standard, especially since ozonation only
reduces the number of microorganisms and does not
completely eliminate them (Vandeputte, 2008).
Since the products shown in Table 3 have all been
tested and at least CE certified, these products are all
safe for application in wound healing therapies. Other
products that do not have such certification or are not
sterilized should be avoided. Besides the safety con-
cerns, there are other issues that need to be consid-
ered before using a product. At least as important and
coupled to the MGH definition, MGH should be effect-
ive as (wound) care product. The effectivity of MGH
rests on two pillars. The first one is the antimicrobial
activity and the second one is the pro-healing activity.
As has been discussed, the efficacy is dependent on the
type of honey and the composition of the MGH formu-
lation. MGH formulations that consist of lower amounts
of honey but which are supplemented with pro-healing
factors may have the strongest wound healing effects.
Conclusions
Honey has made a resurgence as a (wound) healing
agent as a result of rising instances of the development
of antibiotic resistance. In addition to the broad-spec-
trum antimicrobial activity of honey, the physicochemi-
cal composition also contributes to its anti-inflammatory
and anti-oxidative effects and stimulates tissue regener-
ation and wound healing. As the concentration and type
of honey may affect the antimicrobial and pro-healing
activity, MGH formulations should be carefully selected
to improve wound healing. Unfortunately, there is lim-
ited awareness of the risks of using unsterilized honey
directly from the beekeeper or heat-sterilized honey
from the grocery store, both of which are ineffective
for wound healing. Defining the standard for MGH will
guarantee the production of a consistent and effective
wound care product that can be safely applied in clinical
therapies. Therefore, MGH must be organic and must
be collected in an area free of pollutants. It must be
processed and sterilized under standardized conditions
and follow the legal, safety and physicochemical proper-
ties that are important to exert its antimicrobial and
pro-healing activity. Only when following the described
criteria, should honey be certified as MGH, indicating
the preparation of a safe product beneficial to wound
healing, even for immunocompromised patients.
Disclosure statement
RH and NC are employed by Triticum. Triticum is the manu-
facturer of L-Mesitran. Other authors state no conflict
of interest.
ORCID
Ren
ee Hermanns http://orcid.org/0000-0001-7127-4437
Cristina Mateescu http://orcid.org/0000-0002-5856-1578
Andreas Thrasyvoulou http://orcid.org/0000-0001-6731-4184
Chrysoula Tananaki http://orcid.org/0000-0002-0056-483X
Frank A.D.T.G. Wagener http://orcid.org/0000-0003-
4837-1559
Niels A.J. Cremers http://orcid.org/0000-0003-4042-8987
References
Abd Ghafar, N., Ker-Woon, C., Hui, C. K., Mohd Yusof,
Y. A., & Wan Ngah, W. Z. (2016). Mohd Yusof YA, Wan
Ngah WZ. Acacia honey accelerates in vitro corneal ulcer
wound healing model. BMC Complementary and Alternative
Medicine, 16(1), 259. doi:10.1186/s12906-016-1248-0
Abdulla, C. O., Ayubi, A., Zulfiquer, F., Santhanam, G., Ahmed,
M. A., & Deeb, J. (2012). Infant botulism following honey
ingestion. Case Reports, 2012, bcr1120115153. doi:10.1136/
bcr.11.2011.5153
Adams, C. J., Manley-Harris, M., & Molan, P. C. (2009). The
origin of methylglyoxal in New Zealand manuka
(Leptospermum scoparium) honey. Carbohydrate Research,
344(8), 1050–1053. doi:10.1016/j.carres.2009.03.020
Association for Organic Agriculture. (2005). Standards for
organic beekeeping. Gr€afelfing: Naturland.
Ahmed, S., & Othman, N. H. (2013). Review of the medicinal
effects of tualang honey and a comparison with manuka
honey. The Malaysian Journal of Medical Sciences: MJMS,
20(3), 6–13.
Ali, F. R., Fox, J., & Finlayson, A. E. (2013). Hippocrates on
ulcers. JAMA Dermatology, 149(9), 1049. doi:10.1001/jama-
dermatol.2013.4779
Allen, K. L., Molan, P. C., & Reid, G. M. (1991). A survey of
the antibacterial activity of some New Zealand honeys.
