Authors

Matthew Carlisle BS, William A. Rutala PhD, Jennifer L. Cadnum BS, Brigid M. Wilson PhD, Abhishek Deshpande MD, PhD, and Curtis J. Donskey MD

Download the full article here.

Overview

Dr. Curtis Donskey and his research group at the Louis Stokes Cleveland VA Medical Center conducted a randomized trial evaluating an UV-C decontamination device compared with Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic sprayer as a finishing step. Standardized cultures were taken from high-touch surfaces and the floor after completion of manual cleaning and disinfection by environmental services personnel. Pathogens examined included: C. difficile, vancomycin-resistant Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus (MRSA).

Key Findings

Methods

After completion of manual cleaning and disinfection by the environmental services (EVS) personnel at the Cleveland VA Medical Center, 40 non-Clostridioides difficile infection (CDI) hospital rooms were randomized to either UV-C or Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system. Research personnel operated both the UV-C device and the Total 360® system. EVS personnel were not made aware of the study.

The UV-C device was operated for 5 minutes on each side of the bed and in the bathroom. The Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system was sprayed on all room and bathroom high-touch surfaces and the entire surface area of the floor. Surfaces were allowed to air dry. Enough disinfectant was applied to remain visibly wet for 2 minutes or longer. In alignment with manufacturers, instructions for use (IFU), the patient rooms were unoccupied during use.

Before and after use of the UV-C or Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system, standardized cultures were collected from high-touch surfaces (bedrail, bedside table, call button, telephone, toilet seat, and bathroom handrail) and from areas on the patient room floor and bathroom floor. Pathogens examined included C. difficile, vancomycin-resistant Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus (MRSA).

Conclusions

This study demonstrated that high-touch surfaces and floors in patient rooms were frequently contaminated with healthcare-associated pathogens after manual cleaning and disinfection. Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic sprayer provided an effective and efficient option as an adjunct finishing step compared to manual cleaning and disinfection and required less overall time until the room was ready to be occupied by another patient than the UV-C device.

Download a pdf version of this study here.

References

Carlisle, M., Rutala, W., Cadnum, J., Wilson, B., Deshpande, A., & Donskey, C. (2022). A randomized trial of ultraviolet-C (UV-C) light versus sodium hypochlorite delivered by an electrostatic sprayer for adjunctive decontamination of hospital rooms. Infection Control & Hospital Epidemiology, 1-4. doi:10.1017/ice.2022.132

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/.

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.

For nearly 60 years, GLIDE Foundation has been a center for social justice, dedicated to fighting systemic injustices, creating pathways out of poverty and crisis, and transforming lives. Located in San Francisco’s diverse and culturally rich Tenderloin neighborhood, most of GLIDE’s clients are experiencing poverty and struggling to afford housing, food, and meet other basic needs. GLIDE has remained open throughout the pandemic and continues to provide wraparound services that include: three free meals every day, case management, housing navigation, childcare, harm reduction, policy advocacy, and spiritual nourishment via GLIDE Memorial Church, a subsidiary of GLIDE Foundation.

GLIDE knows that providing a caring environment starts with providing a clean and safe environment. Surface disinfection is critically important and it is no small task to ensure that the 135,000 square-foot community service hub, childcare facilities, kitchens, offices, and church Sanctuary are kept clean and healthy year-round. We spoke with Erby Foster, Chief Financial and Operating Officer, and Matt Dudley, assistant manager of GLIDE’s facilities team, about the role disinfection has played in providing life-changing services to the community amidst the ever-evolving pandemic environment.

The Challenge: Safely Serving Those in Need During a Global Pandemic

Not once in the last two years has GLIDE stopped serving the community. When the pandemic first hit San Francisco in early 2020, the biggest challenge for the facilities team was to maintain a high level of cleanliness throughout GLIDE’s facilities, with a limited number of staff available to get the job done.

“Our goal at GLIDE Foundation is to help maintain a safer and healthier environment while providing our services to the community,” says Foster.

