Travel Medicine and Infectious Disease (2014) 12, 494e498

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journal homepage: www.elsevierhealth.com/journals/tmid

Does the use of alcohol-based hand gel

sanitizer reduce travellers’ diarrhea and
gastrointestinal upset? : A preliminary
survey
Delphine Henriey a, Jean Delmont a, Philippe Gautret a,b,*

a
Assistance Publique Hôpitaux de Marseille, CHU Nord, Pôle Infectieux, Institut Hospitalo-
Universitaire Méditerranée Infection, 13015 Marseille, France
b
Aix Marseille Université, Unité de Recherche en Maladies Infectieuses et Tropicales Emergentes
(URMITE), UM63, CNRS 7278, IRD 198, Inserm 1095, Faculté de Médecine, 27 bd Jean Moulin,
13005 Marseille, France

Received 30 April 2014; received in revised form 3 July 2014; accepted 8 July 2014
Available online 11 July 2014

KEYWORDS Summary Introduction: Use of alcohol-based hand sanitizer is recommended by the CDC to
Travellers’ diarrhea; reduce the risk for travellers’ diarrhoea, but its effectiveness has not been assessed.
Hand sanitizer; Materials and methods: We investigated the potential protective effect of hand sanitizer use
Knowledge; on the occurrence of diarrhoea and/or vomiting in 200 international travellers, who were re-
Aptitude; turning home, at an international airport. We also conducted a knowledge, aptitude and prac-
Practice tice survey about hand gel use among international travellers consulting for pre-travel advice
at a specialized clinic.
Results: 200 returning travellers were included of which 32.5% declared having used alcohol-
based hand sanitizer during travel. Travellers who used hand sanitizer reported diarrhoea
and vomiting significantly less frequently than those who did not (17% vs. 30%, OR Z 0.47;
95% CI [0.21e0.97], p Z 0.04).
A total of 257 travellers consulting for pre-travel advice were included. A majority of trav-
ellers knew that hand sanitizer may be used for hand hygiene and had already used hand sa-
nitizer; 72% planned to bring hand sanitizer during their next travel.
Conclusions: Use of hand sanitizer is highly acceptable by travellers and is associated with a
reduction in the incidence of travellers’ diarrhoea and/or vomiting.
ª 2014 Elsevier Ltd. All rights reserved.

* Corresponding author. Assistance Publique Hôpitaux de Marseille, CHU Nord, Pôle Infectieux, Institut Hospitalo-Universitaire Médi-
terranée Infection, 13015 Marseille, France. Tel.: þ33 (0) 4 91 96 35 35/36; fax: þ33 (0) 4 91 96 89 38.
E-mail address: philippe.gautret@club-internet.fr (P.Gautret).

