It’s 3 AM in the Neonatal Intensive Care Unit (NICU). I am holding my premature 4-pound baby on my chest in the same rocking chair I have sat in for the past several days. It’s dark, quiet and lonely. The days have melted together as my constant focus remains over this tiny human. Suddenly, there is a quiet knock on the door and a worker appears apologizing profusely and explaining he is there to empty the trash and wipe down certain surfaces. He is kind, considerate, sympathetic, and the first human besides the amazing NICU nurses that I have seen in days. I thank him as I try to move all the cords attached to my infant out of his way. He tells me he has been an Environmental Services (EVS) worker for over 20 years and that he is proud to work in the NICU and knows his work is invaluable to protecting these very vulnerable babies. Not knowing my background, he talks to me about how important cleaning and disinfecting is in preventing the spread of pathogens in the hospital. The pride visible on his masked face is evident. Working the night shift, I wonder how lonely he must be and how few people get to fully appreciate all he is doing to protect their children.

EVS workers are in every healthcare facility across the United States. Those outside of healthcare, often incorrectly use the term “housekeeping” and “janitor” to describe these workers, but in healthcare, they are so much more. EVS professionals are highly trained in disinfection practices against contagious pathogens, such as C. difficile and MRSA, and in cleaning complex medical equipment. During the pandemic, their role became even more critical as we were still learning about the SARS-CoV-2 virus and how it was spread. EVS personnel are often underappreciated and not recognized for their shared responsibility to help prevent healthcare-associated infections from spreading on surfaces by prioritizing high-risk areas, and following guidelines for cleaning and disinfection.1,2,3   

September 10-16, 2023 is Environmental Services Week #EVSWeek

According to the Association for the Health Care Environment (AHE):

“Environmental Services Week is a time to show appreciation for the dedicated EVS personnel that ensure healthcare facilities across the country are clean, safe places for patients, their families and other staff members. With all the challenges and changes the last few years have brought, these staff members have remained resilient in their efforts to protect others from dangerous pathogens.”

At Clorox, we want to take this week to show our appreciation for the EVS professionals protecting not only countless patients throughout the United States, but also our babies, mothers, fathers, and vulnerable family members. Their tireless efforts keep healthcare facilities safe for all of us!

As Pinnacle Corporate Champion Sponsors of AHE, we have partnered with their team to develop educational tools and training videos to help EVS professionals succeed. These training videos, developed by the CloroxPro Clinical and Scientific Affairs team, highlight critical aspects of cleaning and disinfection in the healthcare environment.

Advance Your EVS Career with a New Certificate in Healthcare Environmental Cleaning and Disinfection

In Research and Development, we are also developing and designing products with EVS in mind. Our ready-to-use wipes allow workers to cover more surfaces with fewer wipes, saving time while still meeting the appropriate contact kill times to ensure dangerous pathogens are not putting patients at risk.

To all the EVS workers out there — we support you and give our thanks for all you do!

References

1. Ni K, Chen B, et al. Knowledge, attitudes, and practices regarding environmental cleaning among environmental service workers in Chinese hospitals. Am J Infect Control [Internet]. 2017 [Cited September 5, 2023]; 45(9):1043‐1045. Available from: https://pubmed.ncbi.nlm.nih.gov/28343703/
2. Bernstein D, Salsgiver E, Simon MS, et al. Knowledge, attitudes, and practices of environmental service workers related to environmental cleaning and healthcare‐associated infections (HAI). Open Forum Infect Dis [Internet]. 2015 [Cited September 5, 2023]; 2(suppl 1): S466. Available from: https://academic.oup.com/ofid/article/2/suppl_1/1711/2634325
3. Ream PS, Tipple AF, Salgado TA, et al. Hospital housekeepers: victims of ineffective hospital waste management. Arch Environ Occup Health [Internet]. 2016 [Cited September 5, 2023]; 71(5):273‐280. Available from: https://pubmed.ncbi.nlm.nih.gov/26359679/

Unlike some other emerging pathogens, such as Zika or even Mpox (previously Monkeypox), Candida auris (C. auris) is not going anywhere any time soon. According to the Centers for Disease Control and Prevention’s U.S. C. auris tracking data, from December 2021 to November 2022, there were 2,314 clinical cases and 5,612 screening cases. For comparison, in 2020, there were just 755 clinical cases and 1,309 screening cases.1 What makes C. auris different than some of these other emerging pathogens is its resistance to antimicrobial medication and its resiliency in our healthcare environments. In many ways, it is a yeast that behaves more like a bacteria.

CDC C. auris tracking data. Number of C. auris clinical cases through November 30, 2022.
Source: https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html

Back in December 2021, my colleague and CloroxPro Principal Infection Preventionist, Doe Kley, highlighted The Problem(s) with Candida auris. The concerns she highlighted are as true today as they were over a year ago:

  1. Surface transmission is the primary route by which C. auris is spread and once it gets a foothold in a facility, it can be very difficult to eradicate.2
  2. Colonized patients (i.e., a person is carrying C. auris but does not have symptoms of an infection) can carry the fungi for a long time, perhaps indefinitely, and can spread C. auris to others in healthcare settings. One recent study demonstrated that a colonized patient can re-contaminate environmental surfaces within a patient’s room within hours despite regular cleaning and disinfection.3
  3. High morbidity and mortality for those that become infected with limited treatment options due to antifungal resistance.2

The growing awareness over emerging fungal pathogens, like C. auris, is gaining more and more attention. Several infectious disease experts are already predicting that the next major pandemic will be caused by a fungal infection. These fears are not isolated to the United States. The concern globally has triggered the World Health Organization (WHO) to release a Fungal Priority Pathogen List in October 2022. This list is the first global recognition of the ongoing threat these sticky pathogens present and is meant to help drive research, policy interventions, and public health programs around preventing fungal infections and the development of antifungal resistance.4 The WHO list is broken down into three main priority groups of fungi: critical, high and medium.

