The Effect of Hand Sanitizer on Urinalysis
Interaction with Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS)
Counterpoint Volume 4; Issue 4 - Article 3
(Originally published in August 2020; Updated September 2021)
Jan Semenoff, BA, EMA
Forensic Criminalist
Many of us have been using a lot of hand sanitizer recently. Given the crisis surrounding the current pandemic, we should be applauded for using a lot of hand sanitizer over the last few months. You put it on when you enter public places like grocery stores or gas stations, and after touching the point of sale payment terminals. You put it on entering your place of work. You probably keep hand sanitizer in your car, in your office, and in your home. The key ingredient in most commercial or medical grade hand sanitizers is ethanol – plain old beverage alcohol, and it comes in with a very high ethanol concentration.
But, how is that hand sanitizer being absorbed and metabolized in your body? Can it be read in body fluid samples? Can false-positive effects occur? The answer, unfortunately, is “Yes”. It has long been declared by the state forensic science authorities that alcohol-based hand sanitizers (ABHS) do NOT create the potential for false positive breath alcohol readings. The assertion is based on the low amount of dermal (skin) absorption of ethanol, given the brief amount of sanitizer, and time, that it is on the subject’s hands. Is this realistic? Is this correct? Unfortunately, Alcohol based hand sanitizers can and do provide false positive breath testing results, under the right conditions.
See the article "Alcohol Based Hand Sanitizers & Breath Alcohol Testing", Counterpoint Volume 5, Issue 4, Article 3.
Urinalysis is also problematic.
See the article "Alcohol Based Hand Sanitizers & Breath Alcohol Testing", Counterpoint Volume 5, Issue 4, Article 3.
Urinalysis is also problematic.
Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS)
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Your client can provide a urine sample that can be analyzed for the presence and concentration of two metabolites of ethanol consumption – Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS).
Ethyl Glucuronide (C8H14O7 or ethyl ß-D-6-Glururonide) is a metabolite of ethanol, produced following a metabolic process (called glucuronidation) that occurs in the liver. EtG can be found in whole blood, blood plasma, urine and other bodily fluid samples.
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It is used as a biomarker to test for the past presence of ethanol in situations where absolute abstinence from beverage alcohol is necessary, i.e. – military personnel, commercial pilots, health care professionals or following alcohol treatment programs, and of course, situations involving probation, and conditional or early release.
It is used as a biomarker to test for the past presence of ethanol in situations where absolute abstinence from beverage alcohol is necessary, i.e. – military personnel, commercial pilots, health care professionals or following alcohol treatment programs, and of course, situations involving probation, and conditional or early release.
Figure 1 - The chemical structure of Ethyl Glucuronide (EtG)
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The advantage of EtG monitoring is that it can be used to establish ethanol usage over time, as it has a longer detection window than testing for ethanol alone. It can be detected not only in blood plasma or urine, but in the hair and nails (keratin) of the test subject.
The effectiveness of keratin testing as a monitoring platform has not been firmly established. Indeed, due to many lawsuits where keratin analysis has been carried out incorrectly in the past, few laboratories are offering this sort of evaluation. In fact, many agencies outright reject this sort of keratin testing. See the call-out box below... |
Time window for ethanol measurements by sample type
Ethanol is chemically volatile (meaning it evaporates at room temperature) and also considered a fugitive substance, in the sense that it stays in the human body for only so long before it is either metabolized or eliminated completely. As a rough rule of thumb, ethanol is present and can be measured in various body mediums as follows:
Table 1 - Data from: Walsham, N., and Sherwood, R., “Ethyl Glucuronide” Annals of Clinical Biochemistry, 2012 49: 110-117.
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Urinalysis can provide another way of measuring the ethanol in the system directly, or indirectly by measuring the metabolite, EtG. But it is fraught with errors, with both false-positive and false-negative results. Its use should be considered instructive at best, and not definitive.
Urinalysis can provide another way of measuring the ethanol in the system directly, or indirectly by measuring the metabolite, EtG. But it is fraught with errors, with both false-positive and false-negative results. Its use should be considered instructive at best, and not definitive.
