Abstract:
Effective infection control programs must deal with all environmental sources and modes of transmission that lead to the negative effects of microbes on materials. These may include product odors, deterioration, staining, bio-slimes, human impacts of toxic response, allergic response, irritation, sensitization, primary infections, secondary infections, and simple discomfort. With the alarming growth of antimicrobial resistant bacteria we must develop persistently effective cleaning tools and practices for clean air, water, surfaces and hands.
Main Article:
With the CDC and WHO announcing newly emerging infections, pandemic bacteria, fungi, viruses, and more antibiotic-resistance on a regular basis, we need to look to new strategies to protect staff, patients, and the public at large. Our experiences make us advocates for utilizing “best available, evidence based technologies” targeting all sources and modes of transmission. In this article, some of the modes of transmission will be discussed. Modes include, but are not limited to, surfaces, air and textiles. Getting this right will be critical for continuous shedding of bacteria and viruses from human inhabitation of the environment. As millions of bacteria per hour are shed, persistent cleaning is vital to stay on top of infection and bacterial prevention in hospitals.
Airborne
Airborne transmission of disease causing organisms and fomites is well proven and not only originating from fluid emission such as sneezing. There has been some clinical contention that this is a non-factor however, this has been proven by a number of case studies and papers on this subject that go back to Lister, Pasteur, and Semmelweis. The abundant data on morbidity and mortality clearly shows otherwise.
In a study by Hospodsky et al, the authors attempted to determine the origins of indoor airborne bacteria, discussing the aerosolization of particles from surfaces (Hospodsky et al., 2012).
Similar, it was found that Noroviruses were responsible for more than 50 percent of gastroenteritis cases worldwide, can spread by air up to several meters. The study actively measured Norovirus in the air of medical facilities (Bonifait et al., 2015).
The data is supported by Aspergillosis deaths in immunosuppressed children from fungi sourced through an air handling system, and the obvious connection of water and surface sources, air transmitted Legionella spp., and Legionnaires Disease. MERS, pneumonia, and even Clostridium difficili infections are just a few of the infectious disease organisms that are all documented to pass from people to surfaces and from air to people.
There are a number of technologies that are used in industry to clean the air. The two chief technologies are entrapment filters (sometimes treated with antimicrobial treatments) and properly configured UV-C light. The American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE) requires Minimum Efficiency Reporting Value (MERV) of 14 filters or higher in patient areas. Terminal HEPA filters are used in the supply air for surgical areas. Most hospitals don’t have adequate air filtration. HVAC should be under the domain of the infection control team because they can be a source and transmission routes for disease within a facility. Accounting for air circulation and all routes of infiltration and exfiltration need to be accounted for proper particulate, VOC, and microbial control. These sources and transfer routes are rarely considered by the infection control staff.
Hand Hygiene
Hand hygiene and other personal hygiene practices from clothing to respiration are a critical part of the infection cycle. Fomites on the hands can be transferred to the patient, or to a contact point near the patient. Transmission and infection in such scenarios is well documented. Non-compliance with hand hygiene protocol is a huge issue in virtually all facilities. Uniform hygiene and masking are reviewed on an intermittent basis at best. Srigley and associates found a significant increase in efforts to keep hands clean with those being watched versus those not being watched (Srigley, Furness, Baker, & Gardam, 2014). Ultimately, it suggests that people say they are more diligent about hand hygiene than they actually are. Dr. Ignaz Semmelweis first noted the need for hand hygiene and the need to move away from alcohol because it is hard on the skin. Our experience is the use in hand sanitizer doubles when tracked electronically. Moving away from alcohol will encourage hand hygiene. Hand hygiene compliance remains lacking (Markel, 2015).
Surfaces and Fomites
We know that surfaces remain contaminated with bacteria, viruses, and fungi for various lengths of time. Different bacteria, viruses, and fungi can survive on surfaces up to months at a time, all being influenced by temperature and humidity. The microbiome of surfaces within any environment are dynamic and constantly subject to change. Microbial shedding from human cells and surfaces means the microbial load in a room changes with the number of occupants, their activities and surface hygiene practices. In a systematic review analyzing nosocomial pathogens, it was ultimately concluded that “the most common nosocomial pathogens may well survive or persist on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed” (Kramer, Schwebke, & Kampf, 2006).