C. auris is unsurprisingly listed in the Critical Priority Group.

Other fungi listed in the Critical Priority Group include:

CloroxPro is committed to meeting this fungal threat head-on by providing products that can help reduce environmental contamination on healthcare surfaces and protect vulnerable patients in and outside the four walls of the hospital.

The following CloroxPro products are registered with the United States Environmental Protection Agency (EPA) to be effective to kill Candida auris also known as C. auris on hard, nonporous surfaces when used as directed:

All of the CloroxPro® products listed above are on List P, the EPA list of antimicrobials products registered for claims against C. auris. To learn more, please visit List P.

References

1. Centers for Disease Control and Prevention. Candida auris: Tacking Candida auris. [Internet]. [Cited 2023 February 6]. Available from: https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
2. Centers for Disease Control and Prevention. Candida auris: Candida auris. [Internet]. [Cited 2023 February 6]. Available from: https://www.cdc.gov/fungal/candida-auris/index.html
3. Sansom S, Gussin G, Singh R, Bell P, Jinal E, et al. Multicenter evaluation of contamination of the healthcare environment near patients with Candida auris skin colonization. Antimicrobial Stewardship & Healthcare Epidemiology. 2022: 2(S1), S78-S79.
4. World Health Organization (WHO). WHO fungal priority pathogens list to guide research, development and public health action. 25 October 2022 Report. [Internet]. [Cited 2023 February 6]. Available from: https://www.who.int/publications/i/item/9789240060241
5. Centers for Disease Control and Prevention. Fungal Diseases: C. neoformans Infection. [Internet]. [Cited 2023 February 6]. Available from: https://www.cdc.gov/fungal/diseases/cryptococcosis-neoformans/index.html
6. Centers for Disease Control and Prevention. Fungal Diseases: Aspergillosis. [Internet]. [Cited 2023 February 6]. Available from: https://www.cdc.gov/fungal/diseases/aspergillosis/index.html
7. Centers for Disease Control and Prevention. Fungal Diseases: Candidiasis. [Internet]. [Cited 2023 February 6]. Available from: https://www.cdc.gov/fungal/diseases/candidiasis/index.html

Antibiotic resistance remains a grave concern in the healthcare industry and public health, in general. Antibiotics and antifungals (both types of antimicrobials) can save lives, but any time they are used, they can contribute to resistance. Per the Centers for Disease Control and Prevention’s (CDC) 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance, resistant hospital-onset infections and deaths both increased at least 15% during the first year of the COVID-19 pandemic.1 In a 2021 analysis, the CDC also reported that, after years of steady reductions in healthcare-associated infections (HAIs), U.S. hospitals saw significantly higher rates for four out of six types of HAIs in 2020. Many of these HAIs are resistant to antibiotics or antifungals.2 In fact, six out of 18 of the most concerning antimicrobial resistance pathogens cost the U.S. more than $4.6 billion annually.3

As our attention is increasingly on antibiotic resistance organisms, many in the professional cleaning space have begun to wonder whether pathogens can also develop resistance to chemical disinfectants. However, confusion around this question naturally develops as there are actually two types of pathogen resistance:

  1. Innate resistance - Pathogens vary greatly in their natural resistance or susceptibility to antimicrobials and chemical disinfectants (i.e., how easily are they killed by antimicrobials or disinfectants). For example, spores are highly resistant to disinfectants and therefore hardest to kill because of their spore coat and outer shell, which act as a natural barrier. This is not something that is acquired or changing over time. The pathogen hierarchy chart below helps to demonstrate the innate resistance of varying pathogens to the various chemical disinfectants available today.
  2. Acquired resistance - Acquired resistance happens when pathogens, like bacteria and fungi, develop the ability to defeat the drugs designed to kill them. This often happens due to the selective pressure that occurs when antimicrobials are used to kill germs that cause infections, but they fail to kill all of the remaining pathogens because some have natural immunity.4 The antimicrobial-resistant germs survive and multiply.
    @2013 CDC/ Antibiotic Resistance Coordination and Strategy Unit

So, can pathogens also acquire resistance to disinfectants?

The simple answer is yes; disinfectants have been shown to impart selective pressure on some types of bacteria resulting in the development of acquired resistance.5,6,7 However, bacteria are only capable of developing resistance to certain types of disinfectants if the concentration of the active ingredient is too low to be efficacious. This can sometimes occur from the use of unregulated products in the marketplace, human error while mixing, storing, and handling dilutable disinfectants, or when the product label directions for use are not followed correctly (contact time, expiry date, etc.).8,9,10

Though research on disinfectant resistance is ongoing, one thing is clear: pathogens do not become resistant to disinfectants or germicides in the same way they do to antimicrobials. Notable differences include, but are not limited to:

In general, as long as a facility is using a good quality, U.S. Environmental Protection Agency-registered disinfectant and they are using it correctly, there should be no concerns of disinfectant resistance. Disinfectants are one of the most viable protections against multi-drug resistant organisms (MDROs) and disinfectants could play an increasingly important role in managing bacterial infections in the future if the current trend of antibiotic resistance continues.1

