The COVID-19 pandemic has created unprecedented and continuing difficulties for healthcare providers, health systems, and patients alike. With any novel pathogen such as SARS-CoV-2, the virus that causes COVID-19, public health professionals, and healthcare providers continuously evolve their approach to the pandemic response. During times of increased focus on certain infection control practices such as hand hygiene agents and environmental disinfectants, challenges to the supply chain can rapidly emerge. Still, they can be addressed by implementing a robust pandemic response plan to facilitate appropriate product substitutions.

The Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) have released extensive guidance regarding the use of EPA-registered disinfectants during the ongoing COVID-19 pandemic. In addition, the EPA created a specific list, List N. Disinfectants for Coronavirus (COVID-19). This is a list of EPA-registered disinfectants that are deemed effective against SARS-CoV-2. The use of products on this validated list from the EPA provides healthcare users an additional level of assurance of efficacy against the virus that causes COVID-19.

Many disinfectant manufacturers offer the same active ingredient formulations in multiple product formats (ready-to-use wipes, liquids, sprays, etc.), which can mitigate any significant impacts for healthcare facilities during pandemic scenarios. Similar to stockpiling certain medical equipment and supplies such as Personal Protective Equipment (PPE), it would be advisable for healthcare facilities to have a comprehensive pandemic plan in place to address increased environmental disinfection needs across the healthcare continuum of care.

Analogous to the CDC’s approach to the use of PPE, a comparable process can easily be created for identifying appropriate disinfectant product substitutes during a pandemic crisis. As such, a three-tiered approach can be implemented to include:

• Conventional Capacity: During this phase, general infection control and prevention strategies can be utilized, and normal disinfectants would be used.
• Contingency Capacity: During this phase, due to supply chain challenges, alternate disinfectant product formats or formulations should be considered after careful evaluation. For example, if a healthcare facility is using ready-to-use disinfecting wipes as the primary means for facility disinfection, it would be feasible to use the same formulation’s alternate product formats such as ready-to-use sprays or liquids as an acceptable alternative. If neither of these is available, it may be necessary to switch to a concentrated disinfectant (liquid) that requires dilution but is still the same active ingredient.
• Crisis Capacity: During this phase, the healthcare supply chain experiences ongoing and substantial supply chain disruptions. As such, healthcare facilities may be forced to use any EPA-registered disinfectant that is able to be obtained or use other product formats that require mixing or advanced application techniques. Healthcare leaders should plan accordingly and be proactive in their approach to ensure continuity of product supply chain.

When selecting product substitutes, healthcare users should consult the EPA’s master label for the product being evaluated, review any technical information on surface compatibility, as well as carefully review the product’s Safety Data Sheet (SDS). The intended location of use for the product can also impact the ideal product to be used such as inpatient vs. outpatient settings where risks would be substantially different. Certain inert or inactive ingredients, for example, may increase the risk for equipment degradation, so healthcare users should contact the disinfectant manufacturers and request a complete listing of all product ingredients and information on known equipment compatibility with commonly found surfaces and medical devices used in healthcare settings. Healthcare users of disinfectants should also consult the product instructional manual from the medical equipment manufacturer for specific cleaning and disinfection instructions.

When forced to select alternative disinfectants or disinfectant chemistries, Infection Preventionists and Environmental Services Leaders should evaluate these substitutes in terms of three primary criteria:

• Efficacy: Does the product inactivate pathogens?
• Safety: Is this product safe for the healthcare user and for use around the patient in an occupied room?
• Compatibility: Does the use of the product compromise the surface integrity or aesthetics?

The COVID-19 pandemic continues to place significant strains on our healthcare systems and providers. Infection control practices such as disinfection, hand hygiene, and the appropriate use of PPE remain important aspects of decreasing the spread of SARS-CoV-2. Disinfectant manufacturers are the primary sources of expertise in the areas of product formulation, product format, contact times, material compatibility, and product safety. Infection Preventionists and EVS Leaders should closely collaborate with their preferred disinfectant manufacturer and medical suppliers on pandemic preparedness needs and the most appropriate product substitutions.

Moreover, many disinfectant manufacturers have created product substitution tools that can help ensure that all new products utilized within a facility will continue to meet the stringent infection control needs as identified by the Infection Prevention and Control Team. Pandemics require a collaborative, transparent, and highly communicative approach to overcome their impacts. While the healthcare industry continues to face challenges, it is certainly possible to maintain a safe standard of care related to environmental cleaning and disinfection by following a standardized approach.

