Introduction

While the COVID-19 pandemic appears to be slowing down, the next pandemic is knocking at our door – infections caused by antibiotic resistant organisms (ARO). The post-antibiotic era isn’t coming – it’s here.1 According to Dr. Arjun Srinivasan with the Centers for Disease Control & Prevention (CDC), “The COVID-19 pandemic has created the perfect storm for antibiotic resistance. Prolonged lengths of stay; crowding; and infection control challenges, such as training gaps and shortages in PPE, all contribute.”2 It is estimated that in the next 30 years, deaths caused by AROs will surpass those caused by all cancers combined.3

The two AROs we’ll focus on are Candida auris (C. auris) and Clostridioides difficile (C. diff), both of which are considered urgent threats, according to the CDCs most recent Antibiotic Resistance Threats Report. What these two pathogens hold in common is their ability to cause severe infections, survive in the environment for prolonged periods, and spread easily between hospitalized patients and nursing home residents. In 2018, there were only 323 known clinical cases of C. auris.1 As of November 2020, the total has climbed to 1,595 which represents a nearly 400% increase in just two years.4 Moreover, to demonstrate how quickly the C. auris yeast can spread, in March 2017, a single case of C. auris was identified on a ventilator unit in Chicago. Sixteen months later, C. auris prevalence on the unit was 71%.5

Regarding C. diff, while we have made progress in reducing healthcare-onset rates in recent years, some studies show that these rates may have increased during the pandemic.6 But there are also studies that show a decrease.7,8,9 With the CMS reporting waivers during the pandemic, we may never know the true impact, at least not for a while. Regardless, C. diff remains the most common cause of healthcare-associated infections, more than half of which occur among recently hospitalized long-term care facility residents.1

Deviations from recommended infection control practices during the pandemic, fueled by fear of a novel pathogen, staffing challenges and supply chain challenges may have contributed to outbreaks of these two pathogens. For example, at one facility, a C. auris outbreak involving 35 patients was attributed to such deviations. In addition to missed hand hygiene opportunities, the CDC investigators found incorrect use of PPE and inconsistent disinfection of mobile computers and medical equipment between uses. . However, one of the control measures that helped in stopping this outbreak was enhanced cleaning and disinfection practices.10

Take Action to Prevent the Spread

The importance of infection prevention and control measures cannot be over-emphasized. The strategies to control these two pathogens are similar and include antibiotic stewardship, surveillance, diagnostic testing, transmission-based precautions, hand hygiene, inter-facility communication, and cleaning and disinfection of environmental surfaces and medical equipment. In this final section, we will focus on cleaning and disinfection.

Both of these contact-spread pathogenscan survive for prolonged periods on surfaces.  C. auris can survive for weeks and C. diff can survive up to 5 months making cleaning and disinfecting an imperative practice.11,12 Below are some key points around cleaning and disinfection when C. diff or C. auris are present:

Conclusion

These two urgent threat pathogens have many factors in common, which include an affinity for environmental surfaces, including medical equipment and for causing outbreaks. Robust cleaning and disinfecting programs are a key infection control measure.

References

  1. CDC. (2019). Antibiotic Resistance Threats in the United States. [online]. [cited 2021 Mar 13]. Available from https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf.
  2. Medscape Nurses. (2020). CDC Doc Addresses Today’s Pandemic and the Next. [online]. [cited 2021 Mar 13]. Available from https://www.medscape.com/viewarticle/941169.
  3. WHO. [2019]. New Report Calls for Urgent Action to Avert Microbial Resistance Crisis. [online]. [cited 2021 Mar 13]. Available from https://www.who.int/news/item/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis.
  4. CDC. (2021). Tracking Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
  5. Chicago Department of Public Health. (2018). 23rd Annual Infection Control Conference: Candida auris Emergence and Containment Efforts in the Chicago Region. [online].[cited 2021 Mar 14]. Available from https://www.chicagohan.org.
  6. Lewandowski K, Rosołowski M, Kaniewska M, Kucha P, Meler A, Wierzba W, et al. Clostridioides difficile Infection In Coronavirus Disease (COVID-19): An Underestimated Problem? Pol Arch Intern Med. 2021 Feb 26;131(2):121-127.
  7. Assi M, Doll M, Pryor R, Cooper K, Bearman G, Stevens MP. Impact of COVID-19 on Healthcare-Associated Infections: An Update and Perspective. Infect Control Hosp Epidemiol. 2021 Mar 12:1-9.
  8. Bentivegna E, Alessio G, Spuntarelli V, Luciani M, Santino I, Simmaco M, et al. Impact of COVID-19 Prevention Measures on Risk of healthcare-Associated Clostridioides difficile Infection. Am J Infect Control. 2020 Oct 5:S0196-6553(20)30891-9.
  9. Ponce-Alonso M, Sáez de la Fuente J, Rincón-Carlavilla A, Moreno-Nunez P, Martínez-García L, Escudero-Sánchez R, et al. Hospital-Onset Clostridioides difficile Infections During the COVID-19 Pandemic. J.Infect Control Hosp Epidemiol. 2020 Sep 8:1-5.
  10. CDC. (2021). MMWR Vol. 70: Candida auris Outbreak in a COVID-19 Specialty Care Unit – Florida, July-August 2020. [online].[cited 2021 Mar 15]. Available from https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e3.htm
  11. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am. J. Med. 1981; 70:906–908.
  12. CDC. (2019). Candida auris: Healthcare Professional FAQ.[online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-health-qa.html  
  13. CDC. (2020).Infection Prevention and Control for Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html#disinfection.
  14. EPA. (nd). Pesticide Product and Label System. [online]. [cited 2021 Mar 19]. Available from https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1.
  15. CDC. (2019). Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. [online]. [cited 2021 Mar 15]. Available from https://www.cdc.gov/hai/prevent/cdi-prevention-strategies.html.
  16. Donskey C, Cadnum J, Jenscon A, Livingston S, Li D, Redmond S, et al. (2020). Evaluation of an electrostatic sprayer disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. AJIC, (48):951-954.

