Vol:.(1234567890) Environmental Science and Pollution Research (2023) 30:72368–72388 https://doi.org/10.1007/s11356-023-27197-6 1 3 RESEARCH ARTICLE A comprehensive health effects assessment of the use of sanitizers and disinfectants during COVID‑19 pandemic: a global survey Fallah Hashemi1 · Lori Hoepner2 · Farahnaz Soleimani Hamidinejad3,4 · Daniela Haluza5 · Sima Afrashteh6 · Alireza Abbasi1 · Elma Omeragić7 · Belma Imamović7 · Narin A. Rasheed8 · Taqi M. J. Taher9 · Fitri Kurniasari10 · Dhuha Youssef Wazqar11 · Özge Ceren Apalı12 · Ayca Demir Yildirim13 · Bo Zhao14 · Zaruhi Kalikyan15 · Cui Guo16 · Andrea Chong Valbuena17 · Magdalena Mititelu18 · Carolina Martínez Pando19 · Maria Saridi20 · Aikaterini Toska20 · Magalys Lopez Cuba21 · Precious Kwablah Kwadzokpui22 · Niguse Tadele23 · Tohfa Nasibova24 · Stefanie Harsch25 · Luvsan Munkh‑Erdene26 · Wafaa Menawi27 · Efi Evangelou28 · Antoniya Dimova29 · Dimitar Marinov30 · Teodora Dimitrova30 · Anna Shalimova31 · Howieda Fouly32 · Anna Suraya33,34 · Juliana Pereira da Silva Faquim35 · Bouadil Oumayma36 · Maria Antonieta Annunziato37 · Rezarta Lalo38 · Evridiki Papastavrou39 · Anju D. Ade40 · Susanna Caminada41 · Svetlana Stojkov42 · Carmen Gloria Narvaez43 · Lutendo Sylvia Mudau44 · Ines Rassas45 · Daphnee Michel46 · Nur Sema Kaynar47 · Sehar Iqbal48 · Halla Elshwekh49 · Irin Hossain50 · Sadeq AL‑Fayyadh51 · Aniuta Sydorchuk52 · Dua’a M. H. Alnusairat53 · Asli Mohamed Abdullahi54 · Neelam Iqbal55 · Apsara Pandey56 · Brenda Gómez‑Gómez57 · Aysenur Gunaydin Akyildiz58 · Elena Morosan18 · Daniella Dwarica59 · Gantuya Dorj60 · Sumaya Yusuf Hasan61 · Noha M. Al‑Shdayfat62 · Bojana Knezevic63 · Wendy Valladares64 · Cecilia Severi65 · Sofia Cuba Fuentes66 · Sofia Augusto67 · Elizaveta Sidorova68 · Anita Dewi Moelyaningrum69 · Tafaul Alawad70 · Atiqa Khalid71 · Nafisa M. K. Elehamer72 · Anna Mihaylova73 · Oxana Tsigengagel74 · Aziza Menouni75 · Agnieszka Wojtecka76 · Rozita Hod77 · Yusuf Banke Idayat78 · Khadija Othman79 · Rim M. Harfouch80 · Tsonco Paunov30 · Meruyert Omar81 · Nana Christine Benderli82,83 · Globila Nurika69 · Sana Amjad84 · Salma Elnoamany85 · Fatma Elesrigy85 · Marwa Mamdouh Shaban86 · Doménica Acevedo‑López87 · Maria Kartashova88 · Atika Khalaf89,90 · Sabah Abdullah Jaafar91 · Taisir A. Kadhim91 · Nada Ab Hweissa92 · Yulong Teng93 · Fatima E. Mohammed94 · Thayahlini Sasikumar95 · Christabel Nangandu Hikaambo96 · Aditi Kharat97 · Ulyana Lyamtseva98 · Maya Arfan Aldeeb99,100 · Natalia Pawlas101 · Lkhagvasuren Khorolsuren102 · Roopeshwaree Pallavi Koonjul103 · Halima Boubacar Maïnassara104 · Priyanka Chahal105 · Rose W. Wangeci106 · Ainur B. Kumar107 · Irina Zamora‑Corrales108 · Stella Gracy109 · Maimouna Mahamat110 · Jakub Adamczyk111 · Haliza Abdul Rahman112 · Lolita Matiashova113 · Omneya Ezzat Elsherif114 · Nazdar E. Alkhateeb115 · Yamilé Aleaga116 · Shima Bahrami117 · Shaimaa Rahem Al‑salihy118 · Paula Cabrera‑Galeana119 · Mladena Lalic‑Popovic120 · Eugenie Brown‑Myrie121 · Divya Bhandari122 · Cinderella Akbar Mayaboti123 · Svetlana Stanišić124 · Sanda Kreitmayer Pestic125 · Muhammed Yunus Bektay126 · Haleama Al Sabbah127 · Saber Hashemi128 · Bouchetara Assia129 · Anne‑Sophie Merritt130 · Zhian Ramzi131 · Himawatee Baboolal132 · Juman Isstaif133 · Rula Shami134 · Rahma Saad135 · Temwanani Nyirongo136 · Mohammad Hoseini137,138  Received: 21 November 2022 / Accepted: 19 April 2023 / Published online: 11 May 2023 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023 Abstract COVID-19 has affected all aspects of human life so far. From the outset of the pandemic, preventing the spread of COVID- 19 through the observance of health protocols, especially the use of sanitizers and disinfectants was given more attention. Despite the effectiveness of disinfection chemicals in controlling and preventing COVID-19, there are critical concerns about their adverse effects on human health. This study aims to assess the health effects of sanitizers and disinfectants on a global scale. A total of 91,056 participants from 154 countries participated in this cross-sectional study. Information on the use of sanitizers and disinfectants and health was collected using an electronic questionnaire, which was translated into 26 Responsible Editor: Philippe Garrigues Extended author information available on the last page of the article http://orcid.org/0000-0001-5180-3047 http://crossmark.crossref.org/dialog/?doi=10.1007/s11356-023-27197-6&domain=pdf 72369Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 languages via web-based platforms. The findings of this study suggest that detergents, alcohol-based substances, and chlo- rinated compounds emerged as the most prevalent chemical agents compared to other sanitizers and disinfectants examined. Most frequently reported health issues include skin effects and respiratory effects. The Chi-square test showed a significant association between chlorinated compounds (sodium hypochlorite and per-chlorine) with all possible health effects under investigation (p-value <0.001). Examination of risk factors based on multivariate logistic regression analysis showed that alcohols and alcohols-based materials were associated with skin effects (OR, 1.98; 95%CI, 1.87–2.09), per-chlorine was associated with eye effects (OR, 1.83; 95%CI, 1.74–1.93), and highly likely with itching and throat irritation (OR, 2.00; 95%CI, 1.90–2.11). Furthermore, formaldehyde was associated with a higher prevalence of neurological effects (OR, 2.17; 95%CI, 1.92–2.44). Furthermore, formaldehyde was associated with a higher prevalence of neurological effects (OR, 2.17; 95%CI, 1.92–2.44). The use of sodium hypochlorite and per-chlorine also had a high chance of having respiratory effects. The findings of the current study suggest that health authorities need to implement more awareness programs about the side effects of using sanitizers and disinfectants during viral epidemics especially when they are used or overused. Keywords  COVID-19 · Sanitizers and disinfectants · Side effects · Health protocols Introduction COVID-19 is one of the great challenges to human health. According to the report of the World Health Organization, by November 16, 2022, 548 million people were infected and more than 6 million deaths worldwide had occurred (WHO, 2022). The emergence of new and mutated strains of the virus over time and the production of less effective vaccines have exacerbated this catastrophic health challenge (Hashemi et al., 2022b; Viveiros-Rosa et al., 2022). From the beginning of the COVID-19 outbreak, simultaneously with treatment measures, health and preventive measures such as strict quarantine, social distancing, hand washing, disinfection of various surfaces, and wearing a mask among others, as health protocols to reduce and cut off the transmis- sion chain were on the agenda of governments and health organizations (Alimohamadi et al., 2022a; Amanollahi et al., 2021; Hashemi et al., 2022b; Sharun et al., 2022). With the hypothesis of the persistence of the virus on different sur- faces and its transmission through skin contact, personal and public hygiene by hand washing and disinfection of differ- ent surfaces became more important. Among the various surfaces with the most frequent contact were door handles, smartphones, remote controls, keyboards, tables and chairs, light switches, and elevator buttons, etc. (Al-Sayah, 2020; Ghafoor et al., 2021; Jin et al., 2020; Yari et al., 2020). The literature shows that SARS-CoV-2 can float in the air for 3 h, on smooth surfaces (glass, plastic, banknotes) for 4 to 7 days, on the outer layer of the surgical mask for up to 7 days, on copper surfaces, cardboard, and paper for less than 3 h and stainless steel up to 72 h (Chin et al., 2020; Dhama et al., 2021; Doremalen et al., 2020). The shelf life of the virus depends on various factors such as temperature, rela- tive humidity, and pressure (Dindarloo et al., 2020; Ghare- hchahi et al., 2023; Kampf, 2020). To reduce the spread of the virus and disrupt the transmission chain, disinfection using sanitizers and disinfectants for living and non-living surfaces as an efficient method was recommended by the World Health Organization (WHO) and the US Environmen- tal Protection Agency in accordance with the issued instruc- tions (Chen et al., 2021; Dindarloo et al., 2020). Sanitizers and disinfectants used include alcohol-based materials, oxi- dizing agents, detergents, chlorine-releasing agents (sodium hypochlorite, per-chlorine), phenol-based disinfectants, iodine-releasing agents, aldehydes, hydrogen peroxide, and quaternary ammonium compounds, etc. (Al-Sayah, 2020; McDonnell and Russell, 1999; Rutala and Weber, 2019). Using sanitizers and disinfectants may have adverse effects on human health, mainly because of the harmful and cor- rosive compounds in the composition of most sanitizers and disinfectants, such as chlorine-releasing agents, quaternary ammonium cations, or oxidizing agents (Bonin et al., 2020; Dumas et al., 2019; Emmanuel et al., 2004; Nabi et al., 2020; Rafiee et al., 2022). The severity of these side effects may vary depending on the type of chemicals, their target objects (living or non-living surfaces), the frequency and volume of the chemicals, and the risk status of the exposed