On March 11, 2020, the National Basketball Association (NBA) announced the suspension of the 2019-2020 season as COVID-19 rates continued to climb and risk athlete and fan safety. Athletes and fans were unable to reenter the arena for nearly a year as arena operations teams developed multiple plans to ensure a safe and healthy reopening. One arena operation team that worked around the clock to welcome back fans and athletes was located at Chase Center, home of the six-time NBA Champion Golden State Warriors. Chase Center reopened their doors nearly nine months after the Golden State Warriors had played their last game, thanks in part to the implementation of innovative technological solutions and robust cleaning and disinfecting protocols. We spoke with Brandon Schneider, the team’s President & Chief Operating Officer, about how Chase Center’s staff is navigating this tricky time to keep everyone healthy and safe.
A Timeout to Strategize
At the start of the pandemic, guidance changed rapidly as the Centers for Disease Control and Prevention (CDC) continued to research SARS-CoV-2, the virus that causes COVID-19, and how it spreads across populations. The arena operations team at Chase Center also faced difficulties at the start, but leapt into planning mode with Jackie Ventura, the director of facility health and hygiene for Chase Center, among others. “We were the first NBA team to create a dedicated Health and Hygiene department,” said Schneider. Ventura and her team created protocols for every potential athlete and fan interaction, including health and safety plans that were submitted to city health officials, which allowed the Golden State Warriors to host training camps and start the season. The plans established during this time were used to train the dedicated Chase Center Clean Team and will be repurposed moving forward to address other germs, especially during cold and flu season.
Above and Beyond the Guidance
Since the arena operations team wanted to ensure that their cleaning protocols were going above and beyond the guidance, they collaborated with ABM to develop enhanced protocols due to the organization’s wealth of resources in terms of health and hygiene best practices.
Chase Center was also one of the first major sports and entertainment venues to receive the Global Biorisk Advisory Council (GBAC)’s STAR facility accreditation, validating the steps taken by the arena operations team to adhere to effective and efficient cleaning and disinfecting protocols within the cleaning industry.
Deploying New Gameday Measures
When the Chase Center opened to fans in April of this year, proof of a negative COVID-19 test or vaccination was required.
To create an even safer indoor environment, the arena operations team integrated new technological solutions that have proven to also enhance and streamline the spectator experience. One such advancement was the revamp of the Warriors + Chase Center app, which now allows fans to manage their game experience from the palm of their hand. From reserving a parking spot and managing their tickets to ordering and paying for food, the app helps provide convenience to fans by limiting visits to kiosks.
To disinfect, the arena operations team leveraged the Clorox® Total 360® System and the Clorox® Total 360® ProPack System, a backpack electrostatic sprayer, throughout the arena. Both of these electrostatic sprayers thoroughly deliver Clorox disinfectant to surfaces. The Clorox® Total 360® Systems are now being used to disinfect the Golden State Warriors’ player practice facilities on a daily basis, as well as within Chase Center bowl seating areas and premium spaces before and after use for Warriors’ games, concerts or private events.
“The Clorox® Total 360® System and Clorox® Total 360® ProPack System have been invaluable assets in providing an effective disinfection tool that we can use to sanitize and disinfect large surface areas,” stated Schneider. “In a venue the size of Chase Center, they save us a lot of time as we can treat large areas like our seating bowl very quickly. We feel very fortunate to be able to collaborate with a best-in-class company like Clorox whose products the public have a lot of faith in.”
A Bright Season Ahead
Through a dedicated effort and integrating a holistic strategy to support a safe return, Chase Center was successful in welcoming back their fans. And as “The Dubs” fans excitedly head back to their seats, a renewed purpose for delivering and maintaining a seamless and safe visitor experience is top of mind. "My favorite memory from the past year was the moment I got to greet the first fan to enter the building for our first in-person game of the year,” Schneider said. “It marked the culmination of over a year’s worth of planning and hard work to get to that point. We are looking forward to a very busy fall at Chase Center.”
With a long scientific history and many promising attributes, it is hard to understand why hypochlorous acid (HOCl) - based disinfectants aren’t used in every commercial cleaning operation.1-3 In one recent review article focusing on the use as a disinfectant, the authors concluded that HOCl “comprises many of the desired effects of the ideal disinfectant: It is easy to use, is inexpensive, has a good safety profile, and can be used to disinfect large areas quickly and with a broad range of bactericidal and virucidal effects.”4,5 The reason is, as with most things, the devil is in the details. In this blog, I’ll break down those details by answering these questions:
- What is HOCl?