A Little About Me

I have been a nurse since 1993 and have worked as an Infection Preventionist (IP) for the past 20 years. Throughout my infection control career, I’ve faced challenges such as the potential weaponizing of smallpox after 9/11, the SARS outbreak in 2003, the H1N1 pandemic in 2009, and the Ebola outbreak in 2014 (just to name a few). I have seen a lot of tragedy and hardship, most of which I never would have dreamed of seeing in a million years.

In 2018, I made a big change in my infection control path. I was afforded an opportunity to join the Clorox Healthcare team as a Senior Infection Preventionist. After completing my first year in my new role, the COVID-19 pandemic was just beginning – a monumental pandemic that we will likely never see again in our lifetimes. In a matter of a few months, COVID-19 spread like wildfire to nearly every continent. We spent most of 2020 in lockdown, and infection prevention became more relevant than ever.

My COVID-19 Pandemic Story

In March of 2020, as part of the emergency response to COVID-19, California Governor Gavin Newsom released an executive order allowing the state of California to commandeer hotels and medical facilities to treat COVID-19 patients. This was termed “Project Roomkey 2 and local counties were tasked with manning these shelters.1

In my local county, some of these hotels are being used as temporary isolation housing for unsheltered residents. The intent is to reduce transmission in the community from infected persons who are experiencing homelessness or live in congregate or over-crowded settings (e.g., prisons, etc.). Meanwhile, some of the hotels (named Safer Ground sites) are designated for medically fragile persons who meet the above criteria and have not been diagnosed with COVID.2 

The other hotels (named Operation Comfort sites) serve as shelters to quarantine or isolate COVID-positive or COVID-exposed individuals who meet the criteria listed above. Project Roomkey takes referrals from hospitals, clinics, prisons, emergency shelters, and homeless outreach teams.

Last summer, I learned through a friend that our local county public health department was looking for nurses to replace the public health nurses at the shelters, who were desperately needed by the county to return to their usual public health roles. With a full-blown pandemic underfoot, I had been chomping at the bit to be able to put my IP skills to work and contribute in a substantive way. I was hired part-time to supervise nurses at the COVID-positive shelters. Since July 2020, I have been working every other weekend with medically fragile COVID-positive individuals in the hotels in an underserved area of East Oakland, California.

Challenges from the Front Lines

Since an “isolation/quarantine” hotel had never been created or utilized in modern times, we’ve had to continuously learn and adapt to new situations. This often means that our protocols, along with the CDC guidance for COVID-19, is also continuously evolving. Furthermore, as is often the case in public health nursing, we are with faced limited resources. This includes things as simple as having a consistent supply of environmental surface disinfectants.  Just about every time I report for duty, we have a different disinfectant which means having to learn the instructions for use, including the contact time.  Also, with the supply chain shortages, it means we have to remember to save our empty bottles and trigger sprays for refilling.

As if fighting COVID-19 were not enough, we’ve also had to address the complicated health and social issues our patients face on a daily basis outside of the pandemic, such as mental health and/or substance abuse disorders. My fellow nurses and I must simultaneously monitor our patients’ COVID symptoms as well as any withdrawal or suicidal ideation indicators. Some of our patients also have complex health issues (e.g., diabetes) so we work diligently to coordinate the appropriate care.

Additionally, patients at Project Roomkey come from all types of socioeconomic backgrounds. For low-income community members, having to quarantine for 14 days or stay isolated at a hotel could mean missing a paycheck or risking the next meal for their family. Meeting these patients’ social or other medical needs is not easy when your patient also has an infectious disease like COVID-19. I quickly realized that it’s not the same as working in the hospital outside the pandemic where virtually every resource you need to do your job is on-hand.

In addition to our patients, our nursing staff also come from a variety of backgrounds, which range from new graduates to veteran caregivers. Clinical backgrounds include hospital (ICU, OR, and Medical-Surgical), long-term care, home care, infection prevention and control, behavioral health, public health, and even nurses from academia. What I appreciated this past year was that no one used their specialty to appear superior to anyone else. We simply leaned on each other’s strengths and got the work done.

Finding Inspiration Among the Hardship

Since this work takes place in addition to my regular “day job” with Clorox Healthcare, I’ve had to find inspiration to keep showing up every other weekend. Fortunately, this did not prove to be too difficult as I’ve found great inspiration in both my patients and my coworkers. The most vulnerable in our community needed us during this historic event and as a nurse, I felt that it was my duty to help.

Like me, many of my fellow hotel coworkers took on this work in addition to their “day jobs.” Their dedication motivates me to keep showing up week after week. These amazing individuals not only give their time and skills, but they often donate items to these families in need - things like winter clothing, children’s toys, and games to keep them occupied during quarantine. In addition to nurses, the healthcare team includes nurse practitioners, physicians, mental health providers, substance abuse providers, and pharmacists. Meanwhile, we couldn’t do any of this without the relentless work of the facilities team, housing support staff, housekeepers, cooks and security guards in the hotels. The team collaboration and the comradery of this group has been truly something amazing to be a part of. 

Finally, I would be remiss if I didn’t recognize the inspiration provided by all of my fellow IPs out there wherever they have been working during this pandemic. Your dedication to our profession is nothing short of remarkable.

Relief is in Sight

When both the Moderna and Pfizer vaccines were granted Emergency Use Authorization (EUA) from the Federal Drug Administration in December 2020, I was beyond elated to help run the staff vaccination clinic.3 Along with a few of my coworkers, we administered nearly 140 first doses to our fellow shelter workers, which included nurses, medical assistants, housing support staff, housekeepers, cooks, and security guards. I was more than happy to do it all over again four weeks later, too. Being able to offer hope through a vaccine has brought me such joy that I have volunteered to administer vaccinations to the general public as well.