individual (Prajapati et al., 2022). Lack of knowledge and insufficient experience in sanitizer and disinfectant use increases the rate of side effects due to the use of these chemicals (Gharpure et al., 2020; Rai et al., 2020). Potential acute side effects of using sanitizers and disinfectants include skin effects, itch- ing, sore throat, eyes, and nose irritation, and ailments of the respiratory system (cough, sneezing, shortness of breath). Neurological effects such as headache, dizziness, and vomit- ing have been also reported (ECDC, 2020; Goh et al., 2021; Lachenmeier, 2008). Regardless of the sanitizer and disin- fectant safety information and application instructions pro- longed use of these products may cause chronic side effects including disorders of the central nervous system (CNS), 72370 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 reproductive disorders, cancer, pulmonary obstruction, etc. (Choi et al., 2020). Although several studies have been con- ducted regionally in a variety of countries on some of the adverse health effects due to disinfectant use (Dawood et al., 2021; Dhama et al., 2021; Dindarloo et al., 2020; Ghafoor et al., 2021; Rosenman et al., 2021; Shah et al., 2021), the present study is a comprehensive survey aimed to estimate the health effects associated with the use of sanitizers and disinfectants among the general population on a global scale. Methods Design, participants, and sampling procedure This study aims to assess the health effects of sanitizers and disinfectants on a global scale. There were no exclusion/ inclusion criteria for participation in the study, and all indi- viduals regardless of race, gender, occupation, and income level were included. The research project was approved by the ethics committee of Shiraz University of Medi- cal Sciences (IR.SUMS.REC.1400.023). This study fol- lows the principles of the Declaration of Helsinki. Survey design (non-interventional) is not considered a clinical trial under Directive 2001/20/EC and Regulation (Europe) No 536/2014. All participants provided online informed consent before the study. Measurement tools Questionnaire The questionnaire was translated into 26 different languages by native language speakers. The questionnaire included three parts (including 26 items). The first part (7 questions) was referring to demographic information including age, gen- der, educational and occupational status, country, place of residence, and income level. The second part (6 questions) included the type, monthly usage volume, and the number of daily use of sanitizers and disinfectants for living and non- living surfaces. The chemicals which have been investigated included detergents (soap and toilet liquid, dishwashing liq- uid), alcohol or alcohol-based materials, hospital-grade sani- tizers (savlon; antiseptic liquid), other commercial sanitiz- ers (chlorhexidine gluconate, bronopol, triclosan), hospital disinfectants (quaternary ammonium, tetra-acetyl ethylen- ediamine), chlorine-based compounds (sodium hypochlorite, per-chlorine), hydrogen peroxide, and formaldehyde. The third part (13 questions) included health effects. Skin effects (itch- ing and skin irritation, dryness, scaling, and urticaria), ocular (itching and eye irritation, and redness), irritation and itching of the throat, respiratory problems (itching and nasal irritation, runny nose, cough and sneezing, and shortness of breath), and neurological effects (headache, dizziness, and vomiting) were questioned. Questionnaire-related questions and options were reviewed by several specialists, including a dermatologist, oto- laryngologist, ophthalmologist, pulmonologist, and chemist, as well as a biostatistics specialist. Reliability and validity The reliability of the questionnaire showed good internal consistency (Cronbach’s alpha = 0.90). The validity of the questionnaire for only seven living languages (Arabic, English, French, German, Persian, Russian, and Spanish) which are considered official or secondary languages of several coun- tries, was reviewed by 5 to 7 experts in each of the 7 languages with research backgrounds related and faculty members. These experts assessed the validity in light of five components of necessity, relevance, transparency, simplicity, and ambiguity related to each question. Data collection procedure The questionnaire was designed using Google Form®. In some countries (e.g., China), lack of access to Google or due to poor bandwidth, other internal platforms (e.g., wenjuanxing) and sites (e.g.; https://​www.​wjx.​cn/) were used to create online links to the questionnaire. The questionnaire was distributed via email or social networks such as Telegram, WhatsApp, Instagram, Twitter, LinkedIn, and WeChat. The questionnaire was available online for 9 months from August 1, 2021 to April 30, 2022 to achieve maximum participation. Statistical analysis The data were analyzed using IBM SPSS for Windows, ver- sion 28.0 (IBM Inc., Armonk, NY, USA). The Chi-square test was used to analyze descriptive statistics (n, %), and to evalu- ate the significance of the association between variables. To assess risk factors for health outcomes in participants, a mul- tivariable logistic regression analysis was performed, and the relationship between risk factors and adverse effects of using sanitizers and disinfectants are presented as odds ratios (ORs) and 95%CIs, after adjustment for confounders, including age, gender, educational level, occupational status, place of resi- dence (rural and urban areas), and income level. A p-value of <0.001 was considered statistically significant. Result Study design and participants Demographic characteristics are shown in Table 1. A total of 91,056 participants [58,845 (64.60%) females and 32,211 https://www.wjx.cn/ 72371Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 (35.40%) males]. Respondents were well represented by ages 21 to 30 years (37,577, 41.30%), urban areas (76,122, 83.60%), bachelor’s degree (38,924, 42.70%), and median income (48,776, 53.60%). In this study, the income level was considered relative to the average income of each country. Therefore, the majority of participants had an average income in their country. Out of 193 United Nations (UN) members (and 2 countries that are non-member observer states: the Holy See and the State of Palestine), 154 countries partici- pated in this study. The global participation rate was reported Table 1   Demographic characteristics of the study (N = 91,056) *Response Rate Characteristics N Male Female Age ≤20 9861(10.8) 3502(3.8) 6359(7.0) 21 to 30 37,577(41.3) 12,637(13.9) 24,940(27.4) 31 to 40 22,250(24.4) 8093(8.9) 14,157(15.5) 41 to 50 13,338(14.6) 4744(5.2) 8594(9.4) 51 to 60 5746(6.3) 2150(2.4) 3596(3.9) 60 and over 2284(2.5) 1085(1.2) 1199(1.3) Place of residence Urban 76,122(83.6) 25,987(28.5) 50,135(55.1) Rural 14,934(16.4) 6224(6.8) 8710(9.6) Level of education School education 14,784(16.2) 5662(6.2) 9122(10.0) Associate degree 12,546(13.8) 3673(4.0) 8873(9.7) Bachelor’s degree 38,924(42.7) 13,457(14.8) 25,467(28.0) Masters 16,798(18.4) 6348(7.0) 10,450(11.5) Ph.D. and postdoctoral 8004(8.8) 3071(3.4) 4933(5.4) Occupational status Unemployed / housewife / student 12,571(13.8) 2443(2.7) 10,128(11.1) University Student 28,104(30.9) 9489(10.4) 18,615(20.4) Government employee 26,249(28.8) 10,038(11.0) 16,211(17.8) Private office employee 16,619(18.3) 645(7.0) 9974(11.0) Freelance (self-employed) 7513(8.3) 3596(3.9) 3917(4.3) Income Low 8877(9.7) 3004(3.3) 5873(6.4) Lower-middle 11,339(12.5) 4325(4.7) 7014(7.7) Middle 48,776(53.6) 17,165(18.9) 31,611(34.7) Upper-middle 18,308(20.1) 6276(6.9) 12,032(13.2) High-income 3756(4.1) 1441(1.6) 2315(2.5) Number of participating coun- tries by continent: N (RR*) Africa America Asia Europe Oceania 48 (24.6%) 19 (9.7%) 44 (22.5%) 39 (20%) 4(2%) No participation: N 6 16 4 5 10 Fig. 1   Usage status of five groups of sanitizers 74.10% 57.20% 31.90% 27.60% 10.40% 25.90% 42.80% 68.10% 72.40% 89.60% 0 20000 40000 60000 80000 100000 Detergents Alcohol or non- commercial sanitizers Hospital-grade sanitizers Other commercial sanitizers Sodium hypochlorite N um be r of U se rs Sanitizers Yes No 72372 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 to be 79%. 