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.

With COVID-19 showing no signs of slowing, there is a serious and growing pressure put on essential workers on the front lines. These individuals are putting themselves at risk to ensure that others have access to healthcare, food and transportation during this pandemic, and that essential public spaces are clean and disinfected.

These essential workers have a lot of their minds right now. They are worried about their patients and their communities — how widespread is COVID-19, who is coming through their doors, will they be able to help them? They are worried about their own health — what if I’m exposed to a COVID-19 patient, will I have adequate PPE to protect me, what if I contract COVID-19? And they are worried about their families — are they putting loved ones at home at risk of exposure, are they bringing SARS-CoV-2 (the virus that causes COVID-19) back home with them after a shift, what can they do to protect their families?

As a career nurse turned infection preventionist, I’ve spent years on the front lines of healthcare studying epidemiology and seeking to understand how to stop the spread of disease. Much of what I learned in hospitals can be applied back in the home as an after-work routine during this pandemic.

Based on my experience and understanding, here are six actions professionals on the front lines can consider taking to minimize the risk of bringing the virus that causes COVID-19 back into their homes.

  1. Change clothes and shoes before leaving work. Consider changing out of your clothes and shoes before leaving work and avoid wearing these items into any public spaces you stop in on your way home (e.g., grocery store, restaurant, etc.) after your shift. Place your soiled clothes in a bag, preferably a disposable or launderable bag, and perform hand hygiene. Choose a pair of shoes to dedicate for work only. These shoes should remain at work.
  2. Perform hand hygiene as you exit work. By now, we are well aware of proper hand washing techniques, but don’t forget to also use some hand sanitizer, as recommended by the CDC, as you exit the workplace.
  3. When you get home, wipe down anything inside of your car. Use a disinfecting wipe to properly disinfect hard, nonporous surfaces within your car including cup holders, steering wheel, door handles, seat buckles and radio knobs where permitted by with manufacturer’s instructions. Items you may bring out of the home — purses, backpacks — should also be disinfected or washed upon entering the home.1
  4. Wash your work clothes. Without shaking out your soiled laundry, place your used work clothes in the washer and perform hand hygiene. Wash and dry your used work clothes separately at a higher temperature (100 to 135 degrees) for at least 30 minutes to ensure sufficient killing of germs.1 Use bleach (1/2 cup per load), if possible. Dry on hottest dryer setting. You should not re-wear any clothing (including jeans, sweaters, sweatshirt, etc.) until after it has been laundered.2 There are companies, like Prime Medical, that make scrubs and lab coats for medical personnel that not only are fade-resistant to bleach but after washing with bleach they are activated to provide antimicrobial protection while you wear them. Consider these for your next pair of scrubs.
  5. Jump in the shower. Not only can a nice hot shower provide the perfect respite after a hard day, but this ensures any viruses that have come home with you on your skin are physical removed and washed down the drain.
  6. Disinfect high-touch surfaces in your home. Using disinfecting wipes, regularly disinfect things like your cell phone, door knobs, light switches, remote controls, desks, bathroom fixtures, etc. And wash your hands after disinfecting.

While we all want to help protect those we love most when returning home at the end of the day, it’s also important to stay rooted in the facts as we decide how far to take these actions. As you consider making changes to your returning-home routine, keep a few things in mind:

General infection control measures should be on everyone’s list. Here are a few that those in your household can and should be following8:

A heartfelt thanks to all of you hard-working, selfless essential workers out there aiding and supporting us from the frontline. In these uncertain times with this continuously evolving situation we can only control that which we can. I sincerely hope that you find these tips helpful to protect yourself and your loved ones at home.