As public health officials, healthcare workers, and members of our community continue to come together to help fight the spread of COVID-19, I’m grateful for the resilience I’ve witnessed first-hand over the past year. This virus is not done with us yet and we are not done fighting, but I have hope for the future. Before the pandemic struck, 2020 had been designated the International Year of the Nurse in honor of the 200th anniversary of Florence Nightingale’s birthday.4  While this may have been lost in the chaos of the pandemic, we nurses will never forget the additional meaning behind this past year.

References

  1. Alameda County Public Health Care for the Homeless. Isolation Housing for COVID-19 [nternet]. [cited 2021 Mar 7]. Available from: https://www.achch.org/isolation-housing.html
  2. Office of the Governor Gavin Newsom. Governor Newsom Issues New Executive Order Further Enhancing State and local Government’s Ability to Respond to COVID-19 Pandemic [internet]. [cited 2021 Mar 7]. Available from: https://www.gov.ca.gov/2020/03/12/governor-newsom-issues-new-executive-order-further-enhancing-state-and-local-governments-ability-to-respond-to-covid-19-pandemic/
  3. Federal U.S. Food & Drug Administration. COVID-19 Vaccines [internet]. [cited 2021 Mar 7]. Available from: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines
  4.  World Health Organization. Executive Board Designates 2020 as the “Year of the Nurse and midwide.” [internet]. [cited 2021 Mar 7]. Available from: https://www.who.int/news/item/30-01-2019-executive-board-designates-2020-as-the-year-of-the-nurse-and-midwife-

Guidelines from several government and professional organizations lead one to believe that the use of spray disinfectants in healthcare settings is “taboo”.  The primary rationale cited for this is concern for the production of aerosols and also for contaminated solutions. In true Infection Preventionist form, I decided to take a closer look at the evidence that informs these guidelines. The bottom line is that I could not find much evidence to support NOT using sprays disinfectants when appropriate, at least nothing current.  Let’s take a closer look.

The Evidence

What evidence was used to inform these guidelines? For their recommendations around use of spray disinfectants in healthcare settings, the Centers for Disease Control and Epidemiology (CDC) Guidelines cite four studies ranging from 21-49 years old with little relevance to spray disinfectants.1 As I chased the evidence trail, the studies just got older and older. The most curious finding was the lack of relevance of these studies. The guideline authors are generalizing results from studies that looked at floor care and vacuuming with outdated and faulty equipment, construction activities, use of porous insulation in buildings as a source of pathogens, and prevention of opportunistic infections in stem cell transplant patients to support their stance on not using spray disinfectants.

As for the guidelines from the key professional organizations, most simply cite the CDC’s guidance. Take for example the Association for periOperative Registered Nurses (AORN) Perioperative Practice Guidelines which recommend against the use of spray bottles in the operating room.2  AORN cites the CDC guidelines and states that “sprayed disinfectants produce more aerosols compared to other formats”.2 They also provide the rationale that “if the cleaning solution is contaminated, spraying may provide a route for airborne transmission which may contaminate the surgical wound, sterile supplies, or the sterile field”.2

With today’s pre-diluted, ready-to-use (RTU) sprays and liquids, the chance of contaminated product is virtually zero3. I would also like to call out that we should not be carrying out environmental cleaning tasks when the patient with a surgical wound or sterile supplies are present anyway - regardless of the disinfectant format used!

The Association for the Healthcare Environment (AHE) Practice Guidance provides no rationale or evidence for their recommendation to “apply chemicals using pour spouts, rather than sprayers”.4 Like AORN, AHE recommends “no spraying or misting bottles in the OR as they may aerosolize the disinfectant”.  The source for this guidance? AORNs guidelines which point to the CDC Guidance addressed above. As you can see, we are traversing quite the rabbit hole!

Most importantly, I could find no mention on use of spray disinfectants from the Association for Professionals in Infection Control & Epidemiology (APIC) or from the Centers for Medicare & Medicaid (CMS), the latter of which is a regulatory agency.

The basis for non-use of sprays largely centers on the concern of contaminated disinfectants made from concentrate. While this may be possible, this can eliminated with the use of RTU sprays, and the risk decreased by emphasizing the need to clean and dry spray bottles rather than “topping off”.

Modern Day Sprays

Some of today's manufactures have engineered sprayers that create larger droplets rather than an aerosolized mist which would reduce the risk that spray bottles aerosolize microorganisms or pose an occupational hazard. So if we connect the dots of what we have learned so far, spray disinfectants do have a place for use in healthcare settings.

Think about conducting a risk assessment to determine when and where in your facility that the use of spray bottles might be appropriate. Some examples might include: vacant spaces such as operating rooms between patients or at end of the day, waiting rooms, public restrooms, conference rooms, and public spaces to list a few. When considering a spray disinfectant, include the following in your assessment:

  1. The conditions in which it would be appropriate to use spray disinfectants.
  2. Information provided in the Safety Data Sheet (SDS).
  3. Product instructions for use (IFUs), including personal protective equipment (PPE).  

Summary

A reassessment of the evidence from past studies is needed. But in the meantime, we must remember that these are guidelines and not regulations and that healthcare facilities can conduct their own risk assessments and implement the appropriate use of spray disinfectants.

References

  1. Centers for Disease Control & Prevention (CDC). (2003). Environmental infection Control Guidelines from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html.
  2. Association for periOperative Registered Nurses (AORN). (2020). Guidelines for periOperative Practice from https://www.aorn.org/guidelines/about-aorn-guidelines (subscription required).
  3. Weber, D., Rutala, W., Sickbert-Bennett, E. (2007) Outbreaks Associated with Contaminated Antiseptics and Disinfectants. Antimicrobial Agents and Chemotherapy, p. 4217-4224.
  4. Association for the Health Care Environment (AHE). (2020). Practice Guidance for Health Care Environmental Cleaning, 3rd edition from https://www.ahe.org/ahe-publications-home (subscription required).