41 countries (21%) from different continents did not participate in the study. According to Table 1, the num- ber of participating countries from each continent includes Africa (48), America (19), Asia (44), Europe (39), and Oce- ania (4) countries correctly completed the questionnaire. Type and volume of sanitizers and disinfectants used In the second part of the questionnaire, questions were asked about the type, volume, and number of times of daily use of 5 types of chemical compounds as sanitizers (Figure 1) and 7 types of substances as disinfectants (Figure 2). The status of the use of sanitizers and disinfectants is shown in Table 2 and Figures 1, 2, and 3. The usage status of the sanitizers for handwashing or other living surfaces is shown in Figure 1. Compared to other sanitizers, the highest use was detergents (soap and toilet liquid, dishwashing liquid) (67,445 users), and alcohol or non-commercial sanitizers (52,083 users). In contrast, chlorine compounds such as sodium hypochlorite (9490 users) were used less often as sanitizers. Addition- ally, the status of seven groups of disinfectants, which are used for the disinfection of various high-touch surfaces such as door handles, tables, chairs, remotes, keys, elevator but- tons, etc., was explored (Figure 2). In this group, in addi- tion to detergents (54,445 users) and alcohol-based products (49,879 users), which were most used compared to other disinfectants, the use of sodium hypochlorite was reported as a high-consumptive disinfectant (24,296 users). In contrast, formaldehyde (1441 users) and per-chlorine (6605 users) had the lowest usage as a disinfectant. In terms of the frequency of daily use of sanitizers and disinfectants, the results showed that most participants tended to use sanitizers and disinfectants 1 to 3 times a day (29,778 users) and once a day (35,959 users), respectively. The volume of chemicals used was also one of the important factors in creating the scenarios of possible adverse effects and we found that most of the participants stated using the sanitizers and disinfectants at a volume of approximately 101–300 mL, and 0.5–1 L per month, respectively (Table 2). Fig. 2   Usage status of seven groups of disinfectants 26.70% 7.30% 54.80% 59.80% 8.10% 1.60% 15.60% 73.30% 92.70% 45.20% 40.20% 91.90% 98.40% 84.40% 0 20000 40000 60000 80000 100000 N um be r of U se rs Disinfectants Yes No Table 2   Usage status of sanitizers and disinfectants *The users of sanitizers and disinfectants. **It is expressed in CC due to its use for living surfaces. ***It is expressed in liters due to its use for non-living surfaces Frequency of daily use Monthly usage volume (CC**) Once a day 1–3/d 4–6/d > 6/d None Low (≤100) Average (101 to 300) High (301 to 500) Too much (≥500) None Sanitizers: N* (%) 11,069 (12.2) 29,778 (32.7) 27,407 (30.1) 21,608 (23.7) 1140 (1.3) 22,849 (25.1) 45,091 (49.5) 13,292 (14.6) 8572 (9.4) 1198 (1.3) Monthly usage volume (L***) Once a day 1–3/d 4–6/d > 6/d None Low (≤0.5) Average (0.5 to 1) High (1.1 to 2) Too much (>2) None Disinfectants: N (%) 35,959 (39.5) 34,436 (37.8) 11,158 (12.3) 5159 (5.7) 3990 (4.4) 27,727 (30.5) 44,686 (49.1) 10,783 (11.8) 4978 (5.5) 2816 (3.1) 72373Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 The continental distribution of the inclination of users (individuals) to use sanitizers and disinfectants is shown in Figure 3. Four groups of countries were determined accord- ing to the sanitizers and disinfectant usage rate: countries with low usage (blue <1000), medium usage (yellow = 1001–2000), high usage (brown = 2001–3000), and coun- tries that tend to consume too many sanitizers and disinfect- ants (red >3000). The number of countries that were less inclined to use sanitizers and disinfectants was in Africa, while the number of countries with the highest level of usage was in Asia. Similarly, the continental distribution shows that most countries with moderate usage of sanitizers and disinfectants were in continental Europe. Adverse health outcomes of sanitizers and disinfectants The distribution of the frequency of adverse events showed that the most common complaints reported by the partici- pants were related to skin and respiratory system effects (Figure 4). The highest and lowest frequencies were related to skin dryness (65,680 cases) and neurological effects (headache, dizziness, and vomiting) (13,063 cases), respec- tively. Table 3 shows the possible adverse health outcomes as a result of the use of sanitizers and disinfectants based on the reports of the participants in this study. There was a sig- nificant relationship between the use of chlorine compounds such as sodium hypochlorite and per-chlorine with all the adverse effects (p < 0.001) (Table 3). Skin effects The use of detergents and alcohol or alcohol-based prod- ucts resulted in a greater adverse effect on the skin than other chemicals (Table 3). Among the skin effects, the most commonly reported adverse effect was skin dryness. 45,259 and 39,573 of the participants complained of dry skin due to the use of detergents and alcohol or alcohol- based materials, respectively. There was a significant relationship between itching and skin irritation with all chemicals (except other commercial sanitizers and hos- pital disinfectants) (p < 0.001). Unlike other chemicals, there was no significant relationship between skin scaly with alcohols, commercial sanitizers, and hydrogen per- oxide (p > 0.05). Ocular effects The contribution of sodium hypochlorite in causing ocu- lar effects was greater than other chemicals. Participants reported itching and ocular irritation (15,407 cases) and ocular redness (11,302 cases) after using sodium hypochlo- rite. The data show a significant relationship between itch- ing and ocular irritation with all sanitizers and disinfectants (except detergents and alcohol or alcohol-based materials) (p < 0.001) (Table 3). Throat effects Participants reported itching and irritation of the throat after using alcohol or alcohol-based products (12,591 cases), hos- pital-grade sanitizers such as savlon (6671 cases), and other commercial sanitizers (6035 cases). Itching and irritation of the throat as one of the possible side effects of sanitiz- ers and disinfectants was significantly associated with some chemicals such as chlorine compounds (sodium hypochlorite and per-chlorine), hospital disinfectants, hydrogen peroxide, formaldehyde (p < 0.001) (Table 3). Fig. 3   Distribution of the use of sanitizers and disinfectants in different countries < 1000 1001-2000 > 3000 2001-3000 No data 72374 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Respiratory system effects Respiratory effects including itching and nose irritation (19,692 cases), runny nose (12,601 cases), and cough and sneezing (20,148 cases) were reported after using alcohol or alcohol-based products. There was a signifi- cant relationship between shortness of breath with all chemicals except detergents (all p < 0.001). In contrast, except for chlorine compounds, there was no significant relationship between cough, sneezing, and runny nose with the majority of sanitizers and disinfectants (p > 0.05) (Table 3). Neurological effects The present findings showed that less than eight percent of the participants had self-reported neurological effects including headache, dizziness, and vomiting after using sanitizers and disinfectants. In total, 7114 and 419 of par- ticipants complained of headache, dizziness, and vomit- ing after using alcohol (the most) and formaldehyde (the least), respectively. The results indicated that a statisti- cally significant relationship was found between possible neurological problems due to the use of analyzed sanitiz- ers and disinfectants (except detergents) (all p < 0.001) (Table 3). Multivariable logistic regression analysis After controlling for confounders (demographic character- istics), a multivariable logistic regression analysis was per- formed to determine the risk factors associated with adverse health outcomes (Table 4). The use of some sanitizers and disinfectants was associated with skin adverse effects (e.g., Itching and skin irritation after using alcohol or alcohol- based materials: OR, 1.86; 95%CI, p > 0.05; or as a result of using sodium hypochlorite: OR, 1.43; 95%CI, p < 0.001). In contrast, the use of some other sanitizers and disinfectants was associated with a lower chance of itching and skin irrita- tion (hospital disinfectants: OR, 0.91; 95%CI, p < 0.001). The use of Per-chlorine (OR, 1.47; 95%CI, p < 0.001), alcohol-based materials (OR, 1.98; 95%CI, p < 0.001), for- maldehyde (OR, 1.40; 95%CI, p < 0.001) were associated with higher odds of skin dryness, scaling of the skin, skin urticaria respectively. Itching and ocular irritation were reported after using per-chlorine: OR, 1.83; 95%CI, p < 0.001; and sodium hypochlorite: OR, 1.33; 95%CI, p < 0.001. Similarly, ocu- lar redness was associated with the use of per-chlorine (OR, 1.77; 95%CI, p < 0.001), and hydrogen peroxide (OR, 1.49; 95%CI, p < 0.001). The results showed that one of the important risk factors for throat-related effects is chlorine-based com- pounds. Per-chlorine resulted in double the risk for throat- related effects (OR, 2.00; 95%CI, p < 0.001), and sodium hypochlorite use is also a serious risk factor for itching and throat irritation (OR, 1.66; 95%CI, p < 0.001). Fur- thermore, the use of sodium hypochlorite (OR, 1.74; 95%CI, p < 0.001), and formaldehyde (OR, 1.56; 95%CI, p < 0.001) were accompanied by coughing and sneezing. Similarly, shortness of breath was associated with the use of sodium hypochlorite (OR, 1.78; 95%CI, p < 0.001), and per-chlorine (OR, 1.67; 95%CI, p < 0.001). There was a strong association between the use of formaldehyde and the occurrence of neurological effects (OR, 2.17; 95%CI, p < 0.001). Fig. 4   The frequency distribu- tion of 12 health outcomes studied 11.80% 13.20% 18.30% 5.50% 6.80% 4.80% 6.20% 9.40% 6.30% 9.40% 4.70% 3.60% 0 20000 40000 60000 80000 N u m b er o f C as es Health Outcomes 72375Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Ta bl e  3   F re qu en cy ta bl e an d th e re la tio ns hi p be tw ee n sa ni tiz er s/ di si nf ec ta nt s a nd h ea lth o ut co m es (C hi -s qu ar e te st) Ty pe o f c he m ic al Itc hi ng a nd sk in ir rit at io n Sk in d ry ne ss H an d sc al in g Sk in u rti ca ria (H iv es ) Ye s N o Ye s N o Ye s N o Ye s N o N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) D et er ge nt s ( So ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) Ye s 29 ,9 52 (3 2. 