References

1. 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance. Centers for Disease Control and Prevention. 2022 [Cited October 1, 2022]. Available From: https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf
2. Current HAI Progress Report: 2020 National and State Healthcare-Associated Infections Progress Report [Internet]. Centers for Disease Control and Prevention. 2021 [Cited October 1, 2022]. Available From: https://www.cdc.gov/hai/data/portal/progress-report.html
3. Nelson RE, Hatfield KM, Wolford H, Samore MH, Scott RD, Reddy SC, et al. National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States. Clin Infect Dis [Internet]. 2021 Jan 15 [Cited October 1, 2022];72(Suppl 1):S17–26. Available from: https://pubmed.ncbi.nlm.nih.gov/33512523/
4. Antimicrobial Resistance: How Antimicrobial Resistance Happens. Centers for Disease Control and Prevention. 2021 [Cited October 1, 2022]. Available From: https://www.cdc.gov/drugresistance/about/how-resistance-happens.html
5. Rozman U, Pušnik M, Kmetec S, Duh D, Turk SŠ. Reduced Susceptibility and Increased Resistance of Bacteria against Disinfectants: A Systematic Review. Microorganisms [Internet]. 2021 Dec 1 [Cited October 1, 2022];9(12). Available from: /pmc/articles/PMC8706950/
6. Mc Carlie S, Boucher CE, Bragg RR. Molecular basis of bacterial disinfectant resistance. Drug Resist Update [Internet]. 2020 Jan 1 [Cited October 1, 2022];48. Available from: https://pubmed.ncbi.nlm.nih.gov/31830738/
7. Boyce JM, Havill NL. In-use contamination of a hospital-grade disinfectant. Am J Infect Control [Internet]. 2022 [Cited October 1, 2022];0(0). Available from: http://www.ajicjournal.org/article/S0196655322001481/fulltext
8. Harbarth S, Tuan Soh S, Horner C, Wilcox MH. Is reduced susceptibility to disinfectants and antiseptics a risk in healthcare settings? A point/counterpoint review. J Hosp Infect [Internet]. 2014 [Cited October 1, 2022];87(4):194–202. Available from: https://pubmed.ncbi.nlm.nih.gov/24996517/
9. Sheldon AT. Antiseptic “resistance”: real or perceived threat? Clin Infect Dis [Internet]. 2005 Jun 1 [Cited October 1, 2022];40(11):1650–6. Available from: https://pubmed.ncbi.nlm.nih.gov/15889364/
10. Bragg R, Jansen A, Coetzee M, van der westhuizen W, Boucher C. Bacterial resistance to Quaternary Ammonium Compounds (QAC) disinfectants. Adv Exp Med Biol [Internet]. 2014 [Cited October 1, 2022];808:1–13. Available from: https://pubmed.ncbi.nlm.nih.gov/24595606/
11. Weber DJ, Rutala WA. Use of germicides in the home and the healthcare setting: is there a relationship between germicide use and antibiotic resistance? Infect Control Hosp Epidemiol [Internet]. 2006 Oct [Cited October 1, 2022];27(10):1107–19. Available from: https://pubmed.ncbi.nlm.nih.gov/17006819/

In the era of COVID-19, worker shortages seem to be wide-spread. In no industry is this more apparent than in healthcare. According to the U.S. Bureau of Labor Statistics, healthcare employment remains below pre-pandemic levels, with the number of workers down by 1.1%, or 176,000, compared to February 2020.1 This comes at a time when healthcare services are needed more than ever. In March 2022, the American Hospital Association (AHA) wrote a letter to the House Energy and Commerce Committee describing the staffing shortages hospitals were experiencing as a national emergency. They also projected the overall shortage of nurses to reach 1.1 million by the end of the 2022.2 This does not include all of the other critical healthcare roles experiencing shortages; from infection preventionists (IPs) to environmental cleaning service (EVS) professionals. In fact, all parts of the healthcare continuum are feeling the squeeze.

One main safety concern related to the staffing shortages is the potential impact to healthcare associated infections (HAIs). Over the past several years, the healthcare industry has experienced unprecedented challenges, including higher than usual hospitalizations which, combined with the shortages in healthcare personnel and resources, likely resulted in decreased surveillance activities and reporting via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).3 According to the CDC’s 2020 National and State HAI Progress Report, each day, approximately 1 in 31 U.S. patients contracts at least one HAI, highlighting the need for improvements in infection prevention practices in U.S. healthcare facilities.4 This recommendation illustrates the juxtaposition that IPs are faced with today – what are the opportunities for improvement that do not add to an already stretched staff in terms of time or resources?

When it comes to EVS impact, I believe there are two main areas of opportunity: training and cleaning efficiency.

EVS Training

Training is essential for not only worker efficiency, but also overall job satisfaction, as well as retention. In fact, offering employees an opportunity for learning and growth is one of the key metrics of job satisfaction.5 With increased staff turnover and limited time to train new employees, having a best-in-class education and training program in place to help ensure cleaning professionals get the knowledge and skills needed to clean and disinfect effectively, efficiently, and safely is critical. To help address this need, CloroxPro launched a new online learning program in 2022. The course is available on-demand and covers:

Additionally, the Association for the Healthcare Environment (AHE) offers online courses with topics ranging from EVS Leadership: A Seat at the Table to Essentials of Infection Prevention of Environmental Hygiene.

Cleaning Efficiency

In the fight against HAIs, the efficiency and efficacy of ready-to-use disinfectants has been long established. This added benefit is even more important when resources are constrained. Lower priced dilutable disinfectants may be initially attractive, but research has shown6 that initial cost savings is often outweighed by the hidden costs when it comes to cross-contamination, quality control issues, overall efficacy, and low compliance. For example, most dilutable products have varying contact times and pathogen kill claims depending on the dilution. This opens the door for the use of an incorrect dilution and could potentially lead to the spread of HAI-causing pathogens in a facility. This is something we all need to be aware of because we know that:

  1. Disinfectants are one of the most viable protections against multi-drug resistant organisms (MDROs)
  2. Disinfectants could play an increasingly important role in managing bacterial infections in the future if the current trend of antibiotic resistance continues.7

Another way employers can improve cleaning efficiency is by leveraging emerging technologies, such as electrostatic sprayers, in combination with traditional application methods, like disinfecting wipes. Electrostatic sprayers can improve cleaning efficiency by allowing EVS workers to use less time to cover more spaces. In fact, electrostatic spraying has been shown to be 4x faster than manual disinfection.8

Though staffing shortages are not unique to healthcare, they do create an increased concern around patient safety, including HAI prevention. Proper training and the use of efficient strategies, like ready-to-use disinfectants and electrostatic sprayers can be critical in terms of overall HAI prevention and removing the environment as a source of infection. As you evaluate your own team’s needs especially for new hires, be sure to consider where and when ready-to-use products might offer time savings and increased compliance opportunities and do not forget to leverage on-demand training tools to help bridge the gap between teams.