Journal of Pharmacy and Pharmacology, 43(12), 817–822. doi:
10.1111/j.2042-7158.1991.tb03186.x
Alvarez-Suarez, J. M., Gasparrini, M., Forbes-Hernandez, T. Y.,
Mazzoni, L., & Giampieri, F. (2014). The composition and
biological activity of honey: A focus on Manuka honey.
Foods, 3(3), 420–432. doi:10.3390/foods3030420
Alvarez-Suarez, J. M., Tulipani, S., Diaz, D., Estevez, Y.,
Romandini, S., & Giampieri, F. (2010). Antioxidant and anti-
microbial capacity of several monofloral Cuban honeys and
their correlation with color, polyphenol content and other
chemical compounds. Food and chemical toxicology: An
international journal published for the British Industrial.
Food and Chemical Toxicology, 48(8–9), 2490–2499. doi:10.
1016/j.fct.2010.06.021
Alvarez-Suarez, J. M., Gonz
alez- Param
as, A. M., Santos-Buelga,
C., & Battino, M., (2010). Antioxidant characterization of
native monofloral Cuban honeys. Journal of Agricultural and
Food Chemistry, 58(17), 9817–9824. doi:10.1021/jf1018164
Al-Waili, N., Salom, K., Al-Ghamdi, A., & Ansari, M. J. (2012).
Antibiotic, pesticide, and microbial contaminants of honey:
Human health hazards. The Scientific World Journal, 2012, 1.
doi:10.1100/2012/930849
Anthimidou, E., & Mossialos, D. (2013). Antibacterial activity
of Greek and Cypriot honeys against Staphylococcus aureus
and Pseudomonas aeruginosa in comparison to manuka
honey. Journal of Medicinal Food, 16(1), 42–47. doi:10.1089/
jmf.2012.0042
Badawy, O. F., Shafii, S. S., Tharwat, E. E., & Kamal, A. M.
(2004). Antibacterial activity of bee honey and its thera-
peutic usefulness against Escherichia coli O157:H7 and
Salmonella typhimurium infection. Revue Scientifique et
Technique de L'oie), 23(3), 1011–1022. doi:10.20506/rst.23.3.
1543
Bang, L. M., Buntting, C., & Molan, P. (2003). The effect of
dilution on the rate of hydrogen peroxide production in
honey and its implications for wound healing. The Journal of

Alternative and Complementary Medicine, 9(2), 267–273. doi:
10.1089/10755530360623383
Bicchi, C., Belliardo, F., & Frattini, C. (1983). Identification of
the volatile components of some Piedmontese honeys.
Journal of Apicultural Research, 22(2), 130–136. doi:10.1080/
00218839.1983.11100574
Boateng, J., & Diunase, K. N. (2015). Comparing the antibac-
terial and functional properties of Cameroonian and
Manuka Honeys for potential wound healing-have we come
full cycle in dealing with antibiotic resistance? Molecules,
20(9), 16068–16084. doi:10.3390/molecules200916068
Bogdanov, S. (2006). Contaminants of bee products. Apidologie,
37(1), 1–18. doi:10.1051/apido:2005043
Bouseta, A., Scheirman, V., & Collin, S. (1996). Flavor and free
amino acid composition of lavender and eucalyptus honeys.
Journal of Food Science, 61(4), 683–687. doi:10.1111/j.1365-
2621.1996.tb12181.x
Brugman, A. (2014). Effect of extreme heat on bees: Organic
Honey Upper Beaconsfield Apiaries - Vichoney. Retrieved
from https://organichoney.melbourne/effect-of-extreme-
heat-on-bees/
Castillo, A., Mckenzie, K. S., Lucia, L. M., & Acuff, G. R.
(2003). Ozone treatment for reduction of Escherichia coli
0157:H7 and Salmonella serotype typhimurium on beef car-
cass surfaces. Journal of Food Protection, 66(5), 775–779. doi:
10.4315/0362-028X-66.5.775
Chou, J. W., Skornicki, M., & Cohen, J. T. (2018). Unintended
consequences of the potential phase-out of gamma irradi-
ation. F1000Research, 7, 348. doi:10.12688/f1000research.