- How are HOCl-based solutions made and sold?
- Which HOCl-based solution is right for you?
What is HOCl?
HOCl is a weak acid that is formed when chlorine (a gas) dissolves in water. It is used as an active ingredient in sanitizers and disinfectants because of its ability to break apart cell membranes, similar to the mechanism of action of sodium hypochlorite (bleach) or hydrogen peroxide. Water solutions of HOCl are in the neutral to slightly acidic pH range. HOCl has many other common names (not all technically accurate) including “electrolyzed water,” “activated water,” “enhanced water,” “superoxidized water,” and the most technically inaccurate of all is “no-chemical” (because everything, even water, is a chemical!).
HOCl is surprisingly effective at very low concentrations. It takes only a very small amount of HOCl to effectively kill bacteria and viruses and destroy proteins like inanimate pet allergens in comparison to higher pH bleach-based products. Despite this outstanding ability, it is also gentle on surfaces, and when no additional ingredients like surfactants or detergents are added to the final formula, HOCl solutions leave behind minimal residue. Evidence of this is demonstrated by the HOCl-based solutions on the market that are EPA approved as food contact sanitizers. These products do not require a rinse step when used on surfaces that come into contact with food.
How are HOCl-based solutions made and sold?
There are three main ways that HOCl-based solutions are made and sold:
- Ready to Use (RTU) products are typically made by adjusting the pH of a sodium hypochlorite (bleach) solution at the manufacturing plant. To do this, a solution of sodium hypochlorite, which is typically basic (or alkaline) on the pH scale, is brought down to a neutral pH by adding a pH-adjustor.
- In onsite generation systems, electricity is run through a brine of salt and water. To do this, salt (or sometimes called a “precursor”) is added to water prior to the electricity being applied.
- There are also tablet products that are capable of making HOCl solutions on site as well. Sodium dichloroisocyanurate (NaDCC or SDIC) is a colorless, water-soluble solid that creates HOCl when it dissolves in water.
Which HOCl-based solution is right for you?
As with all products, there are pros and cons, and this holds true for HOCl-based solutions too. All HOCl-based solutions offer some promising benefits in regards to safety and surface compatibility, but there are also some watch outs to be aware of. Below is a table that highlights the differences between the three common types of HOCl-based solutions and a list of questions that can be used to assess any HOCl-based product before you buy.
Table: Pros and Cons of three common types of HOCl-based solutions
|Ready to Use (RTU)||• Safety profile|
• Longer shelf life (generally 1 year)
• Guaranteed concentration and micro-efficacy and
• No upfront device costs
• No contamination risk
• No bottles to clean
|Higher price per bottle Bottles may not be reusable|
|On-site generated||• Safety profile |
• Only make what you use
• Cost less per oz. (after system purchase)
|• Shorter shelf life (days to weeks)|
• Up front cost of system
• Cost of system maintenance
• More work/more steps for end users
• Bottles must be cleaned between uses
• Concentration and efficacy not guaranteed
|Tablet||• Safety profile (of final solution)|
• Lower shipping costs (no liquid)
• Takes up less room in storage
• Long shelf life (of tablet)
• No upfront device cost
• Longer contact times
|• Shorter shelf life when in solution (days to weeks)|
• Toxicity of concentrated tablet form (wear gloves and goggles when dissolving)
• Dissolving can take time
• Bottles/dissolving containers must be cleaned between uses
• More work/more steps for end users
Questions to ask about all HOCl-based solutions before you buy:
- Is it EPA-registered? RTU and tablets should have an EPA registration number on the product label. Onsite generation systems may not have an EPA registration because the HOCl-based solution is not made until after the product is sold. Also, watch out that you are not confusing EPA establishment numbers for EPA registration numbers. These are two different things!6
- Does it disinfect and/or sanitize? Disinfectants are EPA registered to kill illness-causing bacteria, viruses, and sometimes fungi, while sanitizers are only EPA registered to kill illness-causing bacteria.
- What is the contact time? As with any product, shorter is usually better, but longer contact times can be acceptable in some cases. Contact times should always be built into your processes so that cleaners don’t have downtime while the product works. In some cases, if HOCl solutions do not need to be rinsed, then longer contact times may be acceptable because they won’t impact the speed of your cleaning processes.