Linens and uniforms also fall into the category of surfaces. Fabrics can harbor fomites, which can be a threat to patients. Nursing and physician attire was identified as a possible source of nosocomial infections in a 2011 study. Wiener-well et al concluded that “up to 60 percent of hospital staff’s uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection” (Wiener-Well et al., 2011).
These modes of transmission are of great concern as observational studies have shown less than 50% of the surfaces are cleaned in a normal room cleaning (Han, Sullivan, & Leas, 2015). A shortened version can be found at: http://www.infectioncontroltoday.com/news/2015/08/study-finds-important-gaps-in-evidence-for-best-methods-for-cleaning-hospital-rooms-to-prevent-hais.aspx
Conclusion
We know that bacterial, fungal, viral shedding and transfer is ongoing. We know the key sources and transfer routes. We have key technologies that are evidence-based and field-tested for prevention, sanitization, and preservation. We need to move toward more persistent surface modifications and more efficient air filtering media added for better, more simple cleaning and hygiene practices. With more professional training and cleaning, this can be improved. Technologies and Programs are available!
References:
Bonifait, L., Charlebois, R., Vimont, A., Turgeon, N., Veillette, M., Longtin, Y., … Duchaine, C. (2015). Detection and quantification of airborne norovirus during outbreaks in healthcare facilities. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 61(3), 299–304. http://doi.org/10.1093/cid/civ321
Han, J., Sullivan, N., & Leas, B. (2015). Cleaning Hospital Room Surfaces to Prevent Health Care–Associated Infections: A Technical Brief. Annals of Internal …. Retrieved from http://annals.org/article.aspx?doi=10.7326/M15-1192&an_fo_ed
Hospodsky, D., Qian, J., Nazaroff, W. W., Yamamoto, N., Bibby, K., Rismani-Yazdi, H., & Peccia, J. (2012). Human occupancy as a source of indoor airborne bacteria. PloS One, 7(4), e34867. http://doi.org/10.1371/journal.pone.0034867
Kramer, A., Schwebke, I., & Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases, 6(1), 130. http://doi.org/10.1186/1471-2334-6-130
Markel, H. (2015). In 1850, Ignaz Semmelweis saved lives with three words: wash your hands | PBS NewsHour. Retrieved January 27, 2016, from http://www.pbs.org/newshour/updates/ignaz-semmelweis-doctor-prescribed-hand-washing/
Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Quality & Safety, 23(12), 974–80. http://doi.org/10.1136/bmjqs-2014-003080
Wiener-Well, Y., Galuty, M., Rudensky, B., Schlesinger, Y., Attias, D., & Yinnon, A. M. (2011). Nursing and physician attire as possible source of nosocomial infections. American Journal of Infection Control, 39(7), 555–9. http://doi.org/10.1016/j.ajic.2010.12.016
Bonifait, L., Charlebois, R., Vimont, A., Turgeon, N., Veillette, M., Longtin, Y., … Duchaine, C. (2015). Detection and quantification of airborne norovirus during outbreaks in healthcare facilities. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 61(3), 299–304. http://doi.org/10.1093/cid/civ321
Han, J., Sullivan, N., & Leas, B. (2015). Cleaning Hospital Room Surfaces to Prevent Health Care–Associated Infections: A Technical Brief. Annals of Internal …. Retrieved from http://annals.org/article.aspx?doi=10.7326/M15-1192&an_fo_ed
Hospodsky, D., Qian, J., Nazaroff, W. W., Yamamoto, N., Bibby, K., Rismani-Yazdi, H., & Peccia, J. (2012). Human occupancy as a source of indoor airborne bacteria. PloS One, 7(4), e34867. http://doi.org/10.1371/journal.pone.0034867
Kramer, A., Schwebke, I., & Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases, 6(1), 130. http://doi.org/10.1186/1471-2334-6-130
Markel, H. (2015). In 1850, Ignaz Semmelweis saved lives with three words: wash your hands | PBS NewsHour. Retrieved January 27, 2016, from http://www.pbs.org/newshour/updates/ignaz-semmelweis-doctor-prescribed-hand-washing/
Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Quality & Safety, 23(12), 974–80. http://doi.org/10.1136/bmjqs-2014-003080
Wiener-Well, Y., Galuty, M., Rudensky, B., Schlesinger, Y., Attias, D., & Yinnon, A. M. (2011). Nursing and physician attire as possible source of nosocomial infections. American Journal of Infection Control, 39(7), 555–9. http://doi.org/10.1016/j.ajic.2010.12.016