EtG Hair and Nail (Keratin) Testing Under Scrutiny
The U.S. Substance Abuse and Mental Health Services Administration has issued an advisory warning against using a positive EtG result as primary or sole evidence of drinking. They write that the EtG hair and nail test is "scientifically unsupportable as the sole basis for legal or disciplinary action" because the highly sensitive tests "are not able to distinguish between alcohol absorbed into the body from exposure to many common commercial and household products containing alcohol and from the actual consumption of alcohol." (Center for Substance Abuse Treatment, 2006)
The U.S. Substance Abuse and Mental Health Services Administration has issued an advisory warning against using a positive EtG result as primary or sole evidence of drinking. They write that the EtG hair and nail test is "scientifically unsupportable as the sole basis for legal or disciplinary action" because the highly sensitive tests "are not able to distinguish between alcohol absorbed into the body from exposure to many common commercial and household products containing alcohol and from the actual consumption of alcohol." (Center for Substance Abuse Treatment, 2006)
It has been well established that EtG and EtS levels can be detected in urine samples anywhere from a number of hours to a number of days after the ethanol has been metabolized and can no longer be detected or empirically measured. Keep in mind that ethanol can only be measured in body fluid samples for less than 24 hours after completion of ingestion, even following fairly heavy consumption episodes. This is why EtG and EtS readings are of use in forensic applications. Since EtG produces higher readings than EtS levels, and fall along a different metabolic pathway, the readings are reported concurrently in order to establish reliability and specificity towards ethanol.
The disadvantage of EtG testing is that false positives are possible, and have been well documented, after exposure either incidentally, or from non-beverage exposure, such as hand sanitizers. It has been identified that exposure to mouthwash, fermenting foods, over-the-counter medications and dermal exposure to hand sanitizers have all resulted in false positive reported readings. Because the EtG levels can be detected in such small amounts, it is impossible to distinguish its presence between ethanol consumption and extraneous exposure to ethanol from other sources of contamination.
Sources of contamination
British researchers report that EtG is relatively stable in urine samples, but both false-positive and false-negative results have been reported in urine arising from bacterial contamination, particularly when samples are contaminated with E. coli. Keep in mind that E. coli is very common in urinary tract infections. This is another reason why EtG and EtS samples should be analyzed concurrently, as EtS is unaffected by E. coli contamination (Walsham & Sherwood, 2012).
EtG levels are generally considered highly indicative of recent consumption of ethanol. It has been long established that EtG levels greater than 1000 ng/mL are considered an indicator of “heavy” consumption within the previous day or so (Shukla and Sharma, 2017).
I had a recent case where the defendant’s urinalysis reported an EtG value at more than five times that level (5272 ng/mL). This would seem to indicate consumption of more than five times a “heavy” drinking period. Is this even possible, or are we getting into the range of alcohol toxicity? The concentration of the EtG and EtS readings themselves gives rise to the probability of contamination by ethanol other than beverage ethanol.
Yale University School of Medicine researchers report that exposure to hand sanitizer can cause false-positive EtG readings.
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False positive EtG reports following use of ethanol containing hand sanitizers have received more publicity. Compared to commercially available mouth washes, hand sanitizers have about three times the ethanol concentration, and, as used, are in contact with a much larger absorptive service area. Thus, they can be expected to be more problematic. Anecdotal reports in the newspapers (Helliker, 2006) and on the internet have described instances wherein health care workers exposed to hand sanitizers, but who denied consumption of alcoholic beverages, have lost their jobs on the basis of positive EtG tests, and a level as high as 770 ng/mL has been described following repeated exposure throughout the day. The possibility of concentrations as high as 1500 ng/mL following incidental exposure to hand sanitizers has been postulated (Skipper and Helliker, 2006).
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Italian researchers Salomone et al (2018), from the University of Turin write that,
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In conclusion, the regular use of alcohol-based hand sanitizers can affect the concentration of urinary EtG and lead to positive analytical results, particularly when specimens are obtained shortly after sustained use of ethanol-containing hand sanitizer.
