IODINE AND ENDEMIC GOITER

THYROID
Volume 23, Number 3, 2013
Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2012.0325

The Effect of Scrubbing Hands

with Iodine-Containing Solutions on
Urinary Iodine Concentrations of the Operating Room Staff
nluturk,1 Necat Cin,2 and Ali Rza Uysal1
1 Fatma Atalay Tatar,2 Ugur
U
Murat Faik Erdogan,

Background: Excessive iodine exposure is associated with thyroid dysfunction and thyroid autoimmunity. Most
surgical hand-scrub solutions contain large amounts of iodine, and transcutaneous and mucosal absorption of
iodine from these antiseptic solutions has been demonstrated. In this study we determined the effect of hand
scrubbing with iodine-containing surgical hand-scrub solutions on urinary iodine concentrations (UICs) in
operating room staff.
Methods: The study included 117 surgeons and surgical nurses from two different hospitals who often used
surgical hand-scrub solutions as the iodine exposure group and 92 age-matched hospital staff from nonsurgical
units of the same hospitals as the controls. In the iodine exposure group, 39 subjects (from hospital 1) used
iodine-containing hand scrub solutions intermittently, and the remaining 78 in the surgical staff (from hospital 2)
used only iodine-containing hand-scrub solutions. Morning spot urine specimens were collected from all participants for the analysis of UIC.
Results: The operating room staff had significantly higher UICs compared to the control group (142 lg/L [12
822 lg/L] vs. 89 lg/L [10429 lg/L], p < 0.001). UICs from 39% of the subjects from hospital 2 were found to
reach levels higher than 300 lg/L.
Conclusion: Scrubbing with iodine-containing solutions might lead to iodine excess among surgical staff. Further
studies investigating the effects of hand scrubbing with iodine-containing products on thyroid function and on
thyroid antibodies of the operating room staff are needed to determine the consequences of this high iodine
exposure.

Introduction

odine is one of the most important essential elements for

humans and is necessary for all living plant and animal
cells (1). In general, a daily intake of 150 lg iodine is required
for thyroid hormone synthesis in adults (2). However, epidemiological data demonstrate that many adults in iodine-sufficient areas, such as in North America, can consume as much as
500 lg/d of iodine (3). The main causes of excessive iodine exposure are related to iodine having many uses in industry. It is a
major constituent of certain food preservatives and supplements, medications, vitamin preparations, and disinfectants.
One of the most important uses of iodine is as a disinfectant
in skin soaps. Notably some surgical hand-scrub solutions,
which are considered to be safe antiseptics, contain large
amounts of iodine and are commonly used as broad-spectrum
topical disinfectants (4). Transcutaneous absorption of remarkable amounts of iodine from these antiseptic solutions
has been demonstrated in patients with burn wounds. This
1
2

has also been noted in infants, possibly related to their thin

and therefore more permeable skin (5,6). In animal experiments, transcutaneous absorption of povidone-iodine, a type
of iodine-rich antiseptic solution, from healthy skin has also
been reported (7). Additionally, exposure to povidone-iodine
via the skin or umbilical cord of preterm infants can lead to
elevated plasma iodine levels, and consequently increased
urine iodine levels and thyroid dysfunction (8,9). In contrast,
similar studies conducted in North America have not shown
any thyroid dysfunction despite elevated iodine levels in the
urine of preterm infants indicating high exposure (10,11).
With regard to transcutaneous iodine absorption in healthy
adults, only a few cases or limited studies have been performed (1214). The skin of healthy adults should be less
permeable that that of neonates or preterm infants. Among
healthy adults, some of the occupations that involve iodine
exposure are those in operating rooms for which hand
scrubbing is done with iodine-containing solutions. As of yet,
there has been no study of the effect of hand scrubbing with

Department of Endocrinology and Metabolism, Ankara University School of Medicine, Ankara, Turkey.
_
Department of General Surgery, Ataturk Training and Research Hospital, Izmir,
Turkey.

342

THE EFFECT OF SCRUBBING HANDS ON IODINE STATUS

such solutions on the urinary iodine concentrations (UICs) of
surgeons and other operating room staff. In the present crosssectional double-center study, we determined the effects of
hand scrubbing with iodine-containing antiseptics on the UIC
of operating room staff. The study was performed in a region
of mild to moderate iodine deficiency.