References

  1. According to Mary Gagliardi, aka “Dr. Laundry,” Clorox’s in-house scientist and cleaning expert.
  2. Centers for Disease Control and Prevention. (2020). Detailed Disinfection Guidance. Retrieved on 3/27/2020 from https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html
  3. Centers for Disease Control and Prevention. (2020). COVID-19 Frequently Asked Questions. Retrieved on 3/26/2020 from https://www.cdc.gov/coronavirus/2019-ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fchildren-faq.html#anchor_1584387482747
  4. National Institute for Health. (2020). New coronavirus stable on surfaces for hours. Retrieved on 3/26/2020 from https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces
  5. Centers for Disease Control and Prevention. (2020). COVID-19: Healthcare Professionals: Frequently Asked Questions and Answers. Retrieved on 3/26/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
  6. Centers for Disease Control and Prevention. (2020). COVID-19: People who are at higher risk for severe disease. Retrieved on 3/26/2020 from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
  7. Centers for Disease Control and Prevention. (2020). COVID-19: Symptoms for Coronavirus. Retrieved on 3/26/2020 from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
  8. Centers for Disease Control and Prevention. (2020). COVID-19: How to Protect Yourself. Retrieved on 3/26/2020 from https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html

At the beginning of this year, the world became aware of an outbreak of pneumonia of unknown cause in Wuhan, China. In a matter of weeks, the source was identified as a novel (or new) coronavirus, which has since been named SARS-CoV-2, causing what is now known as COVID-19. A handful of incidents have quickly become tens of thousands of cases, with spread to six continents. Recent events show community spread (i.e., people are becoming infected who have had no recent travel to China or known contact with a known or suspected case of COVID-19), is occurring outside of China, including here in the U.S. As the condition affects more people across the globe, here are guidance and steps you can take now.

First, remain calm. While concerning, the mortality rate of this virus is still comparatively low to other viruses. Influenza killed more than 34,000 people in the U.S. alone last year,1 while only a tenth of this number have succumbed to COVID-19 worldwide. It is very important to maintain proper perspective: The vast majority of persons infected with SARS-CoV-2 (80%) will have only mild illness and majority will recover.2 With COVID-19, older people and people with certain underlying health conditions seem to be at greater risk of serious illness.1,3

The most empowering thing we can do is to control what we can. So, what can you do today to prepare at home and at work? Listed here are a few:4-7

  1. Get your news only from reputable sources. Centers for Disease Control & Prevention (CDC) and World Health Organization (WHO) will provide you with trustworthy and accurate facts, so you can determine your own level of risk and take reasonable precautions.
  2. Trust the system. Follow public health recommendations, from local or state health departments and the CDC, such as travel restrictions. Also reserve masks for healthcare workers until otherwise advised. Improper mask use can actually increase your risk of infection as you touch your face to put it on or remove it or worse, re-use it.
  3. Get your flu shot. For that matter, be sure you are current on all of your immunizations. This will help keep you as healthy as possible and prevent having multiple epidemics occurring simultaneously. These immunizations help healthcare professionals make a proper diagnosis should you become sick and “makes the healthcare system more robust by preventing an influx of flu patients.”8
  4. Perform frequent hand hygiene. Hand sanitizer is equally as effective for this virus as soap and water washing. When washing with soap and water, be sure to scrub all surfaces of the hands and fingers for at least 15–20 seconds.
  5. Avoid touching your face. The eyes, nose and mouth are portals of entry into your body for viruses.
  6. Cover your cough. This prevents spreading any of your germs to others. And perform hand hygiene afterward.
  7. Avoid contact with people who are sick and stay home if you are sick. Can you work remote? Utilize flexible working arrangements to avoid unnecessary contact with others, especially if you are not feeling well.
  8. If you have fever, cough and difficulty breathing, seek medical attention. Call ahead to let the healthcare facility know you are on your way and specify your symptoms. Put on a mask upon entering the healthcare facility so as not to infect others.
  9. Regularly clean and disinfect frequently touched surfaces. Keep surfaces clean in your immediate environment at home and work. This includes counter tops, doorknobs, cabinet handles, kitchen and bathroom fixtures, computer keyboards, remote controls, telephones, toys, etc. Make sure to use an EPA-registered disinfectant approved under the EPA’s Emerging Pathogen Policy, such as Clorox Commercial Solutions Clorox® Disinfecting Wipes.
  10. Manage your stress. Coping with a large-scale outbreak can be scary. Ways to manage stress include eating healthy, drink plenty of water, exercising regularly, getting enough sleep and talking to someone you trust.