9) 30 ,9 96 (3 4. 0) 45 ,2 59 (4 9. 7) 15 ,6 88 (1 7. 2) 33 ,2 86 (3 6. 6) 27 ,6 62 (3 0. 4) 70 37 (7 .7 ) 48 ,3 20 (5 3. 1) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 A lc oh ol o r a lc oh ol - ba se d m at er ia ls Ye s 24 ,7 86 (2 7. 2) 27 ,3 00 (3 0. 0) 39 ,5 73 (4 3. 5) 12 ,5 13 (1 3. 7) 27 ,9 79 (3 0. 7) 24 ,1 07 (2 6. 5) 10 ,6 14 (1 1. 7) 41 ,4 72 (4 5. 5) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 02 5 < 0. 00 1 So di um h yp oc hl or ite (b le ac h) Ye s 19 ,4 50 (2 1. 4) 74 43 (8 .2 ) 33 ,4 53 (3 6. 7) 34 40 (3 .8 ) 29 ,9 54 (3 2. 9) 69 40 (7 .6 ) 43 64 (4 .8 ) 12 ,5 29 (1 3. 8) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 H os pi ta l-g ra de sa ni tiz - er s ( sa vl on ) Ye s 14 ,3 22 (1 5. 7) 14 ,6 98 (1 6. 1) 21 ,4 17 (2 3. 5) 76 03 (8 .3 ) 15 ,3 69 (1 6. 9) 13 ,6 51 (1 5. 0) 61 34 (6 .7 ) 22 ,8 86 (2 5. 1) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 0. 02 2 O th er c om m er ci al sa ni tiz er s Ye s 11 ,7 19 (1 2. 9) 13 ,3 72 (1 4. 7) 17 ,8 80 (1 9. 6) 72 11 (7 .9 ) 13 ,0 82 (1 4. 4) 12 ,0 09 (1 3. 2) 50 18 (5 .5 ) 20 ,0 73 (2 2. 0) P- va lu e 0. 59 2 < 0. 00 1 0. 84 7 < 0. 00 1 H os pi ta l d is in fe ct an ts Ye s 65 01 (7 .1 ) 76 85 (8 .4 ) 10 ,4 47 (1 1. 5) 37 39 (4 .1 ) 69 43 (7 .6 ) 72 43 (8 .0 ) 34 32 (3 .8 ) 10 ,7 54 (1 1. 8) P- va lu e 0. 05 7 < 0. 00 1 < 0. 00 1 < 0. 00 1 Pe r-c hl or in e Ye s 40 97 (4 .5 ) 25 11 (2 .8 ) 52 34 (5 .7 ) 13 74 (1 .5 ) 45 81 (5 .0 ) 20 27 (2 .2 ) 19 18 (2 .1 ) 46 90 (5 .2 ) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 H yd ro ge n pe ro xi de Ye s 37 88 (4 .2 ) 35 92 (3 .9 ) 53 87 (5 .9 ) 19 93 (2 .2 ) 39 25 (4 .3 ) 34 55 (3 .8 ) 18 72 (2 .1 ) 55 08 (6 .0 ) P- va lu e < 0. 00 1 0. 08 8 0. 04 9 < 0. 00 1 Fo rm al de hy de Ye s 76 8( 0. 8) 67 6( 0. 7) 10 00 (1 .1 ) 44 4( 0. 5) 92 3( 1. 0) 52 1( 0. 6) 43 6( 0. 5) 10 08 (1 .1 ) P- va lu e < 0. 00 1 0. 01 5 < 0. 00 1 < 0. 00 1 Ty pe o f c he m ic al Itc hi ng a nd e ye ir rit at io n Ey e re dn es s Itc hi ng a nd th ro at ir rit at io n Itc hi ng a nd n os e irr ita tio n Ye s N o Ye s N o Ye s N o Ye s N o N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) D et er ge nt s ( so ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) Ye s 62 94 (6 .9 ) 44 ,6 54 (4 9. 0) 11 ,2 55 (1 2. 3) 49 ,5 80 (5 4. 5) 96 4( 1) 45 ,7 54 (5 0. 2) 12 ,9 76 (1 4. 3) 37 ,9 71 (4 1. 7) P- va lu e 0. 03 9 < 0. 00 1 < 0. 00 1 0. 00 2 A lc oh ol o r n on - co m m er ci al a lc oh ol - ba se d sa ni tiz er s Ye s 14 ,1 08 (1 5. 5) 10 ,3 09 (1 1. 3) 92 89 (1 0. 2) 80 77 (8 .9 ) 12 ,5 91 (1 3. 8) 39 ,4 95 (4 3. 4) 19 ,6 92 (2 1. 6) 32 ,3 94 (3 5. 6) P- va lu e 0. 03 4 < 0. 00 1 < 0. 00 1 0. 06 8 So di um h yp oc hl or ite (b le ac h) Ye s 15 ,4 07 (1 6. 9) 11 ,4 87 (1 2. 6) 11 ,3 02 (1 2. 4) 12 ,5 92 (1 3. 8) 55 02 (6 .0 ) 11 ,3 91 (1 2. 5) 17 ,5 51 (1 9. 3) 93 42 (1 0. 3) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 H os pi ta l-g ra de sa ni tiz - er s Ye s 71 80 (7 .9 ) 21 ,8 40 (2 4. 0) 54 50 (6 .0 ) 23 ,5 70 (2 5. 9) 66 71 (7 .3 ) 22 ,3 49 (2 4. 5) 10 ,3 59 (1 1. 4) 18 ,6 61 (2 0. 5) P- va lu e < 0. 00 1 0. 12 6 0. 32 1 0. 21 0 O th er c om m er ci al sa ni tiz er s Ye s 64 40 (7 .1 ) 18 ,6 51 (2 0. 5) 44 82 (4 .9 ) 20 ,6 09 (2 2. 6) 60 35 (6 .6 ) 19 ,0 56 (2 0. 9) 89 11 (9 .8 ) 16 ,1 80 (1 7. 8) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 0. 05 5 H os pi ta l d is in fe ct an ts Ye s 33 10 (3 .6 ) 10 ,8 76 (1 1. 9) 26 58 (2 .9 ) 11 ,5 28 (1 2. 7) 29 78 (3 .3 ) 11 ,2 08 (1 2. 3) 45 30 (5 .0 ) 96 56 (1 0. 6) P- va lu e < 0. 00 1 0. 27 4 < 0. 00 1 < 0. 00 1 Pe r-c hl or in e Ye s 26 14 (2 .9 ) 39 94 (4 .4 ) 19 22 (2 .1 ) 46 86 (5 .1 ) 26 24 (2 .9 ) 39 84 (4 .4 ) 34 84 (3 .8 ) 31 24 (3 .4 ) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 72376 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Ta bl e  3   ( C on tin ue d) H yd ro ge n pe ro xi de Ye s 20 84 (2 .3 ) 52 96 (5 .8 ) 17 50 (1 .9 ) 56 30 (6 .2 ) 20 49 (2 .3 ) 53 31 (5 .9 ) 25 79 (2 .8 ) 48 01 (5 .3 ) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 0. 33 2 Fo rm al de hy de Ye s 52 5( 0. 6) 91 9( 1. 0) 41 0( 0. 5) 10 34 (1 .1 ) 48 2( 0. 5) 96 2( 1. 1) 71 5( 0. 8) 72 9( 0. 8) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 < 0. 00 1 Ty pe o f c he m ic al Ru nn y no se C ou gh a nd S ne ez e Sh or tn es s o f b re at h H ea da ch es , d iz zi ne ss , a nd v om iti ng Ye s N o Ye s N o Ye s N o Ye s N o N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) N (% ) D et er ge nt s ( So ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) Ye s 32 96 (3 .6 ) 45 ,6 53 (5 0. 1) 50 33 (5 .5 ) 36 ,8 68 (4 0. 5) 62 48 (6 .9 ) 49 ,7 00 (5 4. 6) 42 13 (4 .6 ) 52 ,3 35 (5 7. 5) P- va lu e 0. 00 2 0. 06 5 0. 11 8 A lc oh ol o r a lc oh ol - ba se d m at er ia ls Ye s 12 ,6 01 (1 3. 8) 39 ,4 85 (4 3. 4) 20 ,1 48 (2 2. 1) 13 ,7 73 (1 5. 1) 92 06 (1 0. 1) 42 ,8 80 (4 7. 1) 71 14 (7 .8 ) 44 ,9 72 (4 9. 4) P- va lu e 0. 06 8 < 0. 00 1 < 0. 00 1 So di um h yp oc hl or ite (b le ac h) Ye s 57 53 (6 .3 ) 11 ,1 41 (1 2. 2) 78 33 (8 .6 ) 90 61 (1 0. 0) 11 ,7 38 (1 2. 9) 13 ,1 56 (1 4. 4) 29 29 (3 .2 ) 13 ,9 65 (1 5. 3) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 H os pi ta l-g ra de sa ni tiz - er s Ye s 64 73 (7 .1 ) 22 ,5 47 (2 4. 8) 10 ,1 72 (1 1. 2) 18 ,8 48 (2 0. 7) 50 91 (5 .6 ) 23 ,9 29 (2 6. 3) 36 82 (4 .0 ) 25 ,3 38 (2 7. 8) P- va lu e 0. 21 0 < 0. 00 1 < 0. 00 1 O th er c om m er ci al sa ni tiz er s Ye s 58 45 (6 .4 ) 19 ,2 46 (2 1. 1) 88 57 (9 .7 ) 16 ,2 34 (1 7. 8) 42 23 (4 .6 ) 20 ,8 68 (2 2. 9) 33 68 (3 .7 ) 21 ,7 23 (2 3. 9) P- va lu e 0. 05 5 < 0. 00 1 < 0. 00 1 H os pi ta l d is in fe ct an ts Ye s 27 84 (3 .1 ) 11 ,4 02 (1 2. 5) 44 60 (4 .9 ) 97 26 (1 0. 7) 21 64 (2 .4 ) 12 ,0 22 (1 3. 2) 20 05 (2 .2 ) 12 ,1 81 (1 3. 4) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 Pe r-c hl or in e Ye s 25 94 (2 .8 ) 40 14 (4 .4 ) 33 96 (3 .7 ) 32 12 (3 .5 ) 18 81 (2 .1 ) 47 27 (5 .2 ) 14 25 (1 .6 ) 51 83 (5 .7 ) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 H yd ro ge n pe ro xi de Ye s 73 80 (8 .1 ) 55 82 (6 .1 ) 26 77 (2 .9 ) 47 03 (5 .2 ) 15 93 (1 .7 ) 57 87 (6 .4 ) 12 54 (1 .4 ) 61 26 (6 .7 ) P- va lu e 0. 33 2 < 0. 00 1 < 0. 00 1 Fo rm al de hy de Ye s 53 7( 0. 6) 90 7( 1. 0) 70 8( 0. 8) 73 6( 0. 8) 42 8( 0. 5) 10 16 (1 .1 ) 41 9( 0. 5) 10 25 (1 .1 ) P- va lu e < 0. 00 1 < 0. 00 1 < 0. 00 1 72377Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Ta bl e  4   R is k fa ct or s f or h ea lth e ffe ct s b y M ul tiv ar ia bl e Lo gi sti c Re gr es si on A na ly si s Ty pe o f c he m ic al Itc hi ng a nd sk in ir rit at io n Sk in d ry ne ss Sk in sc al in g Sk in u rti ca ria (H iv es ) A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P D et er ge nt s ( So ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) 1. 15 1. 09 –1 .2 1 < 0. 00 1 1. 06 1. 02 –1 .1 0 < 0. 00 1 1. 15 1. 11 –1 .1 9 < 0. 00 1 0. 94 0. 90 –0 .9 7 < 0. 00 1 A lc oh ol o r a lc oh ol - ba se d m at er ia ls 1. 86 1. 77 –1 .9 6 0. 02 0 1. 30 1. 26 –1 .3 4 < 0. 00 1 1. 98 1. 87 –2 .0 9 < 0. 00 1 0. 86 0. 83 –0 .8 9 < 0. 00 1 So di um h yp oc hl or ite (b le ac h) 1. 43 1. 39 –1 .4 8 < 0. 00 1 1. 40 1. 35 –1 .4 6 < 0. 00 1 1. 30 1. 24 –1 .3 7 < 0. 00 1 0. 90 0. 87 –0 .9 3 < 0. 00 1 H os pi ta l-g ra de sa ni tiz er s 1. 08 1. 05 –1 .1 2 < 0. 00 1 0. 82 0. 79 –0 .9 3 < 0. 00 1 1. 01 0. 98 –1 .0 4 0. 39 4 0. 86 0. 83 –0 .8 9 < 0. 00 1 O th er c om m er ci al sa ni tiz er s 0. 90 0. 87 –0 .9 3 < 0. 00 1 0. 86 0. 83 –0 .8 9 < 0. 00 1 0. 95 0. 92 –0 .9 8 0. 00 5 0. 82 0. 79 –0 .8 5 < 0. 00 1 H os pi ta l d is in fe ct an ts 0. 91 0. 88 –0 .9 5 < 0. 00 1 1. 10 1. 06 –1 .1 5 < 0. 00 1 0. 84 0. 81 –0 .8 7 < 0. 00 1 1. 26 1. 21 –1 .3 2 < 0. 00 1 Pe r-c hl or in e 0. 96 0. 94 –0 .9 9 < 0. 00 1 1. 47 1. 38 –1 .5 6 < 0. 00 1 1. 37 1. 29 –1 .4 5 < 0. 00 1 0. 95 0. 90 –1 .0 1 0. 12 5 H yd ro ge n pe ro xi de 1. 15 1. 09 –1 .2 1 < 0. 00 1 0. 95 0. 90 –1 .0 1 0. 12 5 0. 96 0. 91 –1 .0 1 0. 13 6 1. 37 1. 29 –1 .4 5 < 0. 00 1 Fo rm al de hy de 1. 20 1. 07 –1 .3 4 < 0. 00 1 0. 85 0. 76 –0 .9 6 0. 01 1 1. 46 1. 31 –1 .6 4 < 0. 00 1 1. 40 1. 24 –1 .5 7 < 0. 00 1 Ty pe o f c he m ic al Itc hi ng a nd E ye Ir rit at io n Ey e Re dn es s Itc hi ng a nd T hr oa t I rr ita tio n Itc hi ng a nd N os e Ir rit at io n A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P D et er ge nt s ( So ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) 0. 95 0. 92 –0 .9 8 < 0. 00 1 0. 85 0. 82 –0 .8 8 < 0. 00 1 0. 69 0. 62 –0 .7 6 0. 06 3 1. 21 1. 17 –1 .2 4 < 0. 00 1 A lc oh ol o r a lc oh ol - ba se d m at er ia ls 1. 11 1. 07 –1 .1 5 0. 00 2 1. 05 1. 01 –1 .0 8 < 0. 00 1 0. 97 0. 93 –1 .0 0 0. 05 3 1. 07 1. 04 –1 .1 1 < 0. 00 1 So di um h yp oc hl or ite (b le ac h) 1. 33 1. 27 –1 .4 0 < 0. 00 1 1. 65 1. 58 –1 .7 1 < 0. 00 1 1. 66 1. 58 –1 .7 4 < 0. 00 1 1. 48 1. 41 –1 .5 5 < 0. 00 1 H os pi ta l-g ra de sa ni tiz er s 0. 83 0. 80 –0 .8 6 < 0. 00 1 0. 90 0. 86 –0 .9 3 < 0. 00 1 0. 84 0. 81 –0 .8 7 < 0. 00 1 0. 87 0. 84 –0 .8 9 < 0. 00 1 O th er c om m er ci al sa ni tiz er s 0. 89 0. 