This post is part of our “Ask The Pros” blog series for which our internal panel of experts address the latest questions from industry professionals. This month’s query,

“Adjunct disinfection methods such as electrostatics seem to be gaining in popularity. Is a manual cleaning step always required?”

Introduction

Because Infection Preventionists have oversight of all cleaning and disinfection practices within their facilities, it’s really important to keep current on emerging disinfectant technologies, including new adjunct disinfection technologies. One such technology in high demand given the “new normal” is electrostatic sprayers. In addition to getting disinfectant into nooks and crannies, these devices can disinfect large areas in a very short time. This blog post will provide a brief overview of the technology, how best to employ its use within a healthcare facility, and safety considerations.

Electrostatic Sprayer Technology 101

Despite its growing popularity, electrostatic technology is actually not new. It’s been used for many years in other industries such as agriculture, automotive painting, and spray tanning. In healthcare, this adjunct technology is a new way to apply familiar disinfectants. The device charges the disinfectant droplets as they exit the nozzle where the disinfectant is attracted to the surface/object like a magnet. The end result is a uniform coating of disinfectant that wraps 360 degrees around targeted objects. This makes for a fast and efficient disinfecting process.

Incorporating Electrostatic Sprayer Technology into Current Processes

A study conducted by Bhalla et al (2004) showed that only 50% of healthcare surfaces were properly disinfected with manual cleaning1, creating the need for supplemental disinfectant technologies such as electrostatics. Electrostatic sprayers are intended to be an adjunct to routine manual cleaning and disinfection.

For example, consider using an electrostatic sprayer as a finishing step for terminal cleaning of C. diff, COVID, or other isolation rooms. Other considerations include terminal cleaning of operating rooms, waiting rooms, and transport equipment such as wheelchairs and gurneys.

With that said, much like we use hand sanitizer for much of our hand hygiene opportunities and reserve hand washing for specific times such as removing visible soil or C. diff spores from our hands, we can consider using an electrostatic sprayer in a similar way.

If a surface is not visibly soiled or the area did not house a C. diff patient, a manual cleaning step is not required prior to disinfection so consider using electrostatic sprayer technology in these instances. Consider that operating rooms (OR) are manually cleaned multiple times during the day (e.g., after each procedure), so why couldn’t terminal cleaning of the OR be completed using an electrostatic sprayer to apply the disinfectant?

Additionally, consider objects or areas that are likely not getting cleaned and disinfected as often as we would like because they are large spaces, or difficult to clean, such as waiting rooms or wheelchairs. Electrostatic sprayers are a great option and the Donskey study (2020) provides great evidence to support this. Keep in mind, however, just like our hands, we do still need to periodically perform manual cleaning.  

Electrostatic Sprayer Safety

First and foremost, be sure to select EPA-registered products approved for use through an electrostatic sprayer. Use of a disinfectant or sanitizer in a non-approved manner is a violation of federal law. It’s equally important to adhere to the manufacturer’s directions for use (DFUs), including contact time.

Be sure to wear personal protective equipment (PPE) according to both the manufacturer’s DFUs for the selected product and also per Standard Precautions.

We often get asked if it’s safe to use an electrostatic sprayer when other people are in the area being disinfected. In addition to following the manufacturer’s DFUs for both the device and the disinfectant, we recommend that only the operator be present in the room while the device is being used. Another question that frequently gets asked is “what is the room re-entry time after applying the disinfectant?”  The answer: there is none!

The Clorox® Total 360® System

Clorox Healthcare offers an electrostatic sprayer technology called the Total 360® System. The table below is quick overview of the current products in our portfolio that can be used with the Total 360 electrostatic sprayer.

Total 360 DisinfectantsActive IngredientSuggested Use LocationsContact timePersonal Protective Equipment (PPE)
Spore10 Defense™ Cleaner DisinfectantSodium hypochloritePatient care areas where C. diff is a concern (e.g., terminal cleaning, etc)5 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
Total 360® Disinfectant Cleaner1Quaternary ammonium compoundPatient care areas when C. diff is not a concern2 minutesEye protection; Wear an N95 respirator for prolonged use; Wear other PPE in accordance with Standard Precautions.
Anywhere® Hard Surface Sanitizing SpraySodium hypochloriteNon-patient care areas such as offices and conference rooms and anywhere that a food safe product is indicated such as the cafeteria.2 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
 

Summary

Adjunct disinfection technologies such as electrostatic sprayers can be a great addition to your current cleaning and disinfection routines. The technology has been around for many years and it is both safe and efficient.

Related Resources


References

  1. Bhalla A., Pultz N.J., Gries D.M. et al. “Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients.” Infection Control Hospital Epidemiology. 2004 Feb;25(2): 164–7

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in the U.S. to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in US healthcare settings. As Infection Preventionists (IPs), we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. For a more detailed overview, please see our HICPAC 101 blog post by Dr. Hudson Garrett.

Participating in HICPAC meetings puts context and rationale to the recommendations. Furthermore, as an IP, your voice can be heard or questions answered during the public comment period of the meeting. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner.  

Lessons Learned from the COVID-19 Response

Dr. Denise Cardo from the CDC’s Division of Healthcare Quality Promotion presented on the gaps across the healthcare delivery system, the critical needs in post-acute care (PAC), and health equity and access issues that the COVID-19 pandemic has unmasked. There is a huge need to integrate infection prevention across the entire healthcare continuum to be as robust as it is in acute care settings. For example, if you have watched the news in recent months, you have seen the challenges that nursing homes have faced during this time. In fact, 42% of all COVID-19 deaths have occurred in nursing homes.1

This pandemic has certainly highlighted the need for policies for accountability. Dr. Cardo identified three cultural changes that need to happen:

While we may not know exactly how this culture change will take place, it’s reassuring to know that the CDC is keenly aware of these issues and will be working on providing guidance to facilities.