For additional information:

• Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Electronically accessed from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.
• U.S. Environmental Protection Agency. Can I apply a product using a method that is not specified in the directions for use? Electronically accessed from:  https://www.epa.gov/coronavirus/can-i-apply-product-using-method-not-specified-directions-use.
• U.S. Environmental Protection Agency. Disinfectant use and Coronavirus (COVID-19). Electronically accessed from: https://www.epa.gov/coronavirus/disinfectant-use-and-coronavirus-covid-19.

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

The dynamics of healthcare disinfection are constantly changing, especially as a result of the ongoing COVID-19 pandemic. Given the large volume of environmental surfaces that can become contaminated during the routine delivery of clinical care, healthcare facilities are constantly evaluating the most efficient solutions for large-scale disinfection.

There are multiple different modalities that healthcare providers and Environmental Services (EVS) technicians can use to disinfect commonly contaminated environmental surfaces. Most notably, ultraviolet (UV) light devices and electrostatic sprayers are being used on a large scale across the United States to combat potential COVID-19 transmission. Both of these solutions afford the ability to more effectively and easily disinfect large surface areas, especially for terminal turnover of patient care environments.

Healthcare facilities may even use a combination of these different types of devices across the health system to meet specific disinfection needs. During pandemics like the COVID-19 pandemic in high-flow patient settings such as Emergency Departments, room turnover time is a key metric for healthcare delivery efficiency. The use of technologies such as UV devices or electrostatic sprayers can be extremely beneficial as part of an overall Environment of Care and Infection Prevention and Control program.

When using these types of technologies, users should receive specific training on the appropriate use of the technology prior to deploying it in the facility. Additionally, both UV devices and electrostatic sprayers require the patient care room to be unoccupied to maintain patient safety while the technologies are being used. The healthcare marketplace is filled with various different devices that each have unique capabilities. When selecting an electrostatic device, healthcare and EVS leaders should evaluate all technologies using a standardized approach which includes a review of:

• Efficacy: Does the device work and inactivate pathogens? Electrostatic sprayers, for example, require a constant power supply in order to equally disperse the germicide, approved by the Environmental Protection Agency (EPA) for use through electrostatic sprayers, onto the surface. When the power supply is variable during the application of the germicide, this can significantly reduce the efficacy of the product. Products that are EPA-approved to use through electrostatic sprayers are validated for efficacy and safety when used through an electrostatic sprayer.  Products such as UV devices are only approved for adjunctive use, meaning that they are only to be utilized following a manual cleaning process.
• Safety: Is this device safe to use? What type, if any, of Personal Protective Equipment (PPE) is required for safe handling of the device? How long the product requires the space to be unoccupied can impact the overall room turnover time and the ability for the space to be earning revenue for the healthcare facility. Some disinfectant devices such as foggers, misters, and certain UV devices require the room to remain empty for long periods of time. Disinfectant solutions such as foggers and misters are not the same as electrostatic sprayers and many of these older technologies have extended re-entry times which negatively impact room turnover. Ready-to-use and validated disinfectants that hold EPA registration for use with electrostatic sprayers should ideally be used with electrostatic sprayers to prevent workplace injury and illness and to maximize room throughput.
• Compatibility: Does the use of the device breakdown the commonly found environmental surfaces? Ensuring that the EPA-registered germicide is compatible with the facility’s most common types of environmental surfaces will prevent surface and device degradation. Certain disinfecting solutions such as UV can have cumulative negative impacts on certain environmental surfaces and medical devices leading to surface degradation.
• Regulatory Review and Efficacy Claims: The EPA generally has regulatory authority and oversight for disinfectants and disinfecting devices. While traditional disinfection technologies such as ready-to-use germicidal wipes are strictly regulated by the EPA, this is not true for UV devices. The EPA does not currently require registration for UV devices, which can lead to highly variable efficacy and performance for each UV device in the market. The EPA also does not validate UV manufacturers’ efficacy and safety claims, which can be problematic for healthcare systems. In regard to electrostatic sprayers, some like the Clorox® Total 360® System have met the EPA’s criteria and the germicides approved to use with the system received EPA registration for use with electrostatic sprayers. This validation ensures consistent efficacy, device performance and safety criteria are met. While this is not yet an EPA requirement, electrostatic devices that have met these criteria are tested and proven to effectively meet infection control needs for the Environment of Care program across the entire healthcare continuum of care. Most germicides are not validated to be sprayed through electrostatic sprayer devices, which means that the germicide’s efficacy and safety is no longer validated since the properties of the germicide may change as it passes through the device and onto the treated environmental surface. Users should confirm the chemical they use with an electrostatic sprayer is approved for use with the system.