References

1. Economic News Release: Employment Situation Summary [Internet]. U.S. Bureau of Labor Statistics. 2022. Cited September 1, 2022. Available From: https://www.bls.gov/news.release/empsit.nr0.htm
2. AHA Letter Re: Challenges Facing America’s Health Care Workforce as the U.S. Enters Third Year of COVID-19 Pandemic [Internet]. American Hospital Association. 2022. Cited September 1, 2022. Available From: https://www.aha.org/lettercomment/2022-03-01-aha-provides-information-congress-re-challenges-facing-americas-health
3. Wu, Hsiu, et al. Hospital capacities and shortages of healthcare resources among US hospitals during the coronavirus disease 2019 (COVID-19) pandemic, National Healthcare Safety Network (NHSN), March 27–July 14, 2020. Infection Control & Hospital Epidemiology 2021, 1-4; Available From: https://pubmed.ncbi.nlm.nih.gov/34167599/
4. Current HAI Progress Report: 2020 National and State Healthcare-Associated Infections Progress Report [Internet]. Centers for Disease Control and Prevention. 2021 [Cited September 1, 2022]. Available From: https://www.cdc.gov/hai/data/portal/progress-report.html
5. Bersin J. New Research Shows “Heavy Learners” More Confident, Successful, and Happy at Work [Internet]. LinkedIn. 2018; Available from: https://www.linkedin.com/pulse/want-happy-work-spend-time-learning-josh-bersin/
6. Wiemken, T. L. et al. The Value of Ready-to-Use Disinfectant Wipes: Compliance, Employee Time, and Costs. Am. J. Infect. Control 2014, 42, 329–330.
7. 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance. Centers for Disease Control and Prevention. 2022 [Cited September 1, 2022]. Available From: https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf
8. Cadnum JL, Jencson AL, Livingston SH, Li D, Redmond SN, Pearlmutter B, et al. Evaluation of an Electrostatic Spray Disinfectant Technology for Rapid Decontamination of Portable Equipment and Large Open Areas in the Era of SARS-CoV-2. Am J Infect Control [Internet]. 2020; Available from: https://doi.org/10.1016/j.ajic.2020.06.002

Last month, the Society for Healthcare Epidemiology of America (SHEA) held its first in-person conference in over two years. Over 1,100 attendees from 24 countries participated in-person or online and included members and non-members of all disciplines relating to Infection Prevention Programs, Antibiotic Stewardship Programs, Public Health, Pharmacy, Occupational Health, Clinical Microbiology, Quality Improvement, and Patient Safety.

As with previous years, the SHEA Spring conference consisted of:

  1. Two training courses:
    1. SHEA/CDC Training Course in Healthcare Epidemiology
    2. SHEA Antibiotic Stewardship Training Course
  2. General conference sessions focused on innovative topics in Healthcare Epidemiology and Antibiotic Stewardship
  3. New research abstracts related to healthcare, surveillance, epidemiology, patient safety and infection prevention strategies

Notably, COVID-19 was not a main focus of this year’s conference. Presenters shared research that examined the unintended consequences and lessons learned from the pandemic, but it was unmistakable that our collective focus has shifted to identifying, predicting, and hopefully, preventing the next global pandemic. One of the most fascinating talks was a Plenary Session given by Dr. Ali S. Khan and Dr. Tom Chiller on Climate Change and the Emergence of Novel Pathogens in Healthcare. Former Director of the Office of Public Health and retired Assistant Surgeon General, Dr. Khan highlighted that we are in a bit of a perfect storm scenario with (1) climate change, (2) stress on healthcare infrastructure, and (3) the spread of new pathogens in healthcare settings before they are identified. His best guess was that our next pandemic is likely to be viral in nature with some top candidates being Influenza A and other Coronaviruses.

Similarly, Dr. Chiller, who is currently the Chief of the Mycotic Diseases Branch at the Centers for Disease Control and Prevention (CDC) agreed that we are undoubtedly in the “viral era,” but that fungi is the future and potentially on a path to be the source of the next deadly plague. Dr. Chiller cited that this is because fungi are inherently sensitive to environmental and climate change. He went on to explain that this theory is well supported and illustrated by the emergence of Candida auris. C. auris was first identified in 2009 and by 2018 was labeled an urgent threat by the CDC. As of 2022, it has now been found on every populated continent, including North America and the United States.1 It appears to prefer warm, salty conditions and in many ways behaves more like a bacteria than a yeast because it:

For all the above reasons, a robust cleaning and disinfection protocol is critical when C. auris has been identified at your facility. Currently, the CDC recommends use of a disinfectant that is registered with the Environmental Protection Agency (EPA) and is effective against C. auris. If a product with an EPA claim is not available, the CDC recommends using a disinfectant that is effective against C. difficile (see EPA List K).2 Disinfectants with an EPA claim for C. difficile have been used effectively against C. auris.

Ultimately, Drs. Khan and Chiller made clear that we can no longer separate global health and climate change from our work in public health and infection prevention. The good news is that important research is already underway. One example is CDC’s ONE HEALTH. One Health “is a collaborative, multisectoral, and transdisciplinary approach — working at the local, regional, national and global levels — with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants and their shared environment.” You can learn more at https://www.cdc.gov/onehealth/.