86 –0 .9 2 < 0. 00 1 0. 81 0. 77 –0 .8 4 < 0. 00 1 0. 89 0. 86 –0 .9 3 < 0. 00 1 0. 85 0. 82 –0 .8 8 < 0. 00 1 H os pi ta l d is in fe ct an ts 0. 90 0. 86 –0 .9 4 < 0. 00 1 - - - 0. 83 0. 79 –0 .8 7 < 0. 00 1 0. 82 0. 79 –0 .8 6 < 0. 00 1 Pe r-c hl or in e 1. 83 1. 74 –1 .9 3 < 0. 00 1 1. 77 1. 68 –1 .8 8 < 0. 00 1 2. 00 1. 90 –2 .1 1 < 0. 00 1 1. 87 1. 78 –1 .9 7 < 0. 00 1 H yd ro ge n pe ro xi de 1. 15 1. 09 –1 .2 2 < 0. 00 1 1. 49 1. 40 –1 .5 8 < 0. 00 1 1. 19 1. 13 –1 .2 6 < 0. 00 1 0. 92 0. 87 –0 .9 7 0. 00 3 Fo rm al de hy de 1. 40 1. 26 –1 .5 7 < 0. 00 1 1. 34 1. 19 –1 .5 2 < 0. 00 1 1. 29 1. 15 –1 .4 5 < 0. 00 1 1. 56 1. 40 –1 .7 3 < 0. 00 1 Ty pe o f c he m ic al Ru nn y no se C ou gh a nd S ne ez e Sh or tn es s o f b re at h H ea da ch es , D iz zi ne ss , a nd V om iti ng A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P A dj us te d O R C I ( 95 % ) P 72378 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Discussion Regarding the use of sanitizers and disinfectants in different continents, it was observed that in African countries, due to low-income levels, and lack of accessibility the tendency to use disinfectants was lower than in other continents. In contrast, in some less-resourced countries, such as Iran, and more-resourced countries, such as China, the USA, the UK, Germany, and Australia, etc., there was a greater tendency to use disinfectants. Adequate income levels, adequate edu- cation, and information, easy access to the types of sanitiz- ers and disinfectants, and strict controlling measures by the governments have been effective in increasing the use of these chemicals (Becher et al., 2021; Bu et al., 2020; Tran et al., 2020; Unruh et al., 2022; Xu et al., 2020). Although our claim regarding some countries such as Venezuela, Iraq, Afghanistan, etc. was not correct. Contrary to the economic crisis prevailing in these countries, the use of sanitizers and disinfectants was high. In addition to this more attention and the fear of contract- ing the disease, sometimes leads to the excessive usage of sanitizers and disinfectants, which leads to the occurrence of adverse effects due to the toxic nature of these chemicals on the population; finally, the body’s resistance to other infec- tious agents may decrease (Tachikawa, 2020; Vogel, 2011). On the other hand, the denial of the existential nature of the COVID-19 disease by people from different countries (Afolabi and Ilesanmi, 2021; Buguzi, 2021; Cabral et al., 2021; Thagard, 2021) can be one of the main reasons for not tending to use sanitizers and disinfectants as part of health protocols. We found that the disinfectants with the highest rate of causing different adverse health effects are chlorine compounds (sodium hypochlorite and per-chlorine). One of the reasons for this finding could be the widespread use of these compounds as bleaches, cleansers, and vegetable washes, for washing different surfaces, water disinfection as well as easy access and affordability. In addition to the inherent effects of using chemicals as sanitizers and dis- infectants, there are other reasons such as misuse (mixing several chemicals without following the instructions), exces- sive use, and counterfeit and unauthorized products that can cause side effects (Alhouri et al., 2020; Cook and Brooke, 2021). However, some disinfectants (e.g., detergents) may not have serious adverse effects on human health, but pro- longed exposure and overuse of any chemical increase their harmful potential (Baldeo et al., 2022). Similar studies have shown that most disinfectants, such as alcohols and proxy- gene compounds, can be considered potential irritants or skin allergens (Goh et al., 2021; Lachenmeier, 2008; Murphy and Friedman, 2019). The US centers for disease control and prevention (CDC) reported an increase in calls to the center because of overuse and frequent exposure to cleaning A dj us te d fo r a ge , s ex , e du ca tio na l l ev el , o cc up at io na l s ta tu s, pl ac e of re si de nc e (r ur al a nd c ity ), an d in co m e le ve l Ta bl e  4   (c on tin ue d) D et er ge nt s ( So ap a nd to ile t l iq ui d, d is h- w as hi ng li qu id ) 0. 93 0. 90 –0 .9 7 < 0. 00 1 0. 67 0. 61 –0 .7 8 < 0. 00 1 0. 94 0. 90 –0 .9 8 0. 00 4 0. 95 0. 92 –0 .9 9 0. 01 9 A lc oh ol o r a lc oh ol - ba se d m at er ia ls 0. 76 0. 73 –0 .7 9 < 0. 00 1 1. 05 1. 02 –1 .0 8 0. 00 5 0. 91 0. 87 –0 .9 4 < 0. 00 1 1. 06 1. 02 –1 .1 0 0. 00 2 So di um h yp oc hl or ite (b le ac h) 1. 76 1. 6– 1. 8 < 0. 00 1 1. 74 1. 65 –1 .8 3 < 0. 00 1 1. 78 1. 68 –1 .8 8 < 0. 00 1 1. 32 1. 27 –1 .3 8 < 0. 00 1 H os pi ta l-g ra de sa ni tiz er s 0. 76 0. 73 –0 .7 9 < 0. 00 1 0. 83 0. 80 –0 .8 5 < 0. 00 1 0. 77 0. 74 –0 .8 0 < 0. 00 1 0. 90 0. 86 –0 .9 3 < 0. 00 1 O th er c om m er ci al sa ni tiz er s 0. 82 0. 79 –0 .8 5 < 0. 00 1 0. 83 0. 81 –0 .8 6 < 0. 00 1 0. 84 0. 81 –0 .8 8 < 0. 00 1 0. 81 0. 78 –0 .8 4 < 0. 00 1 H os pi ta l d is in fe ct an ts 0. 76 0. 73 –0 .8 0 < 0. 00 1 0. 81 0. 77 –0 .8 4 < 0. 00 1 1. 10 1. 04 –1 .1 5 < 0. 00 1 0. 80 0. 76 –0 .8 4 < 0. 00 1 Pe r-c hl or in e 1. 91 1. 81 –2 .0 2 < 0. 00 1 1. 47 1. 42 –1 .5 2 < 0. 00 1 1. 67 1. 56 –1 .7 7 < 0. 00 1 1. 72 1. 62 –1 .8 1 < 0. 00 1 H yd ro ge n pe ro xi de 1. 06 1. 00 –1 .1 3 0. 03 1 0. 97 0. 92 –1 .0 2 < 0. 00 1 1. 30 1. 22 –1 .3 9 < 0. 00 1 1. 36 1. 28 –1 .4 4 < 0. 00 1 Fo rm al de hy de 1. 59 1. 42 –1 .7 8 < 0. 00 1 1. 56 1. 40 –1 .7 3 < 0. 00 1 1. 15 1. 09 –1 .2 2 < 0. 00 1 2. 17 1. 92 –2 .4 4 < 0. 00 1 72379Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 chemicals during the Covid-19 pandemic (CDC, 2020; Rosenman et al., 2021). Various reports have claimed that long-term use of sur- factants causes dryness and roughness of the skin (Goh et al., 2021; Paudel et al., 2022; Shibuya et al., 2022). Simi- larly, alcohol-based substances despite their low perme- ability to the skin had the most skin effects as a result of prolonged contact and regular and continuous use. Similar studies have reported increased exposure and frequency of alcohol use as a cause of skin irritation or dermatitis (Bout- hoorn et al., 2011; Ghafoor et al., 2021; Lachenmeier, 2008). Unlike sanitizers and other disinfectants, alcohols were more effective in causing skin urticaria. In one study, skin urti- caria was reported as a result of alcohol use (such as isopro- panol) due to the combination of these alcohols with some solvents and organic matter (Berardi et al., 2020; Goh and Ahmed, 2020; Pecquet et al., 1992). The results obtained in this study regarding skin effects were in accordance with some scientific texts and similar studies (Bito et al., 2010; Chan and Maibach, 2008; Europe, 2017; Murphy and Friedman, 2019). The results of the multivariate regression analysis showed that detergents, alcohols or alcohol-based substances, and chlorine compounds have a higher poten- tial of causing skin effects compared to other sanitizers and disinfectants. Ocular effects (itching and irritation and eye redness) due to the use of sanitizers and disinfectants were less common than other effects. However, in terms of frequency, deter- gents and alcohol accounted for the largest share of ocular side effects. The results of some studies confirm our find- ings that itching and eye irritation are a result of the use of alcohol as a sanitizer/disinfectant (Ghafoor et al., 2021). Statistical results showed that among the chemicals studied, chlorine compounds had a higher chance of causing ocular effects compared to other disinfectants. This is probably due to the wide range of applications of chlorine compounds for different purposes as well as their ability to be mixed with other solvents. Studies have shown that the use of chlorine- based compounds in the form of sprays to disinfect surfaces will cause itching and eye irritation (Ghafoor et al., 2021; Schyllert et al., 2016; WHO, 2020). Since people used sev- eral types of chemicals separately or mixed to wash hands, face, and feet or to disinfect different surfaces, improper mixing of chemicals may release toxic gases and vapors that can affect the respiratory system. Studies have shown that mixing bleach with acidic cleaning agents leads to the release of highly irritating gases (PHE, 2015; Racioppi et al., 1994). Rosenman et al. claimed that not following hygienic instructions on how to use or mix cleansing products with other chemicals such as acid would create the conditions for chemical pneumonia or pulmonary edema (Rosenman et al., 2021). Our findings showed that chlorine compounds (sodium hypochlorite and per-chlorine) were involved in causing all effects related to the respiratory system. This claim was consistent with a list approved by the US Envi- ronmental Protection Agency (Alimohamadi et al., 2022b) that sodium hypochlorite is an irritant and allergen for the respiratory system (EPA, 2020). The results of multivari- ate regression analysis showed that formaldehyde had an immensely significant chance of causing neurological effects compared to other sanitizers and disinfectants. Formalde- hyde, as a carcinogen by OSHA (Tarka et al., 2016), has an unpleasant odor and is an irritant that can cause many adverse effects on human health (Ghafoor et al., 2021). Strengths and limitations The present study holds significant