14090.1
Commission, C. A. (1981). Standard for Honey Codex Stan
12-1981. Codex Standard, 12, 1–8.
Connolly, C. N. (2017). Nerve agents in honey. Science,
358(6359), 38–39. doi:10.1126/science.aao6000
Cramer, L., & Beuerle, T. (2012). Detection and quantification
of pyrrolizidine alkaloids in antibacterial medical honeys.
Planta Medica, 78(18), 1976–1982. doi:10.1055/s-0032-
1327900
Crowe, K. M., Bushway, A. A., Bushway, R. J., Davis-Dentici,
K., & Hazen, R. A. A. (2007). comparison of single oxidants
versus advanced oxidation processes as chlorine-alterna-
tives for wild blueberry processing (Vaccinium angustifolium).
International Journal of Food Microbiology, 116(1), 25–31. doi:
10.1016/j.ijfoodmicro.2006.12.027
Crowe, K. M., Bushway, A. A., Bushway, R. J., & Hazen, R. A.
(2006). Evaluation of chemical and photochemical oxidation
processes for degradation of phosmet on lowbush blueber-
ries (Vaccinium angustifolium). Journal of Agricultural and Food
Chemistry, 54(25), 9608–9613. doi:10.1021/jf0616210
Eteraf-Oskouei, T., & Najafi, M. (2013). Traditional and mod-
ern uses of natural honey in human diseases: A review.
Iranian Journal of Basic Medical Sciences, 16(6), 731–742.
European Honey Directive. (2001). Official Journal of the
European Communities12.1.2002 L 10/47 COUNCIL
DIRECTIVE 2001/110/EC of 20 December 2001 relating to
honey, L 10.
Ferreira, I., Aires, E., Barreira, J. C. M., & Estevinho, L. M.
(2009). Antioxidant activity of Portuguese honey samples:
Different contributions of the entire honey and phenolic
extract. Food Chemistry, 114(4), 1438–1443. doi:10.1016/j.
foodchem.2008.11.028
Fukuda, M., Kobayashi, K., Hirono, Y., Miyagawa, M., Ishida, T.,
Ejiogu, E. C., … Takeuchi, M. (2011). Jungle honey enhan-
ces immune function and antitumor activity. Evidence-Based
Complementary and Alternative Medicine, 2011, 1. doi:10.
1093/ecam/nen086
Graddon, A. D., Morrison, J. D., & Smith, J. F. (1979). Volatile
constituents of some unifloral Australian honeys. Journal of
Standards for medical grade honey 9
Agricultural and Food Chemistry, 27(4), 832–837. doi:10.1021/
jf60224a046
Grego, E., Robino, P., Tramuta, C., Giusto, G., Boi, M.,
Colombo, R., … Nebbia, P. (2016). Evaluation of anti-
microbial activity of Italian honey for wound healing applica-
tion in veterinary medicine. Schweiz Arch Tierheilkd, 158(7),
521–527. doi:10.17236/sat00075
Grenda, T., Grabczak, M., Goldsztejn, M., Kozieł, N., Kwiatek,
K., Pohorecka, K., … Bober, A. (2018). Clostridium per-
fringens spores in polish honey samples. Journal of Veterinary
Research, 62(3), 281–284. doi:10.2478/jvetres-2018-0040
Gupta, R. K., & Reybroeck, W. (2014). Management and sani-
tation. In R. K. Gupta, W. Reybroeck, J. W. van Veen, & A.
Gupta (Eds.), Beekeeping for poverty alleviation and livelihood
security: Technological aspects of beekeeping (Vol. 1, p. 665).
Dordrecht: Springer ScienceþBusiness Media. doi:10.1007/
978-94-017-9199-1.
Hagler, J. R., Mueller, S., Teuber, L. R., Machtley, S. A., & Van
Deynze, A. (2011). Foraging range of honey bees, Apis mel-
lifera, in alfalfa seed production fields. Journal of Insect
Science, 11(1), 144. doi:10.1673/031.011.14401
Hoarau, G., Pelloux, I., Gayot, A., Wroblewski, I., Popoff, M.-
R., Mazuet, C., … Croiz
e, J. (2012). Two cases of type A
infant botulism in Grenoble, France: No honey for infants.
