In a study today in Emerging Infectious Diseases, Swiss and German researchers found that alcohol-based hand sanitizers recommended by the World Health Organization (WHO) are effective in killing the novel coronavirus.

And a study today in the Annals of Internal Medicine with important COVID-19 ramifications found that 70.2% of 6,512 electronic consultations (e-consults) made by 1,096 referring clinicians to 121 specialists were appropriate.

Commercially available sanitizers kill coronavirus

In the hand sanitizer study, the researchers evaluated the effectiveness of different concentrations of two WHO-recommended and two modified hand sanitizer formulations on COVID-19 virus.

The WHO recommends two formulas: (1) 80% ethanol, 1.45% glycerol, and 0.125% hydrogen peroxide; and (2) 75% 2-propanol, 1.45% glycerol, and 0.125% hydrogen peroxide.

However, these formulations failed to meet the effectiveness requirements of European Norm 1500, which measures how much live bacteria remain on contaminated fingertips after using hand sanitizer. In response, Suchomel and colleagues, who were not involved in today's study, modified the formulations by adding more ethanol or isopropanol and using less glycerol after finding that glycerol reduced their effectiveness.

The modified versions used in this study consisted of (1) 80% ethanol, 0.725% glycerol, and 0.125% hydrogen peroxide; and (2) 75% 2-propanol, 0.725% glycerol, and 0.125% hydrogen peroxide. The Swiss and German researchers also tested dilutions of the alcohols ethanol and 2-propanol, the active ingredients of hand sanitizers on the market.

They tested virus activity after 30 seconds of exposure to the hand sanitizer using a suspension of 1 part virus, 1 part organic material, and 8 parts disinfectant solution in different concentrations.

They found that all sanitizer formulations and dilutions of 40% or more killed the coronavirus and reduced the virus to background levels within 30 seconds. The two WHO formulations had a virus reduction factor of > 3.8, while the modified versions had a reduction factor of ≥5.9.

Both ethanol and 2-propanol reduced virus to background levels in 30 seconds, with reduction factors of 4.8 to ≥5.9, and a concentration of ≥30% of either ingredient was effective in killing SARS-CoV-2, the virus that causes COVID-19.

The findings reveal that the novel coronavirus has an inactivation profile similar to those of related coronaviruses that cause severe acute respiratory syndrome (SARS), bovine coronavirus (BCoV), and Middle East respiratory syndrome (MERS).

The authors noted that while 30 seconds is the recommended time to rub hand sanitizers into the skin and was the time used in this study, most people don't use them for that long. The study findings, however, support use of WHO sanitizer formulations in healthcare settings during viral outbreaks, they said.

"Our findings are crucial to minimize viral transmission and maximize virus inactivation in the current SARS-CoV-2 outbreak," they wrote.

E-consults avoided 81% of in-person visits

In an e-consult, specialists answer questions about patients from referring physicians using either a shared electronic health record or a secure web-based program.

While e-consults can increase patient access to specialists, minimize travel, reduce the time between referral and specialist feedback, and lower unnecessary in-person clinic visits—which is essential during the COVID-19 pandemic—data on their appropriateness and utility have been limited.

The retrospective cohort study involved primary and specialty care practices at two large academic and two community hospitals within a single health system. Participants were doctors who requested an e-consult with a hematologist, infectious disease specialist, dermatologist, rheumatologist, or psychiatrist from Oct 2017 to Nov 2018.

The researchers evaluated appropriateness of the e-consults via medical record review, with appropriateness defined as meeting four criteria: (1) The clinical question could not have been answered by reviewing evidence-based summary sources, (2) The doctor was not asking for only logistical information, (3) the matter was clinically urgent, and (4) the case in question had an appropriate level of complexity.

The utility of e-consults was determined using the rate of avoided face-to-face visits, defined by the lack of such a visit in the same specialty within 120 days.

The requests were described as diagnostic, therapeutic, for clinician education, or at a patient's request. Most requests for an e-consult were answered within 1 day but varied among specialties, at 73.1% for psychiatry and 87.8% for infectious diseases.

Raters had moderate agreement (94%) on the appropriateness of the e-consults. Overall, the rate of avoided visits in the five specialties was 81.2%, with a low of 61.9% in dermatology to a high of 92.6% in psychiatry.

"Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care," the authors said.

Alternatives for high-risk patients

In a commentary in the same journal, Varsha Vimalananda, MD, MPH, and B. Graeme Fincke, MD, of Boston University, call for research on e-consults' effects on quality and cost of care across health systems over time.

"Clinicians, managers, payers, and policymakers need robust information on how e-consults affect wait times, health care use, and costs to effectively leverage them and facilitate high-quality, efficient health care," they said.

Many healthcare systems already offer e-consults. For example, Children's Hospital in New Orleans provides them as a way to address the shortage of pediatric specialists outside of the city, reduce the chance that a patient would otherwise postpone or go without care, and contain healthcare costs.

Other systems are mulling remote consults. For example, in an article published Apr 1 in the New England Journal of Medicine Catalyst, Ateev Mehrotra, MD, of Beth Israel Deaconess Medical Center in Boston and colleagues note that although remote visits are not without challenges, they are a good way to continue patient care when many clinicians are quarantined or caring for children at home.

"Longer-term strategies we are considering include ensuring that our high-risk patients have technologies at home to track vital signs and other data, and increasing use of e-consults (when available) so that clinicians can virtually incorporate input from specialty colleagues," they said.