- Does it contain a surfactant (aka detergent)? Many HOCl products on the market do not contain a surfactant, but some do. Products that do not contain surfactants can be great for routine, preventative cleaning and disinfecting, but a second product that contains a surfactant may be needed to handle tougher cleaning jobs prior to disinfecting. Solutions that contain surfactants are more likely to leave behind a residue that will need to be wiped off.
- Is it safe to use through an electrostatic sprayer? Not all HOCl-based solutions have been EPA approved to be used through electrostatic sprayers, which means they haven’t been confirmed for safety and microbial efficacy. Check the products master label before utilizing electrostatic applicator technology with HOCl-based solutions.
- Is it considered food-contact safe? HOCl-solutions that are food-contact safe do not need to be rinsed or wiped after use. This can save you time and give your building occupants and management peace of mind. Again, check the EPA master label to confirm the directions for use.
Using the pros and cons list and answering the above questions can help you narrow in on which option to purchase but remember this important implementation tip: Start small with implementing any new product (test it with one crew, in one area for a predetermined amount of time) and don’t make further changes until you have reason to believe that the product is a benefit to your organization. Changes, even great ones, take time.
CloroxPro and Clorox Healthcare are proud tooffer two RTU HOCl-based solutions for consideration in your organization. You can learn more about them here:
1. Smith JL, Drennan AM, Rettie T, Campbell W. Experimental Observations on the antiseptic action of hypochlorous acid and its application to wound treatment. Br Med J. [Internet] 1915 Jul 24; 2(2847):129-36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2302602/pdf/brmedj07241-0005.pdf
2. Garibyan, Lilit et al. Advanced aging skin and itch: addressing an unmet need. Dermatologic therapy [Internet] 2013 26(2): 92-103. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051285/
3. Moorman E, Montazeri N, Jaykus L-A. Efficacy of neutral electrolyzed water for inactivation of human norovirus. Appl Environ Microbiol [Internet] 2017 Aug 1; 83(16). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541222/
4. Block MS, Rowan BG. Hypochlorous acid: a review. J Oral Maxillofac Surg [Internet] 2020 Sep; 78(9): 1461–1466. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315945/
5. CDC. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Properties of an ideal disinfectant. [Internet] 2008. Available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/tables/table2.html
6. EPA Label Review Manual Chapter 14: Identification Numbers. [Internet] 2012. Available from: https://www.epa.gov/sites/production/files/2015-03/documents/chap-14-nov-2012.pdf
This last year has been incredibly hard, but the future looks a little brighter. With the number of vaccinations increasing significantly every day, and the CDC’s new guidance on how kids can safely return to school, there is a real reason to be hopeful that we are heading toward better times, and into our long anticipated “new normal.”
For those of us in the cleaning industry, the future presents us with another glimmer of hope. The pandemic brought to light the importance of cleaning, not only for aesthetics and building preservation, but also for health. In fact, it can be argued that the public had very little knowledge and appreciation of cleaning for health prior to the pandemic. Hundreds if not thousands of articles have been written about cleaning for health, and terms like “disinfecting” and “contact time” (also called “dwell time” or “wet time”) are now household words.
This public awareness has spilled over into the commercial cleaning industry, and businesses have adapted to ensure they are addressing their customer’s concerns and desires for cleaner environments. As a result, the focus on cleaning has increased and I don’t know about you, but as a consumer and public health professional, I LOVE where we are heading. Gone are the days of grimacing every time I need to pump gas or put my pin number into one of those retail or gas station keypads. We have COVID-19 to thank for this new awareness, and I do not want to go back!
But with progress comes reflection, and it is important to recognize that, while we’ve come a long way, we are not done yet. While “disinfecting” and “contact time” may be household words, there are still far too many accounts of misinformation and inappropriate cleaning practices. Some examples include:
- The use of the term “sanitize” to address SARS-CoV-2 (the virus that causes COVID-19) on surfaces. This is inappropriate because sanitizers are not EPA-registered to kill viruses.
- Reports of spraying and immediately wiping to disinfect without waiting the contact time are common. In the keypad example, if an EPA-registered disinfectant wasn’t used, or if the contact time wasn’t met, we cannot be sure that the aesthetically clean keypad was disinfected.
- The internet is full of pictures of the incorrect use of electrostatic sprayers intended for use on surfaces, by inappropriately spraying them into the air. Cleaning companies are expending resources to disinfect surfaces that no one even touches and are not considered higher-risk for germ transmission.