Source: https://www.cdc.gov/onehealth/images/social-media/why-one-health-is-important-twitter.jpg

References

1. General Information about Candida auris. Centers for Disease Control and Prevention website. https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html Updated 2019. Accessed March 24, 2022.
2. Infection Prevention and Control for Candida auris. Centers for Disease Control and Prevention website. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html Updated 2021. Accessed March 24, 2022.

More than 4.5 million people voluntarily left their jobs in November 2021 according to the Bureau of Labor Statistics. This mass exodus highlights the struggle many employers are facing retaining workers. As a consequence, in the midst of an ongoing pandemic, the professional cleaning industry is challenged with not only increased demand for cleaning services, but also severe staffing shortages. In other words, they need to do more with less. The need for improved cleaning efficiencies has never been higher. One way employers can improve cleaning efficiency is by leveraging emerging technologies, such as electrostatic sprayers (ESS), in combination with traditional application methods, like disinfecting wipes.

Electrostatic sprayers can improve cleaning efficiency in three ways:

  1. Use less time to cover more spaces — Electrostatic spraying has been shown to be 4x faster than manual disinfection.1
  2. Use less disinfectant overall equating to saved resources — Electrostatic devices use 65% less disinfectant solution* and 81% less plastic to cover the same area when compared to a trigger sprayer.
  3. Keep workers happy and engaged — Offering employees an opportunity for learning and growth is one of the key metrics of job satisfaction.2

Throughout the 20th century, numerous researchers published work laying out the fundamentals of spray-charging methods to increase the deposition efficiency of finely divided droplets.3 Since then, 21st century researchers have continued to evaluate electrostatic technology, specifically in regards to surface disinfection. One research team at the Cleveland Clinic and the Cleveland VA have investigated utilizing electrostatic spray technology in comparison to a high-level disinfection chamber and UV light. Of the three technologies tested, electrostatic disinfection and the high-level disinfection chamber were the most effective, but the electrostatic device was considered the easiest technology to use as the required spray times for small items were only 20 seconds.4 In another study, the same researchers found statistically significant reductions in pathogen contamination on portable equipment, wheelchairs, and waiting room surfaces when a disinfectant was applied via an electrostatics sprayer, without any wiping or pre-cleaning. They also found that electrostatic application of the disinfectant was just as effective as manual disinfecting but could be applied four times faster. 1

Don’t Forget About Chemistry

Ultimately though, the efficiency gained by an electrostatic sprayer can change based on the chemistry you decide to use with your sprayer device. As highlighted by the EPA, “ESS is only as effective as the disinfectant chemical being sprayed.”5 The disinfectant you use can impact:

Labor shortages may be here for the foreseeable future and that means identifying cleaning efficiencies whenever we can. By retaining employees and improving the efficiency of our tasks, we can continue to Clean for Health in the face of the challenges brought on by the pandemic.

* On a per ounce basis for CloroxPro® Total 360® Disinfectant Cleaner 128 oz. vs. CloroxPro® Total 360® Disinfectant Cleaner in a 32 oz. trigger sprayer
† Vs. a trigger sprayer per square foot

References

1. Cadnum JL, Jencson AL, Livingston SH, Li D, Redmond SN, Pearlmutter B, et al. Evaluation of an Electrostatic Spray Disinfectant Technology for Rapid Decontamination of Portable Equipment and Large Open Areas in the Era of SARS-CoV-2. Am J Infect Control [Internet]. 2020; Available from: https://doi.org/10.1016/j.ajic.2020.06.002
2. Bersin J. New Research Shows “Heavy Learners”​ More Confident, Successful, and Happy at Work [Internet]. LinkedIn. 2018 [cited 2022 Jan 6]. Available from: https://www.linkedin.com/pulse/want-happy-work-spend-time-learning-josh-bersin/
3. Law ES. Agricultural electrostatic spray application: a review of significant research and development during the 20th century [Internet]. Journal of Electrostatics 51(1). 2001 [cited 2022 Jan 5]. p. 25–42. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0304388601000407?via%3Dihub
4. Haydar H, Kumar J, Cadnum J, Hoyen C, Donskey C. Evaluation of Novel “No-Touch” Technologies for Decontamination of Toys in Pediatric Healthcare Settings. Infect Control Hosp Epidemiol [Internet]. 2020;41(S1):S229. Available from: https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/evaluation-of-novel-notouch-technologies-for-decontamination-of-toys-in-pediatric-healthcare-settings/768D8AAC983E75F4B41DC8DBFC179BD8
5. Environmental Protection Agency (EPA). Evaluating Electrostatic Sprayers for Disinfectant Application [Internet]. [cited 2022 Jan 5]. Available from: https://www.epa.gov/covid19-research/evaluating-electrostatic-sprayers-disinfectant-application

“Public health has gone from quietly operating in the background to having the whole nation’s attention.”
– Jill Ryan, Executive Director of the Colorado Department of Public Health and Environment

Public health is a practice that has been referenced continually over the past two years, but I still find that many do not truly appreciate what it means to be a public health professional. In general, public health aims to promote and protect the health and safety of populations of people through prevention. While a doctor focuses on an individual patient, public health professionals are focused on a whole subset of people. In practice this might be a public health nurse at a local health department focusing on a designated county or state. Or this might be an infection prevention practitioner in a hospital that is dedicated to their specific inpatient population. Public health professionals are not limited to just one area of practice. Some are in research, while others work for non-profit organizations. Some are like me and have chosen to use their public health skills to educate and advocate within the professional cleaning industry. While our journeys are different, one thing unites us and that is the passion for the science of protecting and improving the health of people and their communities.

Components of the Public Health System

Source: Centers for Disease Control and Prevention (CDC) Public Health Professionals Gateway: Components of Public Health System Description

The American Public Health Association (APHA) held its annual conference this fall, and I was lucky enough to attend virtually. This year’s meeting focused on a wide variety of hot topics including lessons learned from the COVID-19 pandemic, social connectedness, health equity, climate change, and health advocacy and policy. With over 9,000 public health professionals attending either in-person or virtually, the content delivered on APHA’s commitment to unite members, corporations, organizations, and government agencies for the benefit of society.