value due to its com- prehensive nature, covering 154 out of 192 United Nations member countries, indicating a truly global scope. The primary objective of this study was to achieve optimal participation across diverse segments of the general popu- lation. Regrettably, certain subgroups, namely villagers, individuals above the age of 60, non-academic individu- als, and those employed in blue-collar occupations such as construction, manufacturing, and maintenance, exhibited lower levels of participation. This constraint constitutes a further limitation of the study. The main limitations of this study were the non-participation of individuals for personal reasons or lack of access to the internet, the drop-out of some countries (41 countries), and background effects such as exposure to various pollutants causing effects such as inflammation and respiratory effects, etc. (Hashemi et al., 2022a). Conclusion Our findings could serve as a useful source of information in reducing concerns related to the adverse health effects of sanitizers and disinfectant use through education and information by governments and health organizations dur- ing viral epidemics. Furthermore, the present results can be helpful for safety and health organizations overseeing the production of chemicals in updating instructions on how to use chemicals, as well as replacing low-risk, low- dose, high-impact chemicals in the production process if possible. Supplementary Information  The online version contains supplemen- tary material available at https://​doi.​org/​10.​1007/​s11356-​023-​27197-6. Acknowledgements  We are sincerely thankful to the Research Center for Health Sciences, Department of Environmental Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran. We also gratefully acknowledge the Kharkiv National Medical University and the esteemed president of that university, Dr. Valeriy Kapustnik, for their cooperation in uploading the electronic link of the questionnaire on the university’s website. https://doi.org/10.1007/s11356-023-27197-6 72380 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Author contribution  All authors contributed to the study’s concep- tion and design. Data collection was performed by Fallah Hashemi, Lori Hoepner, Farahnaz Soleimani Hamidinejad,, Daniela Haluza, Sima Afrashteh, Alireza Abbasi, Elma Omeragić, Belma Imamović, Narin A. Rasheed,, Taqi Mohammed Jwad Taher, Fitri Kurniasari, Dhuha Youssef Wazqar, Özge Ceren Apalı, Ayca Demir Yildirim, Bo Zhao, Zaruhi Kalikyan, Cui Guo, Andrea Chong Valbuena, Mag- dalena Mititelu, Carolina Martínez Pando, Maria Saridi, Aikaterini Toska, Magalys Lopez Cuba, Precious Kwablah Kwadzokpui, Niguse Tadele, Tohfa Nasibova, Stefanie Harsch, Luvsan Munkh-Erdene, Wafaa Menawi, Efi Evangelou, Antoniya Dimova, Dimitar Marinov, Teodora Dimitrova, Anna Shalimova, Howieda Fouly, Anna Suraya,, Juliana Pereira da Silva Faquim, Bouadil Oumayma, Maria Antoni- eta Annunziato, Rezarta Lalo, Evridiki Papastavrou, Anju D. Ade, Susanna Caminada, Svetlana Stojkov, Carmen Gloria Narvaez, lute- ndo Sylvia Mudau, Ines Rassas, Daphnee Michel, Nur sema Kaynar, Sehar Iqbal, Halla Elshwekh, Irin Hossain, Sadeq AL-Fayyadh Aniuta Sydorchuk, Dua’a Mohammad Hasan Alnusairat Asli Mohamed Abdullahi, Neelam Iqbal, Apsara Pandey, Brenda Gómez-Gómez, Aysenur Gunaydin Akyildiz, Morosan Elena, Daniella Dwarica, Gantuya Dorj, Sumaya Yusuf Hasan, Noha M. Al-Shdayfat, Bojana Knezevic, Wendy Valladares, Cecilia Severi, Sofia Cuba Fuentes, Sofia Augusto, Elizaveta Sidorova, Anita Dewi Moelyaningrum, Tafaul Alawad, Atiqa Khalid,, Nafisa Mhna Kmbo Elehamer, Anna Mihaylova, Oxana Tsigengagel, Aziza Menouni, Agnieszka Wojtecka, Rozita Hod, Yusuf Banke Idayat, khadija Othman, Rim M. Harfouch, Tsonco Paunov, Meruyert Omar, Nana Christine Benderli,, Globila Nurika, Sana Amjad, Salma Elnoamany, Fatma Elesrigy, Marwa Mamdouh Shaban, Doménica Acevedo-López, Maria Kartashova, Atika Khalaf,, Sabah Abdullah Jaafar, Taisir A. Kadhim, Nada Ab. Hweissa, Yulong Teng, Fatima Elbasri Abuelgasim Mohammed Yagoub, Thayahlini Sasikumar, Christabel Nangandu Hikaambo, Aditi Kharat, Ulyana Lyamtseva, Maya Arfan Aldeeb,, Natalia Pawlas, Lkhagvasuren Khorolsuren, Roopeshwaree Pallavi Koonjul, Halima Boubacar Maïnassara, Priyanka Chahal, Rose Wangeci W, Ainur B. Kumar, Irina Zamora-Corrales, Stella Gracy, Maimouna Mahamat, Jakub Adamczyk, Haliza Abdul Rahman, Lolita Matiashova, Omneya Ezzat Elsherif, Nazdar Ezzaddin Rasheed Alkhateeb, Yamilé Aleaga, Shima Bahrami, Shaimaa Rahem Al-salihy, Paula Cabrera-Galeana, Mladena Lalic-Popovic, Eugenie Brown-Myrie, Divya Bhandari, Cin- derella Akbar Mayaboti, Svetlana Stanišić, Sanda Kreitmayer Pestic, Muhammed Yunus Bektay, Haleama Al Sabbah, Saber Hashemi, Bouchetara Assia, Anne-Sophie Merritt, Zhian Ramzi, Himawatee Baboolal, Juman Isstaif, Rula Shami, Rahma Saad, Temwanani Nyi- rongo, Mohammad Hoseini. Material preparation by Fallah Hashemi and Mohammad Hoseini, and data analysis by Lori Hoepner and Sima Afrashteh were performed. The first draft of the manuscript was written by Fallah Hashemi and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data availability  There is no data to access online. Declarations  Ethics approval  The study sampling protocol was approved by the Eth- ics Committee of the Shiraz University of Medical Science (IR.SUMS. REC.1400.023). Consent to participate  All the people who participated in this study through an electronic questionnaire; Before answering the questions, they should have chosen the option of informed consent to participate in this research. It is necessary to explain that without choosing the option of informed consent, the participants were not able to enter the other sections of the questionnaire. 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Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. https://doi.org/10.7189/jogh.10.020502 https://covid19.who.int/ 72383Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Authors and Affiliations Fallah Hashemi1 · Lori Hoepner2 · Farahnaz Soleimani Hamidinejad3,4 · Daniela Haluza5 · Sima Afrashteh6 · Alireza Abbasi1 · Elma Omeragić7 · Belma Imamović7 · Narin A. Rasheed8 · Taqi M. J. Taher9 · Fitri Kurniasari10 · Dhuha Youssef Wazqar11 · Özge Ceren Apalı12 · Ayca Demir Yildirim13 · Bo Zhao14 · Zaruhi Kalikyan15 · Cui Guo16 · Andrea Chong Valbuena17 · Magdalena Mititelu18 · Carolina Martínez Pando19 · Maria Saridi20 · Aikaterini Toska20 · Magalys Lopez Cuba21 · Precious Kwablah Kwadzokpui22 · Niguse Tadele23 · Tohfa Nasibova24 · Stefanie Harsch25 · Luvsan Munkh‑Erdene26 · Wafaa Menawi27 · Efi Evangelou28 · Antoniya Dimova29 · Dimitar Marinov30 · Teodora Dimitrova30 · Anna Shalimova31 · Howieda Fouly32 · Anna Suraya33,34 · Juliana Pereira da Silva Faquim35 · Bouadil Oumayma36 · Maria Antonieta Annunziato37 · Rezarta Lalo38 · Evridiki Papastavrou39 · Anju D. Ade40 · Susanna Caminada41 · Svetlana Stojkov42 · Carmen Gloria Narvaez43 · Lutendo Sylvia Mudau44 · Ines Rassas45 · Daphnee Michel46 · Nur  Sema Kaynar47 · Sehar Iqbal48 · Halla Elshwekh49 · Irin Hossain50 · Sadeq AL‑Fayyadh51 · Aniuta Sydorchuk52 · Dua’a M. H. Alnusairat53 · Asli Mohamed Abdullahi54 · Neelam Iqbal55 · Apsara Pandey56 · Brenda Gómez‑Gómez57 · Aysenur Gunaydin Akyildiz58 · Elena Morosan18 · Daniella Dwarica59 · Gantuya Dorj60 · Sumaya Yusuf Hasan61 · Noha M. Al‑Shdayfat62 · Bojana Knezevic63 · Wendy Valladares64 · Cecilia Severi65 · Sofia Cuba Fuentes66 · Sofia Augusto67 · Elizaveta Sidorova68 · Anita Dewi Moelyaningrum69 · Tafaul Alawad70 · Atiqa Khalid71 · Nafisa M. K. Elehamer72 · Anna Mihaylova73 · Oxana Tsigengagel74 · Aziza Menouni75 · Agnieszka Wojtecka76 · Rozita Hod77 · Yusuf Banke Idayat78 · Khadija Othman79 · Rim M. Harfouch80 · Tsonco Paunov30 · Meruyert Omar81 · Nana Christine Benderli82,83 · Globila Nurika69 · Sana Amjad84 · Salma Elnoamany85 · Fatma Elesrigy85 · Marwa Mamdouh Shaban86 · Doménica Acevedo‑López87 · Maria Kartashova88 · Atika Khalaf89,90 · Sabah Abdullah Jaafar91 · Taisir A. Kadhim91 · Nada Ab Hweissa92 · Yulong Teng93 · Fatima E. Mohammed94 · Thayahlini Sasikumar95 · Christabel Nangandu Hikaambo96 · Aditi Kharat97 · Ulyana Lyamtseva98 · Maya Arfan Aldeeb99,100 · Natalia Pawlas101 · Lkhagvasuren Khorolsuren102 · Roopeshwaree Pallavi Koonjul103 · Halima Boubacar Maïnassara104 · Priyanka Chahal105 · Rose W. Wangeci106 · Ainur B. Kumar107 · Irina Zamora‑Corrales108 · Stella Gracy109 · Maimouna Mahamat110 · Jakub Adamczyk111 · Haliza Abdul Rahman112 · Lolita Matiashova113 · Omneya Ezzat Elsherif114 · Nazdar E. Alkhateeb115 · Yamilé Aleaga116 · Shima Bahrami117 · Shaimaa Rahem Al‑salihy118 · Paula Cabrera‑Galeana119 · Mladena Lalic‑Popovic120 · Eugenie Brown‑Myrie121 · Divya Bhandari122 · Cinderella Akbar Mayaboti123 · Svetlana Stanišić124 · Sanda Kreitmayer Pestic125 · Muhammed Yunus Bektay126 · Haleama Al Sabbah127 · Saber Hashemi128 · Bouchetara Assia129 · Anne‑Sophie Merritt130 · Zhian Ramzi131 · Himawatee Baboolal132 · Juman Isstaif133 · Rula Shami134 · Rahma Saad135 · Temwanani Nyirongo136 · Mohammad Hoseini137,138  * Mohammad Hoseini mohhoseini@sums.ac.ir Fallah Hashemi info.foo@gmail.com Lori Hoepner Lori.Hoepner@downstate.edu Farahnaz Soleimani Hamidinejad solfarahnaz@gmail.com Daniela Haluza daniela.haluza@meduniwien.ac.at Sima