Project Firstline

Dr. Mike Bell, Deputy Director for the CDC talked about the Project Firstline, a new national training collaborative for healthcare infection prevention and control for frontline healthcare and public health workers. The project was kicked off at the end of October 2020 with a key objective to effectively communicate infection prevention messaging directly to frontline workers.

The educational materials and tools provided to targeted audiences are short, convenient, and provided in easily accessible formats such as videos and podcasts. And to help make the messaging stick, the rationale behind the recommendations is strongly emphasized. Keep an eye on the Project Firstline website as the portfolio continues to expand. IPs can follow this initiative on Facebook or Twitter or sign up for email updates.

Work Group Update: Long-Term Care/Post-Acute Care

HICPAC members JoAnne Reifsnyder and Michael Lin provided an update from the Long-Term Care (LTC)/PAC Work Group. This group is working to move from a culture-based to a task-based risk for determining precautions and personal protective equipment (PPE) in LTC and PAC settings. For example, PPE decisions would be based on patient care tasks, like bathing or wound care, rather than on what is growing (or not growing) in a specimen culture.

This comes on the coat tails of the new set of precautions, Enhanced Barrier Precautions, introduced last year. With the lessons learned from the pandemic, this work group is in the process of drafting a white paper on how nursing homes should implement PPE used for resident care activities. The workgroup plans to employ human factors engineering to design their recommended interventions.

Summary

            Because we understand how difficult it is for busy IPs (especially during a pandemic!) to attend HICPAC meetings, we hope that you find these meeting summaries helpful in your practice. Don’t forget to check out Project Firstline and be on the lookout for the CDCs Enhanced Barrier Precautions white paper (final title to be determined). For additional information, the HICPAC meeting minutes can be reviewed once they are posted.

References

  1. The New York Academy of Medicine, “Virtual Summit for Infection Prevention in Nursing Homes”, [cited 12/2/2020].

This post is part of our "Ask The Pros" blog series for which our internal panel of experts address the latest questions from industry professionals. This month's query,

"It seems like we have a new disinfectant product every week and it's hard to keep up with how and where to use the products. What strategies do you recommend for as little disruption as possible to our current process?"

Introduction

The year 2020 has certainly been a challenging one thus far. The COVID-19 pandemic has created supply challenges in this country that we could not have anticipated that range from U.S. Mint coin shortages to personal protective equipment (PPE) for healthcare workers.  The disinfectant manufacturing industry has also been challenged to keep up with an extraordinary increase in demand.  While production facilities are operating 24/7, supply continues to fall short of demand due to production capacity and raw material shortages.  As a result, many healthcare facilities are having to adjust and adapt to new disinfectants products, whether that means different formats, applications, or actives.  While this may be frustrating, healthcare teams are resilient and they know how to triage.  In response to disinfectant shortages, changes in product and potentially in protocols, we will apply the methodology of triage to the use of disinfectant products in formats that may differ from our usual product. A plan of action can then be developed for the appropriate use of the environmental disinfectants available.

Risk Assessment

The first step when an issue is identified is to assess the risks involved and the potential consequences.  In this case, the issue is that our usual product(s) may be temporarily unavailable, or in limited supply. I recommend downloading and adapting a risk assessment tool from the Centers for Disease Prevention and Control (CDC). Considerations with the risk assessment are:

Once the risk assessment has been completed, the next step is to formulate a plan to mitigate and determine what, if any, safeguards should be put into place.  Your plan should include goals and objectives to tackle high-risk issues. Note that your plan should also address how you will swiftly communicate the change in product and educate staff as the new products come in to your facility. Your vendors may be able to help!

Product Prioritization

Much like the CDC has recommended a strategy to prioritize the use of PPE to preserve supply, consider doing something similar in regards to disinfectants.  I am not proposing cleaning less frequently, but rather to prioritize which products will be used where and by whom.  If you have a limited supply of disinfectant wipes, but you also have some spray bottles of disinfectant, consider prioritizing disinfectant wipes for critical departments, or equipment.  For example, you wouldn’t want to use the spray disinfectant in the ICU where you have patients on a ventilator, so this would be a department in critical need of disinfectant wipes. Another example might be to take the large format disinfectant wipes that Environmental Services (EVS) often use and distribute them to nursing staff for use on the units.  EVS is more accustomed and likely more equipped to utilize different formats of disinfectants such as spray disinfectants, dilutable chemistries and microfibers so consider reserving these formats for them.

If you need help getting started with how to prioritize your products, check out this flow chart (also pictured below) and associated blank and completed risk assessments for reference.

Instructions for Use

Through all of this, it is imperative that the product instructions for use (IFU’s) are reviewed, staff is educated on the IFU’s, and compliance is monitored and enforced by leadership. Healthcare-grade disinfectants registered by the U.S. Environmental Protection Agency (EPA) undergo stringent testing requirements in order to prove their efficacy and safety. For the best results, users should follow the product IFU’s.

For example, Clorox Healthcare® Fuzion, a next-generation sporicidal bleach disinfectant, has an engineered dual-chambered nozzle that combines the active ingredients at the point of dispensing (or spraying).  While highly efficacious, this product is most effective when applied directly to the surface from the bottle itself. If concerned about using sprays but that is all that is available, a better approach would be to consider where use of sprays might be more appropriate, such as in public or common areas after-hours. Finally, until this pandemic is behind us, be sure you are selecting products approved as being effective against SARS-CoV-2, the virus responsible for COVID-19 disease.  You can find these products on the EPA’s List N.

Posts for the Ask The Pros blog series are published every other month. Please submit your cleaning and disinfecting questions to AskThePros@clorox.com for consideration to be addressed in a future edition.