One standout theme I took away from the sessions I attended was the need for safe cleaning and disinfectant use, education, and communication. Below you will find the top public health recommendations while we make our way out of the COVID-19 pandemic and refocus on all the other pathogens of concern in our shared spaces:

As cleaning professionals, it is easy to forget that the work we do every day protects the health and safety of others. In many ways the cleaning professional’s role is one and the same as public health professionals everywhere. Protecting and creating safe environments for our families, employees, patients, customers and students is fundamental to the public health system, but so often a thankless job. As public health champion Dr. William Herbert Foege highlighted so perfectly, “No one will thank you for the disease they didn’t get.” Well, during this holiday season, all of us at CloroxPro would like to show our appreciation for all our fellow public health cleaning ambassadors. Stay safe and THANK YOU for your invaluable work!

In the past year, the words aerosol, particle, and droplet have all been brought front and center as we learn more about SARS-CoV-2, the virus that causes COVID-19 and its transmission. In the world of surface disinfection, these words are equally important particularly when it comes to evaluating new disinfection technologies. However, in my experience both inside and outside the public health community, these words tend to be used interchangeably. It leads me to question how the cleaning industry is supposed to differentiate and identify the information most relevant to them and the safety of their workers. Are all droplets really aerosols? Are particles the same as droplets? How does the particle or droplet size impact the safety of the various surface disinfection applications?

To help clarify, let’s break it down:

  1. Aerosol: A suspension of tiny particles or droplets in the air.1 Aerosol is often used both to define respiratory droplets and particles that are small in size, as well as to explain the collection or cloud of these droplets in the air.2
  2. Particle (also known as particulate matter): Tiny pieces of solids or liquids that are in the air. Examples of these particles include things like dust, smoke, dirt, and drops of liquid. Particles can range in sizes. Some are big enough (or appear dark enough) to see with our naked eye, e.g., you can often see smoke in the air. While others are so small that you cannot see them in the air. As illustrated in the below image, the range of particle size can vary considerably.3
  3. Droplet: Simply defined as a tiny drop of liquid.4 A droplet is a type of particulate matter.
infographic showng relative size of various particles
Source: https://www.visualcapitalist.com/visualizing-relative-size-of-particles/

In April 2021, the Centers for Disease Control and Prevention (CDC) released their updated guidance for prevention of COVID-19 when using electrostatic sprayers, foggers, misters, or vaporizers. In this guidance, they caution operators that “these devices aerosolize chemicals, or suspend them in the air, and they can stay in the air for long periods of time, especially if the area is not well ventilated.” In terms of safety, the size of the droplets or particulate matter in the air is what matters when determining if something is truly inhalable or breathable and sizes can vary greatly.6 Large droplets or particles generally fall to the ground quite quickly because of gravity. To provide scale, inhalable particles or droplets that enter the airways are usually anything below 30 µm (30 microns) and respirable particles or droplets are typically defined as anything less than 10 microns in diameter.7 5  The CDC guidance correctly points out that users should review the requirements and safety protocols for these technologies, but it is important to knowthat the technologies provide different levels of performance and require different safety precautions. 

So where do the common surface disinfection technologies fall in terms of particle or droplet size?

infographic showing droplet size of solution through electrostatic sprayers versus misters

As you can see, foggers, trigger sprays and electrostatic sprayers offer a range of disinfecting benefits. While electrostatic sprayers and foggers are often considered similar, their performance demands different levels of personal protective equipment (PPE), room preparation, and room re-entry wait times. Regardless of the technology you decide is right for your cleaning and disinfection protocols, the droplet size of the delivery system does make a difference.

References

1. CDC. The National Institute for Occupational Safety and Health (NIOSH): Aerosols [Internet]. Centers for Disease Control and Prevention. 2010 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/niosh/topics/aerosols/default.html
2. CDC. Science Brief: SARS-CoV-2 and Potential Airborne Transmission - Updated Oct. 5, 2020 [Internet]. Center for Disease Control and Prevention. 2020 [cited 2021 Apr 28]. p. 4. Available from: https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/scientific-brief-sars-cov-2.html
3. CDC. Air Quality: Particle Pollution [Internet]. Centers for Disease Control and Prevention. 2019 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/air/particulate_matter.html
4. Merriam-Webster. Droplet [Internet]. 2021 [cited 2021 Apr 28]. Available from: https://www.merriam-webster.com/dictionary/droplet#:~:text=Medical Definition of droplet,drop (as of a liquid)
5. CDC. Safety Precautions When Using Electrostatic Sprayers, Foggers, Misters, or Vaporizers for Surface Disinfection During the COVID-19 Pandemic [Internet]. Centers for Disease Control and Prevention. 2021 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/php/eh-practitioners/sprayers.html
6. Baron P. Generation and Behavior of Airborne Particles (Aerosols) [Internet]. National Institute for Occupational Safety and Health. 2020 [cited 2021 Apr 28]. Available from: https://www.sdpt.net/rd/Aerosol_101.pdf
7. European Aerosol Federation. Guide on Inhalation Safety Assessment for Spray Products. 2013.
8. EPA. Instructions for Adding Electrostatic Spray Application Directions for Use to Antimicrobial Product Registrations [Internet]. United States Environmental Protection Agency. 2021 [cited 2021 Apr 28]. Available from: https://www.epa.gov/pesticide-registration/instructions-adding-electrostatic-spray-application-directions-use
9. WHO. Space spray application of insecticides for vector and public health pest control [Internet]. World Health Organization - WHO. 2003 [cited 2021 May 1]. p. 45. Available from: https://apps.who.int/iris/bitstream/handle/10665/68057/WHO_CDS_WHOPES_GCDPP_2003.5.pdf?sequence=1

If there were a theme song for the past few months, I think we would all agree it would be something closely resembling Hear Comes the Sun, the classic by the Beatles. The smiles are returning, and it certainly feels like years since the long, cold lonely COVID-19 winter began! However, as a public health professional, I wish we were all singing the 80’s classic Don’t Stop Believin’ by Journey because this epidemiologist wants you holding on to the feeling of hygiene. I want us, though we are excited to re-open, to remember what we have learned and continue to embrace the public health awareness brought on by the pandemic.