Not only are these examples problematic from a resource perspective, but they have caused many to question the true value of cleaning, leading to concerns about “Hygiene Theater.”
Clearly, there is more work to do. If we want to see the positive changes from COVID-19 continue post-pandemic, we must prioritize correcting the misinformation and inappropriate practices. Here is what I recommend:
- Optimize surface hygiene — Instead of spraying everything, focus cleaning and disinfecting efforts ONLY on shared and commonly touched surfaces that are responsible for spreading germs. While sometimes called targeted disinfection, at CloroxPro, we call this “Smart Disinfection.” Since we know that there are real world limitations – additional staffing needed on top of existing cleaning staff for instance, CloroxPro has great tools (see here and here) to help you prioritize the higher risk areas in your facility. If you still do not have the cleaning staff to clean and disinfect the higher risk areas, one option is to recruit building occupants to help do the work. Employees can help clean in workplaces, teachers can help clean in schools, and clinical staff can help clean in healthcare facilities.
- Increase access to education and training — Cleaning for health takes knowledge and skill. The more training employees have, the better they will be able to do their jobs. Increased training increases job satisfaction, provide cleaners with confidence that they are experts at what they do, and helps them understand why their jobs are important to the greater good. If recruiting building occupants to help, do not forget to train them too. This will not only teach them about the proper use of cleaning products, but it will also open their eyes to some of the rigors of daily cleaning and disinfecting.
- Emphasize Personal Responsibility — This goes for everyone, not just cleaning staff. We all need to get better at washing our hands, coughing into our elbow, staying home when sick, getting vaccinated, and wearing PPE when appropriate. Policies and procedures can go a long way to ensuring that staff and building occupants minimize the spread of germs. Document and train on these policies and procedures, and then be sure to audit for compliance regularly to make sure they are followed.
- Keep Communicating! — As COVID-19 fades, so likely will the public’s focus on cleaning for health. Many years of evidence tells us this will happen, as human interest always spikes with the fear and then declines with the relief. Our job as cleaning professionals is now to stay in the limelight, in a positive way. To do this, we need to continue to spread the word about the importance of cleaning for health, what needs to be true to achieve it, and how to do it responsibly (e.g. SMART Disinfection). We need to keep sharing that cleaning for health is based in science, that it takes knowledge, skill, practice, and that that the people doing the work and the processes they follow are just as important as the great products they are using.
COVID-19 is not the first pandemic, and it certainly will not be the last. Many public health professionals are already working on advocating for better preparedness because it is clear now that the lack of preparation was, at least in part, the cause of so much devastation. The cleaning industry can also help prepare, starting with remaining vigilant with the progress we have made. Yes, we have made great progress, but our journey to be as good as we can be is not quite over yet.
For help with preparing for the New Normal, including the area risk assessment tool I mentioned above, please visit our website: https://www.cloroxpro.com/resource-center/preparing-for-the-new-normal/.
“Never a doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has." ~Margaret Mead
I just attended my favorite conference — APHA (American Public Health Association) 2020. Quoting APHA, “The APHA Annual Meeting and Expo is the largest and most influential yearly gathering of public health professionals, bringing the public health community together to experience robust scientific programming, networking, social events, poster sessions and more.”
I was particularly excited this year as the conference was scheduled to be in my “backyard” (Bay Area, California). However, as a result of COVID-19, the event was cancelled and instead moved to a virtual format. That said, I was grateful for the opportunity to experience it in this way. While I did miss the ability to connect with colleagues and meet other passionate public health professionals face to face, I appreciated the ability to jump from session-to-session easily, and the ability to post questions in the chat box. Gone were the days of nervously standing up in front of the crowd and waiting for someone to bring over the mic.
What didn’t change was that the content was relevant and inspiring, and I’m excited to share three top takeaways, with lots of references for you to peruse.
Get ready: The time to prepare for the COVID-19 vaccine is now.
Vaccines are one of the most important tools in the public health toolbox, and I know we are all anxious for a safe and effective COVID-19 vaccine when it becomes available. The good news is that there are currently eight COVID-19 vaccines in stage three (final robust stage to ensure efficacy and safety) of development, and therefore it is likely that we will see one with approval soon. The FDA has also taken measures to ensure approved vaccines will be safe and effective and that the benefits outweigh the risks.