http://dx.doi.org/10.1016/j.tmaid.2014.07.002
1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
Use of alcohol-based hand gel sanitizer
1. Introduction
Travellers’ diarrhoea is experienced by 20e50% of inter-
national travellers who visit developing tropical areas and
is a major cause of morbidity among international travel-
lers who are sick [l]. A study in a cohort of 17,228 Euro-
pean travellers presenting at EurotravneteGeoSentinel
clinics revealed that 2 out of 10 ill travellers suffer from
this disease [2]. Increasing antimicrobial resistance of
pathogens responsible for travellers’ diarrhoea is of
concern [3]. Chemoprophylaxis using rifamixin, bismuth
subsalycilates or fluoroquinolones are not unanimously
recommended because of poor efficacy and or potential
toxicity [3]. Further research to evaluate the value of
immunoprophylaxis is needed before any recommendation
can be made [4].
Numerous studies have been conducted to evaluate the
potential effect of food or water consumption patterns on
the prevalence of diarrhoea in travellers, with negative
results [5e10]. Hand hygiene; by contrast has not been
addressed in these studies. Use of alcohol-based hand
sanitizer is recommended by the CDC to reduce the risk for
travellers’ diarrhoea. (http://wwwnc.cdc.gov/travel/
yellowbook/2014/chapter-2-the-pre-travel-consultation/
travellers-diarrhea). However, this recommendation is
empirical, since the effectiveness of hand sanitizer use
against travellers’ diarrhoea has not been assessed to the
best of our knowledge [11].
In this preliminary study we investigated the potential
protective effect of hand sanitizer use on the occurrence of
diarrhoea and/or vomiting in 200 international travellers
returning home who were included at an international
airport. We also conducted a knowledge aptitude and
practice survey about hand gel use among international
travellers consulting for pre-travel advice at a specialized
clinic.
2. Materials and methods
2.1. Airport survey
Travellers aged >18 years, living in metropolitan France
more than 6 months per year and returning from developing
or emerging countries were included at the Marseille in-
ternational airport (Southern France). A standardized
questionnaire addressing demographics, travel character-
istics, occurrence of diarrhoea and preventive measures
was administered orally by a single investigator while
travellers were waiting for a shuttle. Developing or
emerging countries were selected according to the
Inequality-adjusted Human Development Index (http://
hdr.undp.org/en/statistics/ihdi). Interviews were con-
ducted anonymously between January and April 2012.
2.2. Travel clinic survey
Travellers presenting to our travel clinic for pre-travel
advice were invited to self-answer anonymously a stan-
dardized written questionnaire, before their consultation.
The questionnaire addressed demographics, travel
495
characteristics and knowledge aptitude and practice
about alcohol-based hand sanitizer use. Questionnaires
were collected between November 2012 and January
2013.
2.3. Statistics
Data were analysed using EpiInfo 6.0. Chi-square, Yates and
Fischer’s tests were used to compare variables. A p value
<0.05 was considered significant. Odd ratio (OR) with 95%
confidence interval (CI) was calculated for univariate
analysis.
3. Results
3.1. Airport survey
A total of 404 travellers were approached. 200 did not
fulfill the inclusion criteria and four refused to participate.
So, 200 travellers were included in the study (Table 1). The
female to male ratio was 2.3 with a mean age of 50 years
(range 18e82). Most travellers were French-born and for
the majority, this was not the first travel to a developing or
emerging country. Africa, Asia and the Caribbean were the
prominent travelled areas. Tourism was stated as the main
reason for travel followed by visiting friends and relatives
(VFR). A proportion of 56.7% of VFRs were foreign-born
immigrants travelling back temporarily to their country
of birth. The mean travel duration was 21 days (median: 15
days; range 4e170). Pre-travel advice was reported by a
majority of travellers. Most of them took advice from their
general practitioner or from media. The great majority
declared as having acceptable preventive dietary and hy-
gienic practices. Alcohol-based hand sanitizer was used by
32.5% of travellers. One third of travellers declared having
received vaccination against hepatitis A (or to present
protective antibody level) and less than one traveller out
of ten declared having received vaccination against
typhoid fever during the last three years. One fourth of
travellers reported diarrhoea and/or vomiting during
travel (Table 2). None of the demographic and travel
characteristics had any significant influence on the occur-
rence of diarrhoea and/or vomiting (data not shown).
Practice of preventive dietary-hygienic measures did not
influence the prevalence of diarrhoea. By contrast, trav-
ellers who used hand sanitizer reported diarrhoea and
vomiting significantly less frequently than those who did
not (17% vs. 30%, OR Z 0.47; 95% CI [0.21e0.97],
p Z 0.04). Immunization against hepatitis A and typhoid
fever had no significant effect on the occurrence of diar-
rhoea and/or vomiting.
3.2. Travel clinic survey
Among 855 travellers consulting during the study period, a
total of 272 (31.8%) answered the questionnaire, of which
257 (94.5%) answered to all questions and were included in
the analysis (Table 3). The female to male ratio was 0.9
with a mean age of 42 years (range 11e83). Africa, Asia and
South and Central America were prominent travel desti-
nations. Tourism was the main reason for travel followed by
496 D. Henriey et al.