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And while not close to our 5000+ ng/mL level, researchers from the University of Florida, conclude:
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Intensive exposure to ethanol-containing hand sanitizer can produce urinary EtG concentrations in excess of 2000 ng/mL. or a two- to fourfold greater than commonly accepted threshold concentrations used to identify ethanol consumption. False accusations of ethanol consumption can have catastrophic consequences for individuals being monitored in programs that require abstinence (Reisfield et al, 2011).
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Walsham & Sherwood additionally report:
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It has also been demonstrated that detectable concentrations of EtG can be generated using alcohol-containing hand sanitizer gels. These products can contain 60–65% ethanol by weight, and when used eight times over an eight-hour period, subjects achieved urine EtG and EtS concentrations up to 103 and 51 µg/L*, respectively. A more intensive regimen in which 11 volunteers cleansed their hands with a sanitizer (62% ethanol) every five minutes for 10 h on three consecutive days showed that EtG and EtS could be detected (maximum concentration 2001 and 84 µg/L, respectively) at the end of the study day, but only two specimens had detectable EtG the next morning (96 and 139 µg/L) and only one detectable EtS (64 µg/L) (Walsham & Sherwood, 2012).
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Practice Tip - Watch the units being represented in various papers: |
The possibility that the EtG and EtS levels are present due to repeated, multi-day, frequent and copious use of hand sanitizers cannot be excluded. Keep in mind that the hand-sanitizers being recommended to combat SARS-CoV-2 and COVID-19 contain 60-80% of ethanol by volume, higher than even normal commercially available hand sanitizers than come in at around the 60% concentration. The fact that measured urinary EtG and EtS levels can be reported at levels so incredibly high suggest the possibility of a source other than normal consumption of beverage alcohol under certain circumstances.
That being said, pass the hand sanitizer...
Send me your questions or comments:
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For further study:
- Center for Substance Abuse Treatment. "The Role of Biomarkers in the Treatment of Alcohol Use Disorders. Substance Abuse Treatment Advisory". Volume 5, Issue 4, 2006.
- Helander, A., Bottcher, M., et al, “Detection Times for Urinary Ethyl Glucuronide and Ethyl Sulfate in Heavy Drinkers During Alcohol Detoxification”, Alcohol & Alcoholism, Volume 44, No. 1, pp. 55-61, 2009.
- Jatlow, P. and O’Malley, S., “Clinical (Non-forensic) Application of Ethyl Glucuronide Measurement: Are We Ready?”, Alcohol Clin Exp Res. 2010 June; 34(6): 968-975.
- Jones, J., Jones, M., Plate, C., and Lewis, D. “Ethyl Glucuronide and Ethyl Sulfate Concentrations Following Use of Ethanol Containing Mouthwash”. United States Drug Testing Laboratories Research Monograph, 2006. 2006; 1:1–4.
- Reisfield, Gary & Goldberger, et al, “Ethyl Glucuronide, Ethyl Sulfate, and Ethanol in Urine after Sustained Exposure to an Ethanol-Based Hand Sanitizer”. Journal of Analytical Toxicology. (2011) 35. 85-91.
- Salomone, A., et al, “Occupational Exposure to Alcohol-Based Hand Sanitizers: The Diagnostic Role of Alcohol Biomarkers in Hair”, Journal of Analytical Toxicology, Volume 42, Issue 3, April 2018, Pages 157-162.
- Shukla, L., Sharma, P, et al, “Value of Ethyl Glucuronide and Ethyl Sulfate in Serum as Biomarkers of Alcohol Consumption”, Indian J. Psychol Med., 2017 Jul-Aug; 39(4): 481-487.
- Skipper, G. E., Wurst, F., Weinmann, W., and Liepman, M., “Ethanol-Based Hand Sanitizing Gel Vapor Causes Positive Alcohol Marker, Ethylglucuronide, and Positive Breathalyzer”, J. Addict. Med, Volume 3, Number 2, June 2009.
- Walsham, N., and Sherwood, R., “Ethyl Glucuronide” Annals of Clinical Biochemistry, 2012 49: 110-117.