When a vaccine is approved, however, it will take time to vaccinate a significant part of the population, which will be essential in order to move forward as quickly as possible. In fact, until herd immunity is reached, which is the goal of any successful vaccination campaign, current prevention measures will remain important to help mitigate the spread of the infection. So, while a vaccine is coming, social distancing, wearing masks, and hand and environmental hygiene won’t be going away for a while.
Another thing to prepare for is who will get the vaccine first, as demand is surely going to outpace supply. The National Academies of Sciences, Engineering and Medicine has published a Framework for prioritization of vaccines, based on those who need it most. Take a look and see where you and your employees line up.
Double check: Workplace safety is more important than ever.
According to the Occupational and Safety and Health Administration (OSHA), current requirements apply to preventing occupational exposure to SARS-CoV-2 (the virus that causes COVID-19). In addition, there are 28 OSHA-approved State Plans, operating statewide occupational safety and health programs, with standards and enforcement programs that are at least as effective as OSHA's and may have different or more stringent requirements.
Despite these facts, there continue to be concerns about too many workplace related deaths, injuries and illnesses each year, and concern continues to build as the U.S. works to keep the economy strong while controlling the spread of COVID-19. A recent assessment published by The Harvard Center for Population and Development Studies found a correlation between COVID-19 complaints to OSHA, and U.S. deaths 17 days later, suggesting ineffective workplace protections may be a driving factor behind the high U.S. death toll.
This and other data has led to a number of states, including Virginia, Oregon, Michigan and California to take additional measures (in the form of Executive Orders and/or Emergency Temporary Standards) to protect workers against COVID-19. Public health leaders like David Michaels, Ph.D, MD from George Washington University believe that ensuring employee health and safety is essential if we are going to stop the pandemic. With COVID-19 cases at an all-time high, it’s a good time to double check that you are doing everything possible to protect yourself and your employees from the consequences of infection with the virus.
OSHA also requires employers to protect workers from exposure to hazardous chemicals used for cleaning and disinfection, which is another important consideration given the increase in cleaning and disinfecting that many businesses have adopted as a result of the pandemic.
Get involved: Public Health is everyone’s business.
While much of public health is funded by government and non-profit organizations, public health helps everyone and should be a shared responsibility. The more we can all get involved, the less reliant we will be on the government for this basic human right.
Getting involved is easy. Here are some ideas to help you get started:
- Learn more about public health and public health issues. This can be done by reviewing the recently published Healthy People 2030 priorities, the renewed 10 Essential Public Health Services, attending free webinars sponsored by APHA, and by attending APHA 2021 in Denver Oct 22–27.
- Provide health and wellness programs for all employees, and prioritize keeping them safe at work by preventing exposures to dangerous situations and workplace accidents. As an added bonus, helping employees stay physically, mentally and emotionally healthy can pay dividends for businesses later on.
- Prioritize the development of products and services that seek to make a difference to public health.
- Donate funding, expertise and/or time to groups that work hard to improve public health.
- Volunteer in Public Health.
If you’re already involved, these ideas can help you continue with your public health journey. Remember, as the late C. Everett Koop (former pediatric surgeon and U.S. Surgeon General) once said, “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.”
Have you been asked to take on the role of part time cleaner in your facility or business? If so, welcome to the club!
With the COVID-19 virus still widespread across the U.S., employers everywhere, from schools, offices, athletic facilities, movie theaters, hotels, restaurants, hospitals, and more, are asking non-cleaning staff to clean.
In a recent back to school survey, more than half (58%) of 120 educators polled responded that they would be asking current staff members/teachers to do some cleaning and disinfecting as part of their regular duties. In other facilities, box office staff, airline gate attendants, check-out clerks, nurses, receptionists and more are being asked to help out with daily cleaning and disinfecting of frequently touched and shared surfaces. The CDC has even stated in the Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes, that “This guidance is intended for all Americans.”
Depending on your personality and past experiences, you may have had any one of these three reactions:
- What? No way, cleaning isn’t in my job description and I don’t have time for that!
- Great, cleaning is easy enough. I just use common sense, right?
- OK, but I don’t know how to clean properly. Where do I get training?
The good news is that no matter which group you fall into, the COVID-19 pandemic is offering up an opportunity to learn about something many of us wouldn’t have taken the time to do before. And that is how to clean and disinfect properly.
The truth is, although many don’t realize it, properly cleaning and disinfecting surfaces takes education, training, and even practice to perfect