European Journal of Pediatrics, 171(3), 589–591. doi:10.1007/
s00431-011-1649-5
Hsieh, S., Maranda, E. L., Salih, T., Nguyen, A., Marsh, A. M., &
Jimenez, J. J. (2016). The power to heal. JAMA Dermatology,
152(8), 954. doi:10.1001/jamadermatol.2015.4236
International Organization for Standardization. (2007). ISO
14971:2007 Medical devices - Application of risk management
to medical devices. Retrieved from https://www.iso.org/stand-
ard/38193.html
Joseph, C. J., Khoo, T. B., & Lee, K. Y. (2017). Flaccid paralysis
in an infant associated with a dirty wound and application
of honey. BMJ Case Reports, 2017, bcr2016218044.
Ker-Woon, C., Abd Ghafar, N., Kien Hui, C., & Mohd Yusof,
Y. (2014). Mohd Yusof YA. Effect of acacia honey on cul-
tured rabbit corneal keratocytes. BMC Cell Biology, 15(1),
19. doi:10.1186/1471-2121-15-19
Khalil, M. I., Alam, N., Moniruzzaman, M., Sulaiman, S. A., &
Gan, S. H. (2011). Phenolic acid composition and antioxi-
dant properties of Malaysian honeys. Journal of Food Science,
76(6), C921–C928. doi:10.1111/j.1750-3841.2011.02282.x
Kim, J. G., Yousef, A. E., & Dave, S. (1999). Application of
ozone for enhancing the microbiological safety and quality
of foods: A review. Journal of Food Protection, 62(9),
1071–1087. doi:10.4315/0362-028X-62.9.1071
Kleppe, K. (1966). The effect of hydrogen peroxide on glucose
oxidase from Aspergillus niger
. Biochemistry, 5(1), 139–143.
doi:10.1021/bi00865a018
 ızkov
a, H. (2017).
Kruz
ık, V., Gr
egrov
a, A., Rajchl, A., & C

Study on honey quality evaluation and detection of adulter-
ation by analysis of volatile compounds. Journal of Apicultural
Science, 61(1), 17–27. doi:10.1515/jas-2017-0002
Kus, P. M., Szweda, P., Jerkovic, I., & Tuberoso, C. I. (2016).
Activity of Polish unifloral honeys against pathogenic bac-
teria and its correlation with colour, phenolic content, anti-
oxidant capacity and other parameters. Letters in Applied
Microbiology, 62(3), 269–276. doi:10.1111/lam.12541
Kwakman, P. H., Te Velde, A. A., de Boer, L., Vandenbroucke-
Grauls, C. M., & Zaat, S. A. (2011). Two major medicinal
honeys have different mechanisms of bactericidal activity.
PLoS One, 6(3), e17709. doi:10.1371/journal.pone.0017709
Langstroth, L. L. (1922). Langstroth on the hive & honey bee:
Twenty-first edition. Hamilton, IL: The American Bee Journal.
Leveen, H. H., Falk, G., Borek, B., Diaz, C., Lynfield, Y.,
Wynkoop, B. J., … Christoudias, G. C. (1973). Chemical
acidification of wounds. An adjuvant to healing and the
10 R. Hermanns et al.
unfavorable action of alkalinity and ammonia. Annals of
Surgery, 178(6), 745–753. doi:10.1097/00000658-
197312000-00011
Lopez-Laso, E., Roncero-Sanchez-Cano, I., Arce-Portillo, E.,
Ley-Martos, M., Aguirre-Rodriguez, J., & Garcia-Ron, A.
(2014). Infant botulism in Andalusia (Southern Spain).
European Journal of Paediatric Neurology, 18(3), 321–326. doi:
10.1016/j.ejpn.2013.12.008
Lusby, P. E., Coombes, A. L., & Wilkinson, J. M. (2005).
Bactericidal activity of different honeys against pathogenic
bacteria. Archives of Medical Research, 36(5), 464–467. doi:
10.1016/j.arcmed.2005.03.038
Maddocks, S. E., & Jenkins, R. E. (2013). Honey: A sweet solu-
tion to the growing problem of antimicrobial resistance?