This is the final post of a three-part blog series, COVID-19: Transition from Hospital to Home, by Doe Kley. Read part one and part two.

In part one of this 3-part blog series, we learned about SARS-CoV-2, the virus responsible for COVID-19 infection. We reviewed how infections occur using the Chain of Infection framework, including ways in which the chain can be broken to stop transmission. A special emphasis was placed on the role of environmental surfaces in transmission. In part two, we focused on preventing the transmission of COVID-19 within the hospital, looking at both what hospitals are doing and what patients can do. Next, we shared ways to prevent transmission to household contacts within the home environment. In this final part, we will review disinfectant safety and understanding the label.

Disinfectant Safety

The COVID-19 pandemic has brought to light the need for safe use of cleaners and disinfectants. Calls to Poison Control Centers regarding exposures to cleaners and disinfectants have increased since the beginning of 2020. In fact, the CDC published a Morbidity and Mortality Weekly Report (or MMWR) on this very topic in June of this year. They conducted a survey and found knowledge gaps in the safe use of household cleaners and disinfectants. Approximately one-third of the respondents reported engaging in non-recommended high-risk practices with the intent to prevent the spread of COVID-19 virus. Some of these unsafe practices include washing produce with bleach, applying these household cleaner-disinfectants to bare skin, and intentionally inhaling or ingesting these products.

It’s important to be knowledgeable about cleaning and disinfectant products being used. The product label provides a wealth of information so be sure to read it. A very important piece of information to look for is the registration number from the Environmental Protection Agency (EPA). All disinfectants in the US are required to be registered with the EPA. Failure of a disinfectant product to be registered with the EPA is not only against federal law, without it, the safety and efficacy of unregistered products cannot be guaranteed. 

Other important information that can be found on the product label are the chemicals or active ingredients, the germs they kill ("kill claims"), precautions, and directions for use (DFUs). Keep in mind that SARS-CoV-2 is a new pathogen so it may not yet be listed on the label. However, if the product has the emerging viral pathogen claim and is listed on EPA’s List N, then the product is approved for use against the COVID-19 virus.

The precautionary text informs the user of potential hazards when using (or misusing the product). Signal words used in the precautionary text include CAUTION, WARNING, or DANGER and informs the user of physical or chemical hazards such as flammability and corrosiveness. This label section also advises on first aid instructions and if the product should be kept out of reach of children.

The DFUs focus on what task (e.g., disinfect, sanitize, deodorize, etc) the product is intended to perform and how to correctly use the product. This includes surfaces that the product can safely be used on as well as those the product should not be used on. The DFUs provide the contact time or how long the surface must remain wet with the disinfectant in order to be fully efficacious. It also addresses whether it’s safe or not to mix the product with other products or chemicals. For example, toxic fumes can result when bleach is mixed with ammonia or vinegar. Adherence to the DFUs is key.  If product DFUs state to apply the product directly to the surface followed by wiping once the contact time has been met, then applying the product to the cloth first may impede efficacy.

Some key safety measures to consider include:

Conclusion

In this 3-part blog series, we addressed the safe transition from hospital to home during a pandemic as it can be a very scary experience. And we learned that with basic infection control measures we can protect both ourselves and our loved ones. The COVID-19 pandemic has shown a glaring light on the need to faithfully adhere to these basic practices. Frequent hand hygiene, respiratory etiquette, and routine cleaning and disinfection go a long way in preventing transmission of pathogens, including SARS-CoV-2, the cause of COVID-19.

Be sure to educate yourself on proper cleaning and disinfection and understand what is in the bottle and how to safely use it. Always follow the instructions for use. Be sure you allow surfaces to remain wet long enough to kill the targeted pathogens.  This means adhering to the contact time on the label for the product you are using.  

To learn more, visit the CloroxPro Resource Center which includes valuable educational resources such as videos, pathogen education sheets, CE webinars and more.

References

1. Coronaviruses. Retrieved from https://www.niaid.nih.gov/diseases-conditions/coronaviruses

2. Coronavirus Disease 2019: Frequently Asked Questions. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html

3. Disease 2019: How it Spreads. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html.

4. New coronavirus stable for hours on surfaces. Retrieved from https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces.

5. COVID-19, FAQ, Spread. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html#:~:text=At%20this%20time%2C%20CDC%20has,Coronavirus%20Spreads%20for%20more%20information.

6. Coronavirus Disease 2019: Symptoms. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

7. Are You at Higher Risk for Severe Illness? Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhigh-risk%2Fhigh-risk-complications.html

8. Severe Outcomes Among Patients with COVID-19 – United States, February 12-March 16, 2020. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm

9. COVID-19 Cases in U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

10. CDC Media Telebriefing: Update on COVID-19, March 9, 2020. Retrieved from https://www.cdc.gov/media/index.htmlhttps://emergency.cdc.gov/coca/calls/2020/callinfo_013120.asp

This is the second post of a three-part blog series, COVID-19: Transition from Hospital to Home, by Doe Kley. Read part one and part three.

In part one of this blog series, we described COVID-19 disease and used the chain of infection to demonstrate how this and other infections occur. In part two of this series, we will address how the spread of COVID-19 can be prevented within the hospital, as well as how to prevent its spread to loved ones within the home.

Preventing Transmission in the Hospital

Measures the healthcare team is taking to prevent transmission of COVID-19 to patients and others within the hospital walls include:

For additional recommendations, see CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.

For disinfectants effective against the SARS-CoV-2 virus, see the Environmental Protection Agency’s (EPA) List N. This list includes disinfectants used in healthcare settings as well as disinfectants used at home. It’s important to note that while SARS-CoV-2 can cause severe illness in some, the virus is very easy to kill on surfaces with appropriate disinfection.