Just like other emergencies that can occur at any time, we can similarly prepare for SARS-CoV-2 at home and at work. With an outbreak such as this, it’s important to keep in mind that it can last for several months. This is a good time to dust off your emergency kits and take an inventory of the contents. Replace batteries and other outdated items as needed. Other considerations include the following:3-5

In conclusion, knowledge is powerful. Stay informed, prepare and stay well. 

References:

  1. CDC: https://www.cdc.gov/media/releases/2020/s-0303-Additional-COVID-19-infections.html 
  2. CDC COVID-19 Response Call, March 4, 2020, Dr. Jay Butler-Deputy Director of Infectious Diseases.
  3. CDC:  https://www.cdc.gov/mmwr/volumes/69/wr/mm6908e1.htm  
  4. CDC: https://www.cdc.gov/flu/about/burden/2018-2019.html
  5. WHO: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
  6. Red Cross: https://www.redcross.org/about-us/news-and-events/news/2020/coronavirus-safety-and-readiness-tips-for-you.html
  7. Public Health Insider: https://publichealthinsider.com/2020/02/24/what-happens-if-the-novel-coronavirus-covid-19-spreads-here-a-conversation-with-our-health-officer/

­Originally published by Contagion Infectious Diseases Today.

The new decade started off with a mysterious outbreak of pneumonia in Wuhan, the capital of Central China’s Hubei province. In just the matter of weeks, the respiratory illness evolved into a global health concern, with cases reported on 4 continents—Asia, North America, Australia and Europe—including several cases here in the United States. The virus has been identified as a novel coronavirus.

The US Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and other global entities are working together to understand and control this novel coronavirus and provide important guidelines for health care professionals. Here’s what you should know.

Novel Coronavirus 2019-nCoV

Coronaviruses are a species of enveloped viruses that were first discovered in the 1960s. Coronaviruses are most commonly found in animals, including camels and bats, and rarely spread to humans. However, sometimes viruses jump species from animals to humans, which are known as zoonotic diseases, or infectious diseases that spread from animals to humans. Researchers still don’t fully understand why only certain coronaviruses are able to infect people. Examples of zoonotic coronaviruses include the severe acute respiratory syndrome (SARS)-CoV outbreak of 2003 and the Middle East respiratory syndrome (MERS)-CoV outbreak of 2012.

The latest strain of human coronavirus, originating from Wuhan, has been named Coronavirus 2019-nCoV. The initial case of 2019-nCoV reported to the WHO on December 31, 2019 stemmed from a pneumonia outbreak in China, linked to a large market where raw seafood and live animals are commonly sold. The market was closed for cleaning and disinfection on January 1, 2020. Since then, there have been thousands of reported cases across the globe, with 80+ deaths in China. There have been 5 confirmed cases of the coronavirus in the United States in 4 states (Arizona, California, Illinois and Washington).

Guidelines for Health Care Facilities

The CDC is constantly monitoring developments of 2019-nCoV and has posted guidelines for health care providers. Since there is limited information regarding this coronavirus, the clinical criteria have been developed based on what is known about SARS-CoV and MERS-CoV.

Health care providers are urged to take proactive steps to prevent the spread of 2019-nCoV, including obtaining a travel history for patients presenting with fever and/or symptoms of lower respiratory illness (eg, cough, difficulty breathing). For patients under investigation, providers should:

An important part of the prevention plan is surface disinfection to help remove the virus from surfaces and prevent its spread in the facility and externally into the community. In the US, the outbreak situation has triggered the Environmental Protection Agency’s Emerging Pathogen Policy. This policy determines whether disinfectants that meet certain efficacy criteria can be considered effective against the 2019-nCoV. Contact your disinfection product manufacturer for the latest information on whether their products can be considered to be effective against 2019-nCoV.

In addition to the CDC guidelines, here are some other actions that healthcare providers can start to do:

This is an evolving situation and there is still much to learn about 2019-nCoV, how it is transmitted, and its virulence and pathogenicity. The CDC will continue to monitor this situation and will provide the most up-to-date information on its website. You can also find additional information on 2019-nCoV here.

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