But I cannot say everyone agrees. In the past few weeks, the number of articles written to combat “Hygiene Theater” disinfection antics is increasing at an alarming pace.1,2 The pendulum of public opinion is swinging and we are ready to move into the future by returning to the pre-2020 “normal” instead of a “new normal” as I had hoped. As I sit here contemplating how to articulate why I feel strongly we should not return to old behavior, I need to pause to reach for a tissue. I have a cold. This is a strange and rare phenomenon lately, but I have concerns it will soon be a wide-spread experience as more of us begin to re-emerge from our homes and our careful precautions give way to old habits. Instead, my hope is that as we enter a post-pandemic world, we bring forth the lessons we have learned over the past year to create a healthier future for all.

Here’s what we know: COVID-19 can be transmitted on surfaces, but it is unlikely to be the main source of transmission.

We all remember the early days of the pandemic when we would wipe down our groceries, packages, and lived in constant fear of catching the virus. We did this because we did not yet know enough about this emerging pathogen and we wanted to protect our loved ones. We now know much of this was unnecessary as the principal mode of transmission of SARS-CoV-2 is through exposure to respiratory droplets in the air and not through surfaces (or fomites).3 Though some might call this theater, I think it was simply our attempt to mitigate the risk of a very scary pathogen from entering our homes. Similarly, out of this fear and with a hope to restart our economy during a pandemic, our communities and businesses went into disinfection and sanitization overdrive (i.e., Hygiene Theater).

If a business is purely using disinfectants for show and more importantly, not using them safely and in accordance with label instructions, then I believe we will all lose sight of the lessons we have learned over the past year.

In this way, I agree with many voicing their concerns publicly. However, we cannot just throw away the public health awareness we have gained over the past year and we cannot make the mistake of thinking COVID-19 is the only pathogen posing a threat to our future health, safety and economy. My optimism on this subject in my November Hygiene Theater Blog still holds true today. We have an opportunity to turn this heightened awareness of germ transmission into actionable infection prevention in our communities.

Over the past year, we have also seemingly forgotten about all the other microbes and pathogens that live and thrive on our surfaces. 

Illnesses such as the Flu have virtually been wiped out by our COVID-19 precautions but as evidenced by my current nasal congestion, they have not gone away and will return to our spaces with us. Norovirus, for example, is a virus that causes vomiting and diarrhea and thrives on surfaces in areas where large numbers of people congregate. Norovirus outbreaks are common and frequently found on cruise ships, in long term care facilities, and in school and childcare settings. You may hear norovirus illness referred to as “food poisoning,” “stomach flu,” or “stomach bug” and because of the large number of variants, we can be infected repeatedly.Close quarters, shared spaces, and high-touch surfaces make it easy for norovirus to spread.

Although the number of norovirus outbreaks have been drastically reduced during the pandemic, norovirus, on average, each year results in over 19 to 21 million cases of vomiting and diarrhea in the United States. It is estimated by the age of five, 1 in 110,000 children will die and 1 in 160 will be hospitalized due to norovirus.4 In 2016, researchers estimated that norovirus resulted in a total of $4.2 billion in direct health system costs and $60.3 billion in societal costs (including productivity loss and income) per year.5

People are ready to return to normal life and we have an opportunity to impact what that looks like.

We must, now more than ever, implement sanitation protocols and base them on risk assessments and scientific evidence. One of the best examples of this is hand hygiene. The simple act of washing our hands more frequently is our first line of defense yet hand hygiene compliance rates are low and we often contaminate surfaces without even realizing it. In fact, nearly 80% of infectious diseases are spread by our hands and the surfaces we touch.6 This is why surface disinfection is such a critical tool in our efforts to break the chain of infection. Our approach to the use of disinfectants and sanitizers needs to be in a way that is not only effective but also efficient. This involves prioritizing places where the risk of pathogen spread is greater, like high traffic, shared spaces, and frequently touched surfaces. By utilizing SMART Disinfection practices (think “work smarter, not harder”), we can target disinfecting higher risk areas to reduce pathogen transmission while also optimizing the use of disinfectants and hopefully preventing concerns of overuse in our communities.

The curtain might be closing on COVID-19 theater, but that doesn't mean our work is done.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

1.       Thompson D. Deep Cleaning Isn’t a Victimless Crime The CDC has finally said what scientists have been screaming for months: The coronavirus is overwhelmingly spread through the air, not via surfaces. [Internet]. The Atlantic. 2021. Available from: https://www.theatlantic.com/ideas/archive/2021/04/end-hygiene-theater/618576/

2.          Anthes E. Has the Era of Overzealous Cleaning Finally Come to an End? [Internet]. The New York Times. [cited 2021 Apr 23]. Available from: https://www.nytimes.com/2021/04/08/health/coronavirus-hygiene-cleaning-surfaces.html

3.          CDC. Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for Indoor Community Environments - Updated Apr. 5, 2021 [Internet]. Centers for Disease Crontrol and Prevention. 2021. p. 5. Available from: https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html

4.          CDC. Norovirus Burden of Norovirus Illness in the U.S. CDC [Internet]. Centers for Disease Crontrol and Prevention. 2020 [cited 2021 Apr 23]. Available from: https://www.cdc.gov/norovirus/trends-outbreaks/burden-US.html

5.          Bartsch SM, Lopman BA, Ozawa S, Hall AJ, Lee BY. Global economic burden of norovirus gastroenteritis. PLoS One [Internet]. 2016; Available from: https://pubmed.ncbi.nlm.nih.gov/27115736/

6.          Healthcare T-C. Gross! Hand hygiene and other germy facts [Internet]. 2018 [cited 2021 Apr 29]. Available from: https://www.tchc.org/blog/2018/12/12/hand-hygiene-and-germ-facts/

What do smallpox, polio, and measles1 all have in common? They have all been successfully eliminated in the U.S. via wide-spread vaccination. After ten long months, the COVID-19 vaccine roll-out is finally happening and we are well on our way to successfully combating another infectious disease.

What will determine if the new vaccines are successful?

Simply put, people need to get vaccinated for a vaccine to be effective. Yes, the vaccine itself must be safe and have high efficacy (i.e., create an adequate immune response in those vaccinated), but ultimately what determines if a vaccine is truly successful at eliminating a disease in a population comes down to herd immunity.

What is herd immunity?

Herd immunity is the act of protection that is provided when enough of a population gains immunity to an illness that it halts transmission. Every infectious disease has a reproduction number or R0 (pronounced “R naught”). This calculation is the average number of people an infected individual will infect in an at-risk (non-immune) population. Inevitably, for any given disease, the R0 calculations can vary widely, but are generally based on three primary characteristics:

  1. How long an individual is contagious while infected
  2. The likelihood of infection per contact between an infectious person and a susceptible person
  3. How often people are encountering one another (contact rate)

With COVID-19, R0 estimates change based on location and population, but some studies calculate it being as high as 5.7 (95% CI 3.8–8.9) .2 So, if I am infected with COVID-19 and interacting with a completely vulnerable group of individuals, on average, I could expect to infect five other people. To reach herd immunity, you essentially need to pass an immunity threshold that makes it so that an infected person has no one to transmit the infectious disease to because no one around them is susceptible (R0 < 1).3

Herd Immunity Blog Post

Why do we need to get vaccinated?

Herd immunity has been a hot topic throughout the pandemic as there are only two ways to truly achieve it: 1) natural immunity via infection and 2) immunity via vaccination. Unfortunately, when it comes to most infectious diseases, natural immunity through active infection might not be enough to offer full protection and any immunity provided could dissipate over time leaving some individuals vulnerable to reinfection. Additionally, waiting for a population to become infected, and therefore immune, can take a very long time and may result in unnecessary deaths and long-term health implications.

One great example of this is chickenpox. Not long ago, parents would purposely expose their children to infectious individuals to ensure immunity was developed at a young age. I can remember vividly being forced on a play date while covered in spots. Unfortunately, to achieve this natural herd immunity, each year, over 10,000 were hospitalized and an estimated 100-150 died. After the vaccine became widely available in the U.S. in 1995, more than 3.5 million cases of chickenpox are now prevented each year.4

How many people need to get vaccinated to achieve herd immunity?

The estimated number of people that need to get vaccinated to achieve herd immunity depends on several factors:

  1. The infectious disease and how contagious it is.
  2. The proportion of people that are susceptible in a population.
  3. The overall effectiveness of the vaccine.

Experts do not yet know what that threshold is for COVID-19. This is because we do not know how many of us already have immunity. Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, estimates that around 75% of the public needs to get vaccinated for herd immunity to provide protection and truly stop the spread of COVID-19.5

How do we learn more about the COVID-19 vaccines and the plan to reach herd immunity?

Concerns over the speed with which these vaccines were developed are warranted. We should all do our due diligence with any new public health intervention. Thankfully, the information on safety is widely available. Here are three comprehensive resources to help address any concerns you, your family, or your staff may have:

What can we do now?

The Centers for Disease Control and Prevention (CDC), in consultation with the U.S. Advisory Committee on Immunization Practices (ACIP), is prioritizing vaccine distribution in a fair and ethical way and continuing to provide transparent updates on the vaccine roll-out plan. While we wait for our turn to be vaccinated, we need to remind our family, friends, and staff to continue to do all the things that we have been doing – wear masks, maintain social distance, avoid indoor and poorly ventilated spaces, wash our hands, and clean and disinfect regularly. We do these things to protect ourselves, but more importantly, to protect others. That is also true of vaccines. We get them to create herd immunity and protect those in our society that are most vulnerable. I, for one, am looking forward to adding another eliminated disease to the above vaccine success list – smallpox, polio, measles, and COVID-19!

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

  1. Measles Elimination [Internet]. Centers for Disease Control and Prevention (CDC). 2020. [cited 2020 Dec 8] Available from: https://www.cdc.gov/measles/elimination.html
  2. Sanche S, Lin YT, Xu C, Romero-Severson E, Hengartner N, Ke R. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. Emerg Infect Dis [Internet]. 2020. [cited 2020 Dec 8] Available from: https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article
  3. Delamater PL, Street EJ, Leslie TF, Yang YT, Jacobsen KH. Complexity of the basic reproduction number (R0). Emerg Infect Dis [Internet]. 2019. [cited 2020 Dec 8] Available from: https://wwwnc.cdc.gov/eid/article/25/1/17-1901_article
  4. Chickenpox (Varicella) [Internet]. Centers for Disease Control and Prevention (CDC). 2020. [cited 2020 Dec 8] Available from: https://www.cdc.gov/chickenpox/about/index.html
  5. Armour, S. Fauci Calls Coronavirus Vaccine a Game Changer, Decries Misinformation [Internet]. The Wall Street Journal. 2020 Dec 8. [cited 2020 Dec 8] Available from: https://www.wsj.com/articles/deborah-birx-and-anthony-fauci-to-discuss-coronavirus-response-11607432098