Table 1 Demographics, travel characteristics and pre- Table 1 (continued )

ventive measures among 200 travellers returning from Number of
developing or emerging countries (JanuaryeApril 2012). travellers (%)
Number of Immunization
travellers (%) Hepatitis A 58 (29.0)
Gender Typhoid fever 18 (9.0)
Female 141 (70.5) a
Washing hands before eating, avoiding ice cubes and unsafe
Male 59 (29.5) water, peeling fruits and vegetables, avoiding raw shellfish, fish
Age group (years) and meet.
18e29 28 (14.0)
30e49 66 (33.0)
50e64 70 (35.0) business and humanitarian works. The mean duration of
>65 36 (18.0) travel was 58 days (median: 17 days; range, 3e1100). A
Place of birth majority of travellers knew that hand sanitizer may be used
France 182 (91.0) for hand hygiene and had already used hand sanitizer. Six
Africa 14 (7.0) travelers out of ten had hand sanitizer at home and seven
South America 3 (1.5) out of ten planned to bring hand sanitizer during their next
Southeast Asia 1 (0.5) travel. Willingness to bring hand sanitizer during planned
First travel to developing countries travel was significantly higher among females compare to
No 182 (91.0) males; lower among travellers to Latin America compared
Yes 18 (9.0) to other regions; and lower among individuals travelling for
Traveled area less than 8 days or more than 30 days compared to others
Sub-Saharan Africa 52 (26.0) (Table 4).
North Africa 31 (15.5)
Asia 58 (29.0)
4. Discussion
Caribbean 23 (11.5)
Indian Ocean 15 (7.5)
Central and South America 14 (8.0)
The consent rate in the airport survey was remarkably high,
Middle East 7 (3.5)
which may be due to the fact that travelers were
Reason for travel
approached when they were waiting for a transfer shuttle,
Tourism 124 (62.0)
so that they had time to answer. In this survey, we observed
Visiting friends and relatives 60 (30.0)
a 26% prevalence rate of travellers reporting diarrhoea
Business 9 (4.5)
Missionary 5 (2.5)
Study 2 (1.0) Table 2 Number of travellers reporting diarrhoea and/or
Type of accommodation vomiting according to preventive measures among 200
High standard quality hotel only 95 (47.5) travellers returning from developing or emerging countries
Basic accommodation 105 (52.5) (JanuaryeApril 2012).
Duration of travel (days)
Number of travellers (%) p value
0e7 39 (19.5)
8e15 96 (48.0) All patients 52 (26.0) e
16e30 49 (24.5) Pretravel advice
>30 16 (8.0) Yes 46 (27.2) 0.35
Preetravel advice No 6 (19.4)
Medical advice 111 (55.5) Preventive measures against diarrhoea and/or vomiting
General practitioners 99 (49.5) Compliance with preventive dietary-hygienic measuresa
Travel clinics 14 (7.0) Yes 45 (27.1) 0.43
Other physician 4 (2.0) No 7 (20.6)
Pharmacy 9 (4.5) Use of alcohol hand sanitizer
Media 50 (25.0) Yes 11 (16.9) 0.04
Official website 32 (16.0) No 41 (30.4)
Not official website 15 (7.5) Vaccination against hepatitis A
Guidebooks and press 15 (7.5) Yes 18 (31.0) 0.27
Friends 35 (17.5) No 32 (23.5)
Travel agency 26 (13.0) Vaccination against typhoid fever
No information sought 31 (15.5) Yes 4 (19.0) 0.60
Preventive measures against diarrhoea No 45 (26.5)
Compliance with preventive 166 (83.0) a
Washing hands before eating, avoiding ice cubes and unsafe
dietary-hygienic measuresa water, peeling fruits and vegetables, avoiding raw shellfish, fish
Use of alcohol hand sanitizer 65 (32.5) and meet.
Use of alcohol-based hand gel sanitizer 497