343

urinary iodine concentrations were evaluated by Kruskal

Wallis variance analysis. When the p-value from the Kruskal
Wallis test statistics was significant, a multiple comparison
test was used to determine the groups that differed from each
other. A p < 0.05 was considered as statistically significant.
Analyses were carried out using the SPSS software version
15.0 (SPSS, Chicago, IL).

Materials and Methods

The study involved 117 operating room staff from two
different tertiary care hospitals (mean age 35 8.6 years, 37
women and 80 men) who used iodine-containing surgical
hand antiseptics (iodine exposure group) and 92 age-matched
hospital staff (mean age 33 9.5, 33 women and 84 men) from
nonsurgical units who did not have any exposure to iodinecontaining hand-scrub solutions. The volume of operations in
hospital 1 and hospital 2 was similar, with an average number
of operations under general anesthesia of about 25,000 cases/
year. In the iodine exposure group, 39 subjects (from hospital
1) used iodine-containing hand-scrub solutions intermittently
(they used hand scrubs with or without iodine randomly) and
the remaining 78 surgical staff (from hospital 2) used only
iodine-containing hand-scrub solutions (povidone-iodine
products). In the iodine exposure group, the subjects scrubbed
up to the elbow joint for at least for 5 minutes to standardize
the iodine effect. All of the participants had actively participated in operations for at least the previous 2 weeks. Subjects
with a history of iodine exposure, including having had any
involvement with interventions using iodine-containing
contrast agents or a history of thyroidal diseases, were excluded from the study. Morning spot urine specimens were
collected from all participants for the analysis of UIC on
Fridays. Informed consent was obtained from each subject in
the study. Urine samples were kept at 4C in deionized tubes
and analyzed within 30 days after the collection. UICs were
determined using the method recommended by the World
Health OrganizationInternational Council for the Control of
Iodine Deficiency Disorders (WHO-ICCIDD); specifically, the
calorimetric ceric ion arsenous acid wet ash method based on
the SandellKolthoff reaction, using Fisher reagents (Spectrum Chemicals and Laboratory Products, Gardena, CA) and
a spectronic 20 (Thermo Scientific Instruments Group, Madison, WI) and Genesis autoanalyzer (McKinley Scientific,
Sparta, NJ) (15) in our iodine laboratory controlled by the
Ensuring the Quality of Urinary Iodine Procedures (EQUIP)
program of the Centers for Disease Control and Prevention.

Results

Statistical analysis

FIG. 1. The median values of urinary iodine concentrations

(UICs) of operating room staff from hospital 1 and hospital 2
had significantly higher levels compared to the control group
(see Table 1).

All parameters are shown as the median and the interquartile ranges (IQRs). Differences among three groups for

Demographic data and UIC levels of the study subjects are

summarized in Figure 1 and Table 1. The median values of
UIC of operating room staff from hospital 1 (126 lg/L [IQR
98155]) and hospital 2 (166 lg/L [IQR 128410]) were significantly higher compared to the control group (89 lg/L
[IQR 42139], p < 0.017 and p < 0.001, respectively; Table 1).
When subjects from both hospitals were analyzed together,
the median UIC (142 lg/L [IQR 114347]) was significantly
higher compared to the control group ( p < 0.001). The median
values of UIC of operating room staff from hospital 2 had
significantly higher levels compared with hospital 1 (166 lg/L
[IQR 128410] vs. 126 lg/L [IQR 98155], p < 0.001) as well.
UIC levels from 39% (30/78) of the subjects, involving eight
cardiothoracic surgeons, seven nurses, five general surgeons,
four urologists, two gynecologists, two neurosurgeons, and

Table 1. Median Values of Urinary Iodine Concentrations of Operating Room Staff

from Hospital 1, Hospital 2, and Control Group
Group
HSG from hospital 1
HSG from hospital 2
HSG (total)
Control

N, total (F/M)
39
78
117
92

(13/26)
(24/54)
(33/84)
(50/42)

Age (years), mean SD

32 6.5
33 9.3
32 8.6
31 9.5

UIC (lg/L), median (IQR 25th75th)

126
166
142
89

(98155)
(128410)
(114347)
(42139)

p-Valuea
0.017
< 0.001
< 0.001

a
Compared to the control group.
F, female; M, male; UIC, urinary iodine concentration; SD, standard deviation; IQR, interquartile range; HSG, hand-scrubbing group.