Future Microbiology, 8(11), 1419–1429. doi:10.2217/fmb.13.
105
MAFF. (1995). Food surveillance information sheet. London:
Ministry of Agriculture, Fisheries and Food, Food Safety
Directorate.
Majtan, J., Bohova, J., Prochazka, E., & Klaudiny, J. (2013).
Methylglyoxal may affect hydrogen peroxide accumulation
in Manuka honey through the inhibition of glucose oxidase.
Journal of Medicinal Food, 17(2), 290–293.
Mandal, M. D., & Mandal, S. (2011). Honey: Its medicinal prop-
erty and antibacterial activity. Asian Pacific Journal of Tropical
Biomedicine, 1(2), 154–160. doi:10.1016/S2221-
1691(11)60016-6
Ministry for Primary Industries. (2018). Apiculture: 2017 apicul-
ture monitoring programme. Retrieved from https://landusenz.
org.nz/wp-content/uploads/2018/03/2017-Apiculture-moni-
toring-report-FINAL.pdf
Molan, P. C. (1992). The antibacterial activity of honey: 2.
Variation in the potency of the antibacterial activity. Bee
World, 73(2), 59–76. doi:10.1080/0005772X.1992.11099118
Molan, P. C., & Allen, K. L. (1996). The effect of gamma-irradi-
ation on the antibacterial activity of honey. The Journal of
Pharmacy and Pharmacology, 48(11), 1206–1209. doi:10.
1111/j.2042-7158.1996.tb03922.x
Moniruzzaman, M., Amrah Sulaiman, S., & Gan, S. H. (2017).
Phenolic acid and flavonoid composition of Malaysian hon-
eys. Journal of Food Biochemistry, 41(2), e12282. doi:10.1111/
jfbc.12282
Murray, C. K., Hinkle, M. K., & Yun, H. C. (2008). History of
infections associated with combat-related injuries. The
Journal of Trauma, 64(3), S221–S231. doi:10.1097/TA.
0b013e318163c40b
Nakano, H., Okabe, T., Hashimoto, H., & Sakaguchi, G.
(1990). Incidence of Clostridium botulinum in honey of
various origins. Japanese Journal of Medical Science and
Biology, 43(5), 183–195. doi:10.7883/yoken1952.43.183
Novak, J. S., & Yuan, J. T. (2004). Increased inactivation of
ozone-treated Clostridium perfringens vegetative cells and
spores on fabricated beef surfaces using mild heat. Journal of
Food Protection, 67(2), 342–346. doi:10.4315/0362-028X-67.
2.342
Olaitan, P. B., Adeleke, O. E., & Ola, I. O. (2007). Honey: A
reservoir for microorganisms and an inhibitory agent for
microbes. African Health Sciences, 7(3), 159–165. doi:10.
5555/afhs.2007.7.3.159
Pasini, F., Gardini, S., Marcazzan, G. L., & Caboni, M. F. (2013).
Buckwheat honeys: Screening of composition and proper-
ties. Food Chemistry, 141(3), 2802–2811. doi:10.1016/j.food-
chem.2013.05.102
Pasquet, R. S., Peltier, A., Hufford, M. B., Oudin, E., Saulnier,
J., Paul, L., … Gepts, P. (2008). Long-distance pollen flow
assessment through evaluation of pollinator foraging range
suggests transgene escape distances. Proceedings of the
National Academy of Sciences, 105(36), 13456–13461. doi:10.
1073/pnas.0806040105
Porcza, L. M., Simms, C., & Chopra, M. (2016). Honey and
cancer: Current status and future directions. Diseases, 4(4),
30.doi:10.3390/diseases4040030
Postmes, T., van den Bogaard, A. E., & Hazen, M. (1993).
Honey for wounds, ulcers, and skin graft preservation. The
Lancet), 341(8847), 756–757. doi:10.1016/0140-
6736(93)90527-N
Postmes, T., van den Bogaard, A. E., & Hazen, M. (1995). The
sterilization of honey with cobalt 60 gamma radiation: A
study of honey spiked with spores of Clostridium botu-
linum and Bacillus subtilis. Experientia, 51(9–10), 986–989.
doi:10.1007/BF01921753
Pridal AMZaLU. (2002, October). Ustav Zoologie a Vcelarstvi,
Vorlova L. Honey and its physical parameters. Brno, Czech
Republic, p. 47.