Afrashteh sima.afrashte3@gmail.com Alireza Abbasi alireza.abasi1986@gmail.com Elma Omeragić elma.omeragic@ffsa.unsa.ba Belma Imamović belma.imamovic@ffsa.unsa.ba Narin A. Rasheed narin.rasheed@gmail.com Taqi M. J. Taher ttahir@uowasit.edu.iq Fitri Kurniasari fitri.kurniasari04@ui.ac.id Dhuha Youssef Wazqar dwazger@kau.edu.sa Özge Ceren Apalı oapali@hacettepe.edu.tr Ayca Demir Yildirim ayca.demiryildirim@uskudar.edu.tr Bo Zhao zhaobo@yonsei.ac.kr Zaruhi Kalikyan zkalikyan@yandex.ru Cui Guo guocuicui815@gmail.com Andrea Chong Valbuena chong.valbuena@gmail.com Magdalena Mititelu magdalena.mititelu@umfcd.ro http://orcid.org/0000-0001-5180-3047 72384 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Carolina Martínez Pando martinezpando_carolina@hotmail.com Maria Saridi sarmar32@windowslive.com Aikaterini Toska Ktoska07@yahoo.gr Magalys Lopez Cuba mlcuba@uhas.edu.gh Precious Kwablah Kwadzokpui kwadzokpuipreciousk@gmail.com; 015pkwadzokpui@uhas.edu.gh Niguse Tadele niguse.tadele@aau.edu.et Tohfa Nasibova tnesibova@amu.edu.az Stefanie Harsch stefanie.harsch@ph-freiburg.de Luvsan Munkh‑Erdene munkherdene@mnums.edu.mn Wafaa Menawi w.menawi@najah.edu Efi Evangelou evangeloue@hotmail.com Antoniya Dimova ant_dimova@abv.bg Dimitar Marinov dr.marinov.md@gmail.com Teodora Dimitrova tdimitrovatvd@gmail.com Anna Shalimova anna.shalimova83@gmail.com Howieda Fouly hoida.elfouly2@aun.edu.eg Anna Suraya Anna.suraya@binawan.ac.id Juliana Pereira da Silva Faquim julianafaquim@ufu.br Bouadil Oumayma Bouadiloumayma94@gmail.com Maria Antonieta Annunziato annunziato.maria@gmail.com Rezarta Lalo rezarta_lalo@yahoo.com Evridiki Papastavrou e.papastavrou@cut.ac.cy Anju D. Ade anju.ade@gmail.com Susanna Caminada susanna.caminada@uniroma1.it Svetlana Stojkov svetlanastojkov22@gmail.com Carmen Gloria Narvaez cgnarvaez@udd.cl Lutendo Sylvia Mudau mudauls72@gmail.com Ines Rassas inesrassas@yahoo.fr Daphnee Michel daphnee.michel@uniq.edu Nur Sema Kaynar nursemakaynar1@gmail.com Sehar Iqbal Sehar.iqbal@aau.ac.ae Halla Elshwekh Halla.h.m@btc.org.ly Irin Hossain Irin.hossain@gmail.com Sadeq AL‑Fayyadh s.al-fayyadh@conursing.uobaghdad.edu.iq Aniuta Sydorchuk sidorchuk@bsmu.edu.ua; aniuta.sydorchuk@gmail.com Dua’a M. H. Alnusairat duaalnusairat@gmail.com Asli Mohamed Abdullahi aslimaxamed10@gmail.com Apsara Pandey apsara.pandey@mnc.tu.edu.np Brenda Gómez‑Gómez bred_gomez@hotmail.com Aysenur Gunaydin Akyildiz gunaydinaysenur@gmail.com Daniella Dwarica Danielladwarica@gmail.com Gantuya Dorj gantuya.d@mnums.edu.mn Sumaya Yusuf Hasan sumayayousif@agu.edu.bh Noha M. Al‑Shdayfat dr.nuhash@aabu.edu.jo Bojana Knezevic bojana.knezevic@kbc-zagreb.hr Wendy Valladares Wendy.valladares@unah.edu.hn Cecilia Severi severi.cecilia@gmail.com Sofia Cuba Fuentes maria.cuba@upch.pe Sofia Augusto s.augusto@fc.ul.pt Elizaveta Sidorova elizavsid@gmail.com Anita Dewi Moelyaningrum anitamoelyani@gmail.com; anitadm@unej.ac.id Tafaul Alawad tafaulalawad@gmail.com 72385Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Atiqa Khalid atiqakkhalid@gmail.com Nafisa M. K. Elehamer elehamer.nafisa@med.unideb.hu Anna Mihaylova annamihaylova@abv.bg Oxana Tsigengagel tsigengagel.o@gmail.com Aziza Menouni aziza.menouni@kuleuven.be Agnieszka Wojtecka awojtecka@gumed.edu.pl Rozita Hod rozita.hod@ppukm.ukm.edu.my Yusuf Banke Idayat bitab19@yahoo.com Khadija Othman khadijaothman1993@gmail.com Rim M. Harfouch r.h.foph.LAT@aspu.edu.sy Meruyert Omar Meruyertomar92@gmail.com Nana Christine Benderli christinenana@yahoo.fr Globila Nurika nurikaglobila@unej.ac.id Sana Amjad sana@ualberta.ca Salma Elnoamany salmaalnomany6@gmail.com Fatma Elesrigy Fatma.abdalgawad.12@med.menofia.edu.eg Marwa Mamdouh Shaban Marwamamdouh.mamdouh70@gmail.com Doménica Acevedo‑López domeacevedo@gmail.com Maria Kartashova kmk8963@gmail.com Atika Khalaf atika.khalaf@hkr.se; a.khalaf@squ.edu.om Sabah Abdullah Jaafar sabah.abd@mu.edu.iq Taisir A. Kadhim taisirak14@mu.edu.iq; taiseer.alhussainy@gmail.com Nada Ab Hweissa n.hweissa@zu.edu.ly Yulong Teng yulongteng@yonsei.ac.kr Fatima E. Mohammed fatima.abuelgasim12@gmail.com Thayahlini Sasikumar thaya.viswa@gmail.com Christabel Nangandu Hikaambo xbellhikaambo@gmail.com; Christabel.hikaambo@unza.zm Aditi Kharat aditi.kharat@utah.edu Ulyana Lyamtseva ulyamtseva@gmail.com Maya Arfan Aldeeb maldeeb@hamad.qa; mayaldeeb@yahoo.com Natalia Pawlas natalia.pawlas@sum.edu.pl Lkhagvasuren Khorolsuren khorolsuren.l@mnums.edu.mn Roopeshwaree Pallavi Koonjul pallavikoonjul1234@gmail.com Halima Boubacar Maïnassara amhalima@gmail.com Priyanka Chahal drchahal10@gmail.com Rose W. Wangeci rwanjohi40@gmail.com Ainur B. Kumar a.kumar@kaznmu.kz Irina Zamora‑Corrales irigaz87@gmail.com Stella Gracy gracystella1985@gmail.com Maimouna Mahamat m_mahamat@yahoo.fr Jakub Adamczyk j.adamczyk@ujd.edu.pl Haliza Abdul Rahman dr.haliza@upm.edu.my Lolita Matiashova lota94s@gmail.com Omneya Ezzat Elsherif oelsherif@hotmail.com Nazdar E. Alkhateeb nazdar.alkhateeb@hmu.edu.krd Yamilé Aleaga Yamile.aleaga@ipk.sld.cu Shima Bahrami bahramishima31@gmail.com Shaimaa Rahem Al‑salihy Sh.r802011@gmail.com Paula Cabrera‑Galeana draPaulacabrera@gmail.com Mladena Lalic‑Popovic mladena.lalic-popovic@mf.uns.ac.rs Eugenie Brown‑Myrie ebrown@utech.edu.jm Divya Bhandari rayordeal3@gamil.com 72386 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 Cinderella Akbar Mayaboti cinderellamaya18@gmail.com Svetlana Stanišić sstanisic@singidunum.ac.rs Sanda Kreitmayer Pestic kreitmayersanda@gmail.com Muhammed Yunus Bektay yunusbektay@gmail.com Haleama Al Sabbah haleemah.alsabah@zu.ac.ae Saber Hashemi hashemisaber04@gmail.com Bouchetara Assia bouchetaraa@gmail.com Anne‑Sophie Merritt anne-sophie.merritt@ki.se Zhian Ramzi zean.ramzi@univsul.edu.iq Himawatee Baboolal himawatee.baboolal475@we.utt.edu.tt Juman Isstaif j.isstaif@gmail.com Rula Shami ra1704753@qu.edu.qa Rahma Saad Rahmasaad63@gmail.com Temwanani Nyirongo temsnyirongo@gmail.com 1 Department of Environmental Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran 2 Department of Environmental and Occupational Health Sciences, School of Public Health, SUNY Downstate Health Sciences Center, Brooklyn, NY, USA 3 Department of Medicine, O.O. Bogomolets National Medical University, Kyiv, Ukraine 4 Department of Medicine, Tehran University of Medical Sciences, Tehran, Iran 5 Center for Public Health, Department for Environmental Medicine, Medical University of Vienna, Kinderspitalgasse 15, 1090 Vienna, Austria 6 Department of Biostatistics and Epidemiology, Faculty of Health and Nutrition, Bushehr University of Medical Sciences, Bushehr, Iran 7 Faculty of Pharmacy, University of Sarajevo, Sarajevo, Bosnia and Herzegovina 8 Department of Medical Laboratory Technology, College of Health and Medical Technology Shekhan, Duhok Polytechnic University, Duhok, Kurdistan Region, Iraq 9 Family and Community Medicine Department, College of Medicine, University of Wasit, Kut, Wasit, Iraq 10 Department of Environmental Health, Faculty of Public Health, University of Indonesia, Jakarta, Indonesia 11 Department of Medical‑Surgical Nursing, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia 12 Faculty of Medicine, Hacettepe University, Ankara, Turkey 13 Midwifery Department, Üsküdar Universty, Istanbul, Turkey 14 Department of Health Administration, Graduate School, Yonsei University, 1 Yonseidae‑Gicl, Wonju, Gangwon‑do 26493, South Korea 15 Department of Clinical Immunology and Allergology, Yerevan State Medical University, Yerevan, Armenia 16 Department of Urban Planning and Design, The University of Hong Kong, Hong Kong, China 17 Division of Epidemiology, Public Health Center of Valencia, Valencia, Spain 18 Department of Clinical Laboratory and Food Safety, Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 19 Department of Medicine, University of Granada, Granada, Spain 20 School of Social Sciences, Hellenic Open University, Patras, Greece 21 Department of Pathology, School of Medicine, University of Health and Allied Sciences, Ho, Ghana 22 Department of Medical Laboratory Science, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana 23 Department of Nursing, School of Nursing & Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia 24 General and Toxicological Chemistry Department, Azerbaijan Medical University, Baku, Azerbaijan 25 Institute of Sociology, University of Education Freiburg, Freiburg, Germany 26 Department of Health Policy, School of Public Health, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia 27 Public Health Management Program, Faculty of Graduate Studies, An-Najah University, Nablus, State of Palestine 28 Nursing Department Limassol, Cyprus University of Technology, Limassol, Cyprus 29 Faculty of Public Health, Medical University Varna, 55 Marin Drinov Street, 9002 Varna, Bulgaria 30 Department of Hygiene and Epidemiology, Faculty of Public Health, Medical University of Varna, Varna, Bulgaria 31 Internal Medicine N1, Kharkiv National Medical University, Kharkiv, Ukraine 32 Reproductive Health Nursing (Gynecology and Obstetrics Nursing), Faculty of Nursing, Assiut University, Asyut, Egypt 33 CIHLMU Center for International Health, University Hospital, LMU, Munich, Germany 34 Occupational Safety and Health Department, Binawan University, East Jakarta, Indonesia 35 Technical School of Health, Federal