 AN ET AL.
ERDOG

344
two orthopedic surgeons in the iodine exposure group from
hospital 2, were found to be >300 lg/L. One of the neurosurgeons from hospital 1 had a UIC >300 lg/L.
Discussion
In this cross-sectional double-center study, we demonstrated for the first time that the operating room staff can have
significantly higher levels of UIC compared with the staff
from nonsurgical units. In nearly 40% of the staff using solely
the iodine-containing scrub solutions, UICs were >300 lg/L.
According to WHO-ICCIDD, a median urinary iodine level
>300 lg/L indicates excessive iodine intake for a surveyed
population and can be associated with adverse health consequences. However, the upper limit for iodine intake is not well
defined on an individual basis (16).
Povidone-iodine is widely used as a topical antiseptic for
mucosa, skin, and surgical procedures. Topical preparations
of povidone-iodine contain 8% to 12% iodine (17). Elevated
serum or urine iodine levels have been reported in patients
with skin burns (5,18), neonates (19), infants (6), and patients
with pressure wounds (2022), who were treated with povidone-iodine. It was previously accepted that adult skin
is much less permeable and therefore, transcutaneous absorption of iodine might be ignored. However, Tomoda et al.
(13) demonstrated in iodine-sufficient regions that the UIC of
postsurgical patients, whose skin was prepared only once
using povidone-iodine, was markedly increased compared to
the preoperative UIC. It has also been shown that acute exposure to povidone-iodine preoperatively in infants from
endemic iodine-deficient regions and to nonionic contrasts in
some procedures such as radiography can cause thyroid
dysfunction (6,23). In the present study, the median UIC of the
control group was 89 lg/L, a value that is below an optimal
UIC (> 100 lg/L). Moreover, we demonstrated in a recent
study that the median UIC of the Turkish population was
107 lg/L after iodine prophylaxis; however 50% of the population still experienced various degrees of iodine deficiency
(severe iodine deficiency in 7.2% of the population, moderate
in 20.6%, and mild in 19.3%) (24).
The major aim of this study was to assess UIC in seldom,
repetitive, and continuous users of iodine-containing antiseptics. We found that repetitive povidone-iodine use
among the operating-room staff may cause excessive iodine
exposure by transcutaneous absorption. A similar study was
conducted with a limited number of nonsurgical ward nurses, who had to use povidone-iodine products for hand
washing and gargling several times a day in Japan (14).
Although it was demonstrated that the serum levels of iodine did not significantly increase in the group using povidone-iodine, the mean serum-free thyroxine levels were
slightly, but significantly, higher compared to the controls.
However, this study included only a small group of nurses,
and the mucosal or cutaneous exposure time to the povidone-iodine products were probably shorter compared to
operating room staff. The operating room staff might also be
exposed to more gaseous forms of iodine because of the
large number of people using hand scrubs within the same
time-frame and in the same scrubbing sinks, in addition to
the topical, preoperatively applied povidone-iodine on
patients in the operating rooms. Interestingly, besides the
repetitive use of povidone-iodine, residual effects of iodine-

based disinfectants have also been demonstrated after the

solution is removed by rinsing the skin with water. These
effects were mostly due to the retention of the agents in the
skin surface (25).
Although the individual participants were questioned
whether they had any thyroid disorders, a limitation of the
study is that thyroid function tests were not done.
A recent study suggested that on an individual basis, more
than 10 urine samples are needed to evaluate iodine excretion
correctly (26). Another study reported that a transient increase
in urinary iodine levels was followed by a return to basal
values on the third or fifth day after a single topical application of povidone-iodine (13). In the present study, as other
limiting factors, UIC measurements of the study subjects were
not repeated and urine creatinine levels were not measured.
Nevertheless, the urine specimens were collected only on
Fridays in order to detect the change of UIC, and this method
was consistent with findings of the latter study (13).
In conclusion, it was demonstrated for the first time in this
study that operating room staff using iodine-containing surgical hand antiseptics are exposed to significantly higher
levels of iodine compared to the staff from nonsurgical units.
Furthermore, approximately 40% of all operating room staff,
especially those using iodine-containing solutions continuously, were exposed to iodine levels that exceeded the recommended daily intake. Further studies investigating the
effects of hand scrubbing with iodine-containing products on
thyroid function and thyroid antibodies in the operating room
staff are needed to clarify the issue.
Author Disclosure Statement
The authors declare that no competing financial interests
exist.
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Address correspondence to:

nluturk, MD
Ugur U
Department of Endocrinology and Metabolism
Ibn-i Sina Hospital
Ankara University School of Medicine
06100 Ankara
Turkey
E-mail: ugurunluturk@gmail.com

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