While COVID-19 may not spread primarily via surfaces, the pandemic did bring greater attention to pathogens that can spread in high-traffic areas, and the facilities team found themselves in need of a highly effective yet efficient process for enhanced disinfection.

“Whether in the church Sanctuary or in the kitchen where we prepare our free daily meals, there are so many high-touch surfaces at GLIDE that need attention,” Dudley says. “We have to make sure we’re reaching every critical surface. It’s probably three or four times the amount of disinfecting than we had done before the pandemic, which was already a lot.”

CloroxPro Products Filling the Need

Although Dudley’s team was short on manpower and time, they responded to meet the challenge of keeping their spaces safe. To balance the staff’s capacity with growing demand, GLIDE Foundation and Dudley’s team turned to CloroxPro for help, and brought in the Clorox® Total 360® Electrostatic Sprayer and Clorox® TurboPro™ Handheld Electrostatic Sprayer.

“The day our CloroxPro devices were delivered might still be my favorite day,” Dudley recalls. “Incorporating the electrostatic devices and chemistry allow us to clean and disinfect more spaces, more effectively and in less time.”

Saving time while still achieving the right level of cleaning and disinfection is critical for GLIDE Foundation as more volunteers, staff, and clients start to return to the building, including those attending the iconic GLIDE Memorial Church Sunday celebrations. Though the organization continues to observe social distancing protocols, mask requirements, and vaccine checks, the proper disinfection of high-touch surfaces is a key component in helping to keep their spaces safe. As the church reintroduces in-person weekly Sunday Celebrations, the facilities team disinfects the Sanctuary between the two morning services.

“As far as efficiency, it’s a no-brainer,” Dudley says. “On Sundays, we go through the space with the TurboPro™ and it takes one person 25 minutes to do the whole building — every pew, every handrail. Without the Clorox TurboPro™ device, it would take a crew of four or five people to do the same work in the same amount of time.”

The facilities team was also able to reduce their disinfectant chemistry usage. “The Clorox® Total 360® System allows us to more effectively and efficiently cover high-touch and hard-to-reach surfaces for more comprehensive disinfection,” Foster explains. Since the Clorox Total 360® Disinfectant Cleaner stays wet for the recommended contact time and then dries on surfaces, the team can spray and keep on going with no wiping needed.

Staying Safe While Expanding Services

GLIDE has continued to extend its reach throughout the pandemic to meet community needs citywide, and the 2021 holiday season was no exception. Many communities in San Francisco were hit hard, especially those who were already struggling. In fact, 93% of the families that GLIDE serves have lost income as a result of COVID-19. Entering a second COVID-ridden holiday season, GLIDE recognized how important it was to provide kids with the holiday joy that they deserve and was determined to continue its Annual GLIDE Toy Wonderland tradition.

In mid-December, GLIDE delivered nearly 800 bags of new toys across San Francisco that were hand-picked for children based on their interests and ages. This was an increase of 150 more children served from 2020, which helped meet the rising need caused by the pandemic, inflation and the current economy.

Prior to the pandemic, the Toy Wonderland was an in-person event that gathered hundreds of children and families together for a special, joyful day. With the growing threat of the Omicron variant, the event was modified for a second year. Rather than convening families under one roof, GLIDE brought the toys to the children in their home neighborhoods.

Over the course of several weeks leading up to the toy deliveries, the toys were collected, sorted and packed in the GLIDE Memorial Church Sanctuary, the same place where the Sunday Celebrations are held. For the facilities team, special attention was paid to the disinfection of the Sanctuary during the toy packing to ensure that GLIDE was minimizing any threats that could be caused by the spreading of germs.

“Having the Clorox® Total 360® Electrostatic Sprayer and TurboPro™ Handheld Electrostatic Sprayer made disinfection really convenient and easy,” Dudley explains. Because the Total 360® Disinfectant Cleaner can be left on surfaces without wiping it off when used as directed, the staff was able to disinfect all critical surfaces in less than 30 minutes.