Novel technologies such as UV devices and electrostatic sprayers are important aspects of a comprehensive Environment of Care program and the reduction of healthcare-associated infections. These technologies must be carefully evaluated prior to use, implemented and used according to the manufacturer’s instructions for use, and then environmental monitoring principles should be followed in accordance with the recommendations from the Centers for Disease Control and Prevention. Whether during a pandemic or for regular disinfection purposes, electrostatic sprayer technologies are playing a larger role in the reduction of cross transmission across both healthcare and non-healthcare sectors.

For additional information:

• https://www.cloroxpro.com/resource-center/evaluating-electrostatic-sprayers-for-surface-disinfection-white-paper/
• U.S. Environmental Protection Agency. Expedited Review for Adding Electrostatic Spray Application Directions for Use to Antimicrobial Product Registrations https://www.epa.gov/pesticide-registration/expedited-review-adding-electrostatic-spray-application-directions-use 
• U.S. Environmental Protection Agency. Can I use fumigation or wide-area spraying to help control COVID-19? https:// www.epa.gov/coronavirus/can-i-use-fumigation-or-wide-area-spraying-help-control-covid-19 
• U.S. Environmental Protection Agency. Can I apply a product using a method that is not specified in the directions for use? https://www.epa.gov/coronavirus/can-i-apply-product-using-method-not-specified-directions-use 

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

The following is an abridged article featured in the December 2020 issue of Healthcare Hygiene Magazine (see page 32).

As a healthcare provider that is part of a Regional COVID-19 response team, I have sadly seen the direct and indirect impacts of the ongoing threat posed by COVID-19. Countless lives have been directly or indirectly impacted including those of many healthcare providers at the front lines and healthcare executives charged with leading their organizations during challenging pandemic times. This ongoing pandemic is not expected to cease anytime soon, and the upcoming fall and winter respiratory infections season could potentially produce a new dilemma with concurrently circulating infectious pathogens such as Influenza, RSV, Rhinovirus, and SARS-CoV-2, the novel coronavirus that causes COVID-19. Due to this concurrent circulation of respiratory viruses during the Fall and Winter, it is all the more important for healthcare facilities to not succumb to infection prevention fatigue and maintain an appropriate level of vigilance to the core practices of infection prevention and control.  

The Centers for Disease Control and Prevention (CDC) has identified several core recommendations that can dramatically reduce the potential risk for the transmission of respiratory viruses. Below are several key steps that healthcare providers and infection prevention professionals should take to reduce the transmission of infectious respiratory illnesses:

• Rapid Identification of Infectious Diseases: Healthcare facilities must continue to diligently screen their patients, visitors, and staff for potential infectious illness. This screening process should include temperature, symptoms, exposure history, and also travel history.
• Social Distancing: Social distancing practices continue to provide for an additional element of safety by distancing persons from each other, including while in healthcare settings. Social distancing continues to be recognized as one of the simplest and most effective infection control interventions to curb the spread of COVID-19. All healthcare providers, patients, and visitors should wear masks as a universal source control and in accordance with institutional policies for respiratory protection.
• Occupational Health and Illness Recognition: Remaining home from work when ill and away from other people remains an important component of any healthcare facility infection control program. The facility’s human resources department must create a culture of safety by making it “safe” for ill healthcare workers to remain home from work when ill with infectious illnesses without penalty or punitive action. National Programs such as Just Culture can assist healthcare organizational leaders in creating a culture of safety that rewards best practices for safety.
• Routine Hand Hygiene: Simply washing or sanitizing our hands as healthcare providers remains the single most important infection prevention intervention to reduce the potential transmission of Healthcare-Associated Infections (HAIs) and respiratory viruses. This can be accomplished by either washing the hands with soap and water for at least 20 seconds or the use of an alcohol-based hand rub that contains an alcohol formulation between 60-90%.
• Cleaning and Disinfection: Routine cleaning and disinfection of high touch surfaces using an Environmental Protection Agency (EPA)-registered disinfectant will help reduce the potential for indirect transmission of respiratory viruses from environmental surfaces to both healthcare providers as well as patients. It is important to always utilize an EPA-registered, healthcare disinfectant which has broad-spectrum efficacy for a wide variety of pathogens common in healthcare settings. In addition, because of the ongoing threat caused by the SARS-CoV-2, the EPA has released a new List, List N: Disinfectants for Coronavirus (COVID-19), which specifically identifies all current EPA registered disinfectants that are deemed effective against the SARS-CoV-2. Users must carefully follow the disinfectant manufacturer’s instructions for use to ensure safety and efficacy of the product.
• Proper Use of Personal Protective Equipment (PPE): The CDC has provided updated guidance for mitigating the risk of transmission of infectious respiratory pathogens within the current pandemic. This guidance includes the use of respiratory protection, glove, gowns, and eye protection as clinically indicated based on the pathogen of suspicion. It is imperative that healthcare providers not only have access to high-quality PPE, but also are properly trained on the specific PPE equipment’s use in accordance with the manufacturer’s instructions for use. This includes proper donning and doffing procedures to minimize the potential risk for healthcare personnel and environmental contamination.

Each of the steps referenced above plays a pivotal role in reducing the potential transmission of infectious respiratory viruses, keeping patients and healthcare providers safe, and also ensuring the continuity of clinical care operations. Every stakeholder in the healthcare delivery system must play an active role in recognizing and preventing the spread of these common respiratory pathogens. Through interprofessional collaboration, the use of efficacious infection prevention products such as disinfectants, hand sanitizers, and PPE, we can help effectively curb the transmission of respiratory illnesses.

For additional information:

To learn more about the EPA List N, visit: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19.

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

Many infection preventionists regularly utilize clinical guidelines to guide their daily practice, but have you ever wondered how these national guidelines are developed? Many of the policies and practices that are used in infection prevention and control are developed by multidisciplinary groups whom create evidence-based guidelines. The Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion is primarily responsible for authoring evidence-based guidelines and guidance documents specifically to assist healthcare facilities and providers in reducing Healthcare-Care Associated Infections (HAIs). To aid the CDC in developing evidence-based guidance to the healthcare community, CDC and the Department of Health and Human Services (HHS) maintain the Healthcare Infection Control Practices Advisory Committee (HICPAC), which is a group of federally appointed healthcare experts who are charged with providing the CDC staff with strategic guidance on a wide variety of infection prevention and control challenges across the healthcare continuum of care. In addition to the voting members of the committee, there are also representatives from 21 clinical organizations which do not hold voting power. A senior member of CDC’s staff, the Designated Federal Official, serves as the official committee Secretary and official government representative to the group. This committee provides input not only to the CDC, but also to HHS. HICPAC is an extremely influential body that has tremendous impacts on the infection prevention and control community through the release of guidelines, guidance documents, and position statements that are viewed as the gold standard for both clinical practice as well as liability. These documents and recommendations are used widely in the infection prevention field and serve as the basis for many policies and procedures used in both inpatient and outpatient healthcare facilities.

As an infection preventionist, it’s critical to closely monitor the ongoing work that is being performed by HICPAC. Most HICPAC documents are sent out for official public comment prior to being finalized by the committee, and all healthcare professionals are encouraged to submit written comments along with supporting evidence. Engaging in this guideline creation and review process is a core responsibility of every infection prevention professional.

HICPAC typically meets 3–4 times per year formally, but members of the committee regularly interact through working group meetings. The in-person meetings are hosted at the CDC Headquarters in Atlanta, Georgia and the meetings are open to the public. All infection preventionists should attempt to participate in HICPAC meetings remotely by registering for the webcast of the event. Space is limited for the webcast, so it is imperative to register early to secure your reservation for each meeting. All of the HICPAC presentations as well as minutes are published on the HICPAC website within ninety days of the meeting concluding.  The many documents produced by HICPAC are routinely used by other regulatory and accreditation agencies to define standards of care and for documentation of compliance of the current CDC recommendations.

To learn more about HICPAC or to register for upcoming meetings, click here. To view the current CDC HICPAC Guidelines and Guidance documents, click here.

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.