University of Uberlândia (UFU), Uberlândia, MG, Brazil 72387Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 36 National School of Applied Sciences of Al Hoceima, Abdelmalek Essaadi University, Tetouan, Morocco 37 Venezuelan and Latin American Association of Clinical Nanomedicine, Caracas, Venezuela 38 Department of Health Care, Faculty of Public Health, The University of Vlore “Ismail Qemali”, Vlore, Albania 39 Cyprus University of Technology, Limassol, Cyprus 40 Department of Community Medicine, SVIMS, Sri Padamavathi Medical College, Tirupati, Andhra Pradesh, India 41 Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy 42 Department of Social Pharmacy, Faculty of Pharmacy, University Business Academy in Novi Sad, Novi Sad, Serbia 43 Facultad de Ciencias de la Salud, Universidad del Desarrollo, Concepción, Chile 44 Department of Environmental Health, Faculty of Science, Tshwane University of Technology, Pretoria, South Africa 45 Department of Occupational Medicine and Ergonomics, Faculty of Medicine, University of Monastir, Monastir, Tunisia 46 West Department, Quisqueya University, Port‑au‑Prince, Haiti 47 Public Health Nursing Department, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey 48 Department of Public Health and Nutrition, Al Ain University, Abu Dahbi, United Arab Emirates 49 Department of Genetic Engineering, The Biotechnology Research Center, Tripoli, Libya 50 Department of Occupational and Environmental Health (OEH), NIPSOM, Mohakhali, Dhaka, Bangladesh 51 Adult Nursing Department, College of Nursing, University of Baghdad, Baghdad, Iraq 52 Department of Infectious Diseases and Epidemiology, Bukovinian State Medical University, Chernivtsi, Ukraine 53 Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates 54 School of Medicine and Health Science, Simad University, Mogadishu, Somalia 55 Environmental Epidemiology Group, UK Health Security Agency, Chilton, Oxon, UK 56 Maharajgunj Nursing Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal 57 Department of Infectious Diseases, Centro Médico ABC, Mexico City, Mexico 58 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Bezmialem Vakif University, Istanbul, Turkey 59 Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago 60 Department of Epidemiology and Biostatistics, School of Public Health, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia 61 Department of Natural Resources and Environment, College of Graduate Studies, Arabian Gulf University, Manama, Bahrain 62 Community and Mental Health Department, Al al-Bayt University, Mafraq, Jordan 63 University Hospital Centre Zagreb, Zagreb, Croatia 64 Microbiology Research Institute, National Autonomous University of Honduras, Tegucigalpa, Honduras 65 Department of Preventive Medicine, Faculty of Medicine, University of the Republic, Montevideo, Uruguay 66 Faculty of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru 67 EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal 68 Moscow State Medical University, Sechenov University, Moscow, Russia 69 Public Health Faculty, Environmental Health and Occupational Health and Savety Departement, University of Jember, Jember, Indonesia 70 Faculty of Public and Environmental Health, University of Khartoum, Khartoum, Sudan 71 Sahiwal Medical College, University of Health Sciences, Lahore, Pakistan 72 Department of Health Education, University of Khartoum, Khartoum, Sudan 73 Medical College, Medical University of Plovdiv, Plovdiv, Bulgaria 74 Department of Public Health, NCJSC “Semey Medical University”, Semey, Kazakhstan 75 Environment and Health Unit, Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium 76 Department of Public Health and Social Medicine, Medical University of Gdansk, Gdansk, Poland 77 Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Bangi, Malaysia 78 Department of Environmental Health Sciences, University of Ibadan, Ibadan, Nigeria 79 Ministry of Foreign Affairs and East African Cooperation, Dodoma, Tanzania 80 Department of Microbiology and Biochemistry, Al Sham Private University, Latakia, Syria 81 Department of Population Health and Social Sciences, Kazakhstan’s Medical University School of Public Health, Almaty, Kazakhstan 82 Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon 83 Department of Animals Biology and Physiology, University of Yaoundé I, Yaoundé, Cameroon 84 Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada 85 Family Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt 72388 Environmental Science and Pollution Research (2023) 30:72368–72388 1 3 86 Community Health Nursing Department, Faculty of Nursing, Cairo-University, Cairo, Egypt 87 Faculty of Medicine, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia 88 Department of Human Pathology, Sechenov University, Moscow, Russia 89 Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden 90 College of Nursing, Sultan Qaboos University, Muscat, Oman 91 College of Nursing, University of Al-Muthanna, Samawah, Iraq 92 Department of Public Health, Faculty of Medical Technology, Zawia University, Zawia, Libya 93 Department of Korean Language and Literature, Graduate School, Yonsei University, Gangwon‑do, South Korea 94 Faculty of Medicine, University of Khartoum, Khartoum, Sudan 95 Institute of Medicine, University of Colombo, Colombo, Sri Lanka 96 Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia 97 College of Pharmacy, University of Utah, Salt Lake City, UT, USA 98 Department of Medicine of the Future, Sechenov University, Moscow, Russia 99 Hamad Medical Corporation, Doha, Qatar 100 Damascus University, Damascus, Syria 101 Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland 102 Institute of Public Health, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia 103 Department of Medicine, University of Mauritius, Moka, Mauritius 104 Conseils Etudes Enquêtes Recherches Formation en Epidémiologie (CEERFE), Niamey, Niger 105 S. Tentishev Asian Medical Institute, Kant, Kyrgyzstan 106 Health Sciences, School of Public Health, University of Nairobi, Nairobi, Kenya 107 Department of Health Policy and Management, School of Public Health, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan 108 School of Public Health, University of Costa Rica, San José, Costa Rica 109 Department of Biomedical Sciences, University of Asmara, Asmara, Eritrea 110 Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, Yaounde, Cameroon 111 Faculty of Health Sciences, Jan Długosz University of Humanities and Life Sciences, Czestochowa, Poland 112 Department of Environmental and Health Sciences, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia 113 T Malaya Therapy National Institute, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine 114 Cairo University Hospitals, Cairo, Egypt 115 Department of Medical Education, College of Medicine, Hawler Medical University, Erbil, Iraq 116 Department of Clinical Microbiology, Institute of Tropical Medicine “Pedro Kouri”, Havana, Cuba 117 Shiraz University of Medical Sciences, Shiraz, Iran 118 Microbiology Department, College of Medicine, University of Diyala, Diyala, Iraq 119 Instituto Nacional de Cancerología, Mexico City, Mexico 120 Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia 121 Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, University of Technology, Kingston, Jamaica 122 Medical Governance Research Institute, Tokyo, Japan 123 University of Oslo, Oslo, Norway 124 Singidunum University, Belgrade, Serbia 125 Family Medicine Department, Medical School, University of Tuzla, Tuzla, Bosnia and Herzegovina 126 Clinical Pharmacy Department, Faculty of Pharmacy, Marmara University, Istanbul, Turkey 127 Department of Health Sciences, Zayed University, Dubai, United Arab Emirates 128 Department of Chemical Engineering, Faculty of Engineering, University of Kurdistan, Sanandaj, Iran 129 Peadiatric’s Infectious diseases, Hospital of Canastel and Faculty of Medicine, Oran, Algeria 130 Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden 131 College of Nursing, University of Sulaimani, Kurdistan, Sulaimani, Iraq 132 Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago 133 Department of Neurology, Faculty of Medicine, Damascus University, Damascus, Syria 134 Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar 135 Department of Public Health, Qatar University, Doha, Qatar 136 Environmental Health, Rusangu University, Monze, Zambia 137 Research Center for Health Sciences, Institute of Health, Shiraz, Iran 138 Department of Environmental Health, School of Health, Shiraz University of Medical Sciences, Razi Blvd, Kuye‑Zahra Ave, Shiraz 1417653861, Iran A comprehensive health effects assessment of the use of sanitizers and disinfectants during COVID-19 pandemic: a global survey Abstract Introduction Methods Design, participants, and sampling procedure Measurement tools Questionnaire Reliability and validity Data collection procedure Statistical analysis Result Study design and participants Type and volume of sanitizers and disinfectants used Adverse health outcomes of sanitizers and disinfectants Skin effects Ocular effects Throat effects Respiratory system effects Neurological effects Multivariable logistic regression analysis Discussion Strengths and limitations Conclusion Anchor 24 Acknowledgements References