Hierarchy of Pathogen Kill

Adapted from Rutala, WA and Weber, DJ retrieved on 8/30/2020 from www.epa.gov

For patients admitted for a health issue other than COVID-19, there are things that they can do to protect themselves from getting COVID-19 while in the hospital. First and foremost, patients must be their own advocate.  This means speaking up when something doesn’t look or seem quite right.   This includes reminding healthcare workers and visitors to perform hand hygiene before touching you. Along these same lines, patients should be sure to perform hand hygiene before they eat or before taking oral medications, after they use the restroom, and upon returning to their room from a test or procedure or even a walk in the halls. It’s also important to ensure your room and bathroom are cleaned every day you are in the hospital. Focal points for cleaning should include surfaces that are frequently touched such as the over-bed table, bed rails, call light, and tv remote to name a few. Additionally, patients should ensure that the healthcare team has disinfected any medical equipment that will come into contact with them. Lastly, during the pandemic, patients should wear a mask as tolerated while in the hospital to help prevent inadvertent exposure to COVID-19.

Similarly, there are things that essential workers can do to prevent bringing COVID-19 home from work with them and infecting their family members. The COVID-19 pandemic has certainly made us take a closer look at how we can safely transition from work to home each day to protect not only ourselves but our loved ones.  Please see my blog post from March 2020 titled “From Outside In: 6 Tips for Minimizing the Risk of Bringing COVID-19 Home After Your Shift”.  

Preventing Transmission in the Home

There are measures that patients infected with COVID-19 can do to prevent infecting their loved ones when it’s time to be discharged from the hospital.  Adherence to the 6 basic measures that we all should be doing will go a long way in preventing the spread of COVID-19:

  1. Stay home if feeling unwell
  2. Practice social distancing
  3. Wear a mask and cover coughs/sneezes
  4. Avoid touching the face
  5. Perform frequent hand hygiene
  6. Perform frequent cleaning and disinfection of environmental surfaces

To clean surfaces in the home that may be contaminated with the SARS-CoV-2 virus be sure to use an EPA-registered household disinfectant.  Most of these will be effective as this is not a difficult virus to kill (see Hierarchy of Kill image above). For a complete list of appropriate household disinfectants for COVID-19, visit the Clorox Coronavirus Resource page to view a list of approved products and tips on how to safely and effectively disinfect surfaces in the home. Additionally, diluted jug bleach can be used to disinfect surfaces.

1:10 Jug Bleach Dilution

In addition to frequent cleaning and disinfection of frequently touched surfaces in the home, only one person in the household should take care of the person who is ill.  And this person should not be someone in the high-risk group for COVID-related complications. In addition to the 6 basic measures mentioned earlier, the ill person should:

Everyone in the household, especially the ill person, should practice respiratory etiquette which includes covering coughs and sneezes, properly discarding used tissues, and performing frequent hand hygiene. Also, avoid sharing personal items with others in the home including dishes, towels, and bedding.

The COVID-19 infected person should remain separated from others in the household, including pets, by staying in a designated room. This person should also have a separate bathroom, if possible. If the bathroom must be shared, then after each use, the frequently touched surfaces should be cleaned and disinfected.

The bathroom and the “sick room” are not the only rooms in the house that should be cleaned frequently. All frequently-touched surfaces in the home should be cleaned and disinfected daily at a minimum according to the Centers for Diseases Control & Prevention (CDC), but it certainly doesn’t hurt to disinfect more frequently.

If sleeping in the same room is necessary, put a curtain up to act as a divider. And if you must share a bed, sleep head-to-toe. Weather permitting, open doors and windows and use fans to help circulate fresh air. The ill person should not prepare food and should eat separately from the rest of the family.

Read part 3 of the blog series as we end with the safe and proper use of disinfectants.

This is the first post of a three-part blog series, COVID-19: Transition from Hospital to Home, by Doe Kley. Read part two and part three.

Transitioning from hospital to home once diagnosed with an infectious disease can be frightening for a patient. The biggest concern is spreading the infection to their loved ones. This blog post focuses on SARS-CoV-2, the virus responsible for COVID-19.  In addition to providing some information on this pathogen and the infection that it causes, key things to consider when it’s time to go home for preventing transmission to others will be addressed. 

About COVID-19

According to the National Institute for Allergy and Infectious Diseases (NIH), over the past 20 years, three new pathogenic Coronaviruses have emerged from animal reservoirs.1 They are a large family of viruses that commonly cause respiratory illnesses in people as well as in many different animal species.2 Examples include Severe Acute Respiratory Distress Syndrome (SARS) back in 2003 and more recently, Middle Eastern Respiratory Syndrome (MERS).2 The COVID-19 strain, genetically related to the SARS virus, has not been identified in humans until now.3 Our lack of immunity to this virus explains its readiness to spread from person-to-person. 

And how is this virus spread? Well, the primary mode is through respiratory droplets when an infected person coughs or sneezes.4 These droplets have about a 6 foot reach.4 While there is some evidence that persons without any symptoms can transmit the virus, persons are most infectious when they are actively ill.4 Additionally, it appears to be possible to acquire COVID-19 by touching surfaces or objects contaminated with the virus and then touching your mouth, nose, or eyes5, but this is not thought to be the main way that this virus is spread.4 Studies are being published at lightning speed and indicate that the virus can survive from several hours to several days on various surfaces.6 Finally, it’s important to point out that this virus is not spread through food or water. 