Radovic, B. S., Careri, M., Mangia, A., Musci, M., Gerboles, M.,
& Anklam, E. (2001). Contribution of dynamic headspace
GC–MS analysis of aroma compounds to authenticity test-
ing of honey. Food Chemistry, 72(4), 511–520. doi:10.1016/
S0308-8146(00)00263-6
Ranzato, E., Martinotti, S., & Burlando, B. (2013). Honey
exposure stimulates wound repair of human dermal fibro-
blasts. Burns & Trauma, 1(1), 32–38. doi:10.4103/2321-3868.
113333
Sanchez, G. M., & Burridge, A. L. (2007). Decision making in
head injury management in the Edwin Smith Papyrus.
Neurosurgical Focus, 23(1), 1–9. doi:10.3171/FOC-07/07/E5
Sergiel, I., Pohl, P., & Biesaga, M. (2014). Characterisation of
honeys according to their content of phenolic compounds
using high performance liquid chromatography/tandem mass
spectrometry. Food Chemistry, 145, 404–408. doi:10.1016/j.
foodchem.2013.08.068
Shah, J. B. (2011). The history of wound care. The Journal of
the American College of Certified Wound Specialists, 3(3),
65–66. doi:10.1016/j.jcws.2012.04.002
Sherlock, O., Dolan, A., Athman, R., Power, A., Gethin, G.,
Cowman, S., & Humphreys, H. (2010). Comparison of the
antimicrobial activity of Ulmo honey from Chile and
Manuka honey against methicillin-resistant Staphylococcus
aureus, Escherichia coli and Pseudomonas aeruginosa. BMC
Complementary and Alternative Medicine, 10(1), 47. doi:10.
1186/1472-6882-10-47
Snowdon, J. A., & Cliver, D. O. (1996). Microorganisms in
honey. International Journal of Food Microbiology, 31(1–3),
1–26. doi:10.1016/0168-1605(96)00970-1
Sobel, J. (2005). Botulism. Clinical Infectious Diseases, 41(8),
1167–1173. doi:10.1086/444507
Spence, A. (2018). Trial plantation to bring new player into bio-
active honey market. Adelaide: Lead.
Stagos, D., Soulitsiotis, N., Tsadila, C., Papaeconomou, S.,
Arvanitis, C., & Ntontos, A. (2018). Antibacterial and anti-
oxidant activity of different types of honey derived from
Mount Olympus in Greece. International Journal of Molecular
Medicine, 42(2), 726–734. doi:10.3892/ijmm.2018.3656
van den Berg, A. J., van den Worm, E., van Ufford, H. C.,
Halkes, S. B., Hoekstra, M. J., & Beukelman, C. J. (2008). An
in vitro examination of the antioxidant and anti-inflamma-
tory properties of buckwheat honey. Journal of Wound Care,
17(4), 172–178. doi:10.12968/jowc.2008.17.4.28839
Vandeputte, J. (2008). Method for sterilizing unheated raw honey.
A honey-based wound care preparation. A wound care treatment
product and a biscuit based on honey. Patent No WO/2008/
049578. Munich, Germany: European Patent Office.
Vestergard, B. (1994). Establishing and maintaining specific
pathogen free (SPF) conditions in aqueous solutions using
ozone. Advances in Space Research: The Official Journal of the
Committee on Space Research (COSPAR), 14(11), 387–393.

WHO. (2018a). Antimicrobial resistance fact sheet. Author.
Retrieved from https://www.who.int/en/news-room/fact-
sheets/detail/antimicrobial-resistance
WHO. (2018b). Botulism fact sheet. Author. Retrieved from
https://www.who.int/news-room/fact-sheets/detail/botulism
Standards for medical grade honey 11
Young, J. C., Zhu, H., & Zhou, T. (2006). Degradation of tri-
chothecene mycotoxins by aqueous ozone. Food and chem-
ical toxicology: An international journal published for the
British Industrial. Food and Chemical Toxicology, 44(3),
417–424. doi:10.1016/j.fct.2005.08.015