Table 3 Demographics, travel characteristics and knowl- Table 4 Demographics and travel characteristics among
edge, aptitude and practice about hand sanitizer use among 185 travellers seen at a travel clinic November
257 travellers seen at a travel clinic (November 2012ejanuary 2013) and willing to carry hand sanitizer
2012ejanuary 2013). during their next travel.
Number of travellers (%) Number of p value
Gender travellers (%)
Female 120 (46.7) Gender
Male 137 (53.3) Female 95 (79.2) 0.016
Age group (years) Male 90 (65.7)
<18 3 (1.2) Age group (years)
18e29 50 (19.5) 0-29 34 (64.1) 0.13
30e49 120 (46.7) 30-49 83 (69.2)
50e64 61 (23.7) 50-64 50 (82.0)
>65 23 (8.9) >65 18 (78.3)
Destination Destination
Sub-Saharan Africa 141 (54.9) Sub-Saharan Africa 106 (75.2) 0.0005
Asia 64 (24.9) Asia, Oceania and 55 (80.9)
Central and South America 47 (18.3) Middle East
Oceania 2 (0.8) Central and South 24 (50.0)
Middle East 2 (0.8) America, Caribbean
Caribbean 1 (0.4) Reason for travel
Reason for travel Tourism 118 (71.1) 0.66
Tourism 166 (64.6) Other reasons 67 (73.6)
Business 52 (20.2) Duration of travel (days)
Missionary 14 (5.4) 0e7 13 (59.1) 0.038
Visiting friends and relatives 7 (2.7) 8e15 77 (78.6)
Other 18 (7.0) 16e30 53 (74.6)
Duration of travel (days) >30 32 (59.3)
0e7 22 (8.6) Unknown 10 (5.4)
8e15 98 (38.1)
16e30 71 (27.6)
>30 54 (21.0)
Unknown 12 (4.7) hand sanitizer, while the willingness to use hand sanitizer
Do you know that alcoholebased hand gel may be used to was 72% among travellers investigated at our pre-travel
clean hands? clinic for their planned trip. It is however interesting to
Yes 241 (93.8) note that more than 90% of subjects included at the airport
No 16 (6.2) did not consult a pre-travel clinic. Airport travellers
Did you use hand sanitizer before? differed from specialized clinic travellers; notably, they
Yes 226 (87.9) were older, travelled less frequently to Sub-Saharan Africa
No 31 (12.1) and Central and South America and traveled for shorter
Do you have hand sanitizer at the moment? periods of time; which have accounted for the lower pro-
Yes 163 (63.4) portion of hand sanitizer use reported in this group.
No 94 (36.6) We acknowledge that the number of travellers analyzed
Do you plan to carry hand sanitizer during your next in our study was limited and that our results cannot be
travel? extrapolated to all travellers. Nevertheless our study is the
Yes 185 (72.0) first to report an association between hand sanitizer use
No 66 (25.7) and the development of diarrhoea and/or vomiting among
Don’t know 6 (2.3) travellers. Additionally, the use of hand sanitizer was not
quantified specifically. We also showed that use of hand
sanitizer is highly acceptable by travellers. Travellers may
not always have access to soap and clean water and hand
and/or vomiting during their trip which is consistent with sanitizers may be an effective option to prevent the
previous reports [1]. As other authors, we found no asso- development of diseases transmitted through hand contact
ciation between dietary consumption pattern and occur- [11]. The use of hand sanitizer in addition to handwashing
rence of diarrhoea and/or vomiting among travellers with soap has been shown an effective measure against
[5e10]. By contrast, we observed a significant association gastroenteritis among school children [12]. Hand sanitizer
with use of hand sanitizer use and lower rates of gastroin- has also been proven to significantly reduce hand carriage
testinal illness. Travellers who reported using hand sani- of rotavirus [13] and Escherichia coli [14]. Large scale
tizer during their trip were two times less likely to report prospective randomized studies addressing the effective-
diarrhoea and/or vomiting during travel. Interestingly, only ness of hand sanitizer against travellers’ diarrhoea and/or
33% of travellers included at the airport reported using vomiting could be of great interest.
498
Declaration of interests
The authors state that they have no conflicts of interest.
Acknowledgement
The authors thank Dr Shruti Sridhar for editing the
manuscript.
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