Symptoms of COVID-19 illness are very similar to influenza and include fever, cough, muscle aches, fatigue, and shortness of breath.6 However, the incubation period is longer than influenza ranging from 2-14 days (average of 4-5 days).6,7 Influenza and COVID-19 illnesses both come on more suddenly as compared to the common cold which tends to come on more gradually. Like influenza, COVID-19 illness can range from mild to severe.8

Coronavirus Sympton Comparison with Other respiratory Illnesses

The vast majority of persons (80%) with COVID-19 infection will experience only mild illness and will recover uneventfully.9 Persons at high-risk of complications from this disease tend to have more severe illness.10 These high-risk individuals include those over the age of 60 years and those with chronic conditions such as heart or lung disease and diabetes.10  Of the older population, those over the age 80 years are at highest risk of complications from COVID-19.10  Currently, there is no specific treatment to cure COVID-19 and there is no vaccine but experts are currently working on both. The mortality rate in the US is approximately 1.3%.10 This means we can expect approximately 1.3 persons in every 100 cases to die as a result of the infection. While this does not seem like a high mortality rate, keep in mind that this is an average. The mortality rate is significantly higher in high risk individuals and lower in low risk individuals.

The Chain of Infection

A framework that can help us to understand how infections occur is the “chain of infection” which describes the sequence of events that must occur in order for an infection to occur. This chain applies to all pathogens. When considering this framework, envision the links of a chain connected in a continuous circle in which the cycle repeats itself unless or until broken. 

The chain of infection is made up of six links. Each link must align in order for an infection to occur, starting with an infectious agent such as SARS-CoV-2, the virus responsible for COVID-19. The second link is the reservoir for the infectious agent. Reservoirs can include people, environmental surfaces, water, air, and so on. And there must be a portal of exit (which is the third link) for the pathogen from its reservoir. An example of a portal of exit would be the respiratory tract of a coughing patient infected with COVID-19. The fourth link is the mode of transmission. This is how the infectious agent or pathogen is carried from one place or person to another.  For example, COVID-19 is spread in the droplets of saliva or mucous coughed out from an infected person. And if those droplets land on and contaminate an environmental surface, the virus can potentially be transmitted by touching that surface and then rubbing one’s eyes or nose. The fifth link in the chain is the portal of entry. This is how the pathogen enters its host or a susceptible person. The portal of entry for the COVID-19 virus is when a susceptible person breathes in the virus carried in droplets from an infected person coughs, sneezes, sings, or talks. The final link is a susceptible host. This is a person who is not immune to or is otherwise susceptible to the infectious agent they are exposed to. In essence, since COVID-19 is caused by a new strain of Coronavirus, we all are susceptible hosts to some degree.

The good news is that we can stop infections from occurring by breaking just one link in the chain. This can easily be accomplished through actions such as covering coughs, performing frequent hand hygiene, cleaning and disinfecting environmental surfaces routinely, and keeping current on immunizations. For COVID-19, we can break the chain of infection for (and possibly put the brakes on this pandemic) by doing these things plus practicing social distancing – keep at least six feet from others and wear a mask. Remember, my mask captures my droplets which protects you and your mask captures your droplets which protects me.

Read part two of this blog series where we discuss preventing the spread of COVID-19 in the hospital, as well as at home.

References

  1. Coronaviruses. Retrieved from https://www.niaid.nih.gov/diseases-conditions/coronaviruses
  2. Coronavirus Disease 2019: Frequently Asked Questions. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html
  3. Disease 2019: How it Spreads. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html.
  4. New coronavirus stable for hours on surfaces. Retrieved from https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces.
  5. COVID-19, FAQ, Spread. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html#:~:text=At%20this%20time%2C%20CDC%20has,Coronavirus%20Spreads%20for%20more%20information.
  6. Coronavirus Disease 2019: Symptoms. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
  7. Are You at Higher Risk for Severe Illness? Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhigh-risk%2Fhigh-risk-complications.html
  8. Severe Outcomes Among Patients with COVID-19 – United States, February 12-March 16, 2020. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm
  9. COVID-19 Cases in U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
  10. CDC Media Telebriefing: Update on COVID-19, March 9, 2020. Retrieved from https://www.cdc.gov/media/index.htmlhttps://emergency.cdc.gov/coca/calls/2020/callinfo_013120.asp

The COVID-19 pandemic, the first of this scale in over 100 years, has been a traumatic event for many, if not all, working on the hospital frontlines. Doctors, nurses, and other members of the healthcare team were forced into working conditions they never expected (without sufficient personal protective equipment [PPE] in many cases) and saw things they never wanted to see. Tragically, more lives were lost to this outbreak than any other in recent history. Infection Preventionists (IPs) were alongside the clinical staff, being placed in the position of having to make decisions that went against their training, such as the extended use of or re-use and decontamination of PPE.

While the healthcare industry has endured many infection control challenges in the past, such as bioterrorism scares (smallpox, anthrax, etc.), influenza pandemics, Ebola outbreaks, emerging pathogens and growing antibiotic resistance, the sheer magnitude of COVID-19 was like no other before it.

As we are still reeling from the COVID-19 pandemic and will do so for some time to come, we need to take a step back and assess five key learnings so we are better prepared for a possible second wave, as well as future pandemics. A few things to reflect on include:

These five S’ above provide a glimpse into considerations moving forward beyond COVID-19. As we heal and mitigate, we must also grow from this pandemic. Evolutions of our previous practices will unfold in the coming weeks and, without a doubt, the role of IPs will be transformed forever. Below are some of the lasting impacts this pandemic could have on IPs, as well as longer-term lessons that industry leaders must come together to address:

Regardless, IPs need to rally and advocate getting the funding needed for pandemic plans and preparedness. If this pandemic has taught us anything it is that we need to be prepared at all times.

While COVID-19 has forever changed the healthcare landscape. What has not changed is the importance of IPs. This pandemic has brought us out of the shadows and has shined a bright light on the great work that we do every day, not just during times of crisis. We are in the business of preventing the spread of disease in healthcare settings to protect patients and staff. A solid IP program can help patients feel safe about coming back into healthcare system to seek medical attention when they need it. I have never been more proud to be an IP and of the work that we do to protect our staff and patients. Thank you all for your hard work and dedication to the profession.  We see you! Please stay safe out there.

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