A "New Normal" for Sanitation at GLIDE

“Even if the pandemic ended two variants ago, it will always be important to clean and disinfect,” Dudley says. GLIDE staff are interacting with thousands of clients on a daily basis and are focused on making every interaction as safe as possible, which includes surface disinfection to help minimize the spread of illness-causing germs.

“The Clorox® Total 360® System enables us to provide our local community with greater peace of mind when visiting our facility,” says Foster. “We are proud to serve our local community with this premium technology and help provide them with enhanced safety against the spread of germs.”

For GLIDE’s facilities team, CloroxPro is here to stay beyond the pandemic and the products have taken the place of other steps done in the past. Incorporating Clorox® electrostatic solutions into GLIDE’s cleaning procedure helps eliminate illness-causing germs from surfaces while also minimizing time spent on disinfection.

“The Clorox® Total 360® Electrostatic Sprayer, TurboPro™ Handheld Electrostatic Sprayer, Total 360® Disinfectant Cleaner, and Anywhere® Daily Disinfectant & Sanitizer are going to be a really important part of our program going forward, regardless of how long the pandemic lasts,” Dudley concludes. “They’re reducing manual labor, they’re eliminating bacteria and viruses on surfaces and they’re more cost effective. It’s a triple win.”

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

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!

There is no question; the COVID-19 pandemic has impacted everyone, from how we do business to how we think about the spread of illnesses. The effects will be felt for a long time to come. For the cleaning and disinfection industry, the public’s attention on infection prevention and public health has never been greater. People are looking beyond aesthetics and while they want safe, clean spaces, they also want to use disinfectants responsibly.

How are businesses finding this balance? One example is the wide adoption of touchless surface disinfection technologies, such as electrostatic sprayers. These devices allow businesses to target specific surfaces (think high risk, high touch), or all surfaces in an area (e.g., restrooms), efficiently and effectively. Operators can disinfect surfaces in a matter of seconds while using less disinfectant overall. In fact, some electrostatic sprayers can disinfect four times faster and use up to 65% less disinfectant compared with traditional trigger sprayers. This is due to the even coating and efficiency of the charged droplets. This means fewer bottles, fewer refills, less potential surface impact, less disinfectant, lower overall cost, and less time spent disinfecting. As with most things, less is truly more.

Clorox® first launched an electrostatic device in March 2017. While the technology had previously been successfully used in industries such as agriculture and inkjet printing, electrostatics were new to the surface disinfection space. In the first two years, electrostatic devices were primarily used in the education, automotive, healthcare, and office industries.  Over the past 17 months, electrostatic sprayers have become increasingly popular. Clorox now offers devices in all shapes and sizes, to accommodate all types of usage occasions, including carts, backpacks, and handheld devices.

As the pandemic progressed, more and more businesses began adopting touchless disinfection technologies. In an effort to better understand which businesses and industries were mobilizing electrostatic devices in their surface disinfection arsenal and how use has changed since before the pandemic, we took a deep dive into our current electrostatic users. Results showed that while electrostatic devices are still very popular in schools, offices, and healthcare, they are becoming increasingly popular across a spectrum of various public spaces and facilities. In total, we found that 72 new industries began using electrostatics since the beginning of the pandemic. Businesses of all sizes, from family-owned restaurants and independent daycare centers to large companies like United, Live Nation, and the NBA have adopted electrostatic technology into their regular disinfecting practices to ensure their facilities are as safe and healthy as possible.

Here is what we found:

As highlighted recently by the former director of the Centers for Disease Control and Prevention (CDC), Dr. Robert R. Redfield, “when we’re talking about making sure high-touch surfaces are disinfected and actually safe to touch, I certainly recommend electrostatic sprayers over non-automated options – the improved surface coverage makes a big difference when it comes to deactivating virus particles.”1

To learn more about which type of electrostatic devices are best for your facility, visit https://www.cloroxpro.com/products/electrostatic-technology/

1. Dr. Redfield interview from July 2021

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.

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/

The world of touchless disinfection is growing quickly and there is a lot of varying information available. Taking on a new technology can be daunting. Maybe you have done your homework and you are interested in adding electrostatic sprayers at your facility. Or maybe you have already added them in and still have questions. Below I have laid out some best practice recommendations. Ultimately, there is no one-size-fits-all for acute healthcare settings, but hopefully some of these give you and your team a place to start.

  1. Educate Internally
    Electrostatics, foggers, misters, oh my! You might have these technologies straight in your mind (if not, check out Breaking Down Electrostatic Technology: Everything You Need to Know), but there is a good chance your colleagues are not completely clear on the key differentiators. As with all areas of Infection Prevention and Public Health, education up front can do a lot to mitigate concerns and misinformation. It can also help to identify those on the Environmental Services (EVS) team that will be your key operators and trainers. I recommend leveraging trainings offered by your electrostatic sprayer and/or disinfectant manufacturer. Many offer online training videos and resources to assist you in setting up a plan for initial and ongoing training.
  2. Confirm your Disinfectant is EPA Approved for Electrostatic Use
    This one seems obvious, but I think it is an important reminder. Your electrostatic sprayer manufacturer should provide a list of safe chemicals that have been tested and approved by the United States Environmental Protection Agency (EPA) for use through an electrostatic sprayer. This ensures safety not only for the operators but also for patients and other staff members in the area. Not all devices are created equally. Similarly, not all disinfectants are safe or effective when used through an electrostatic sprayer. If you are not sure if a disinfectant has been approved for electrostatic use, you can look up the Master Label on the EPA website by using the EPA Registration Number.
  3. Target Your Electrostatic Disinfectant Based on Area
    Once you have identified the list of safe EPA-approved chemicals, consider selecting more than one electrostatic disinfectant for your facility. Your decision to use one disinfectant versus another may vary depending on the type of area, surface compatibility, frequency of use, and the number of devices you are planning on employing. The same strategies you use in your protocols now with wipes and trigger sprays should also be considered when you are adding electrostatic sprayers to your arsenal. For example, you may choose to use a sporicidal product in your patient areas where the risk of C. difficile is a concern and then use a more general hospital disinfectant in your lobby and waiting rooms. Your individual risk assessments can also help to drive these decisions.
  4. Develop a Step-by-Step Protocol
    Having a clear and easy-to-understand protocol will help to prevent any potential issues. Here are some suggestions for setting electrostatic sprayer operators up for success in your protocol development:
    • Always recommend gathering supplies in advance, performing hand hygiene, and putting on appropriate personal protective equipment (PPE) prior to spraying.
    • Have operators remove all linens, paper products and trash from the spray area. I recommend placing a sign outside to indicate that cleaning is in progress. Of note, most products do not recommend use of an electrostatic sprayer while bystanders are in the area. Re-entry time will depend on the disinfectant in use and can be affected by other factors such as air exchange rates, temperature, and humidity.
    • Be sure to include a step for cleaning visible soil. Electrostatic sprayers can be an adjunct to routine manual cleaning and disinfection or a stand-alone step if there is no visible soil on the surface.
  5. Don’t Forget About Spraying Strategy
    • Make sure to clearly spray target surfaces and avoid just spraying into the air.
    • Stick to one spraying path: clockwise or counterclockwise.
    • Use a zone approach to spray, starting with the far side of the area and working towards the door.
    • Spray using a slow, side-to-side motion, working from high to low surfaces.
    • Stand the appropriate distance from surfaces when spraying. The required distance may vary by electrostatic sprayer. Your goal is to have surfaces wet but not saturated. HINT: If you see dripping or pooling of liquid, you have sprayed too much!
    • Try to maintain a consistent spraying approach with the exception of sensitive electronics and glass or mirrored surfaces. These surfaces may require a wiping step after the contact time has been reached to remove residue and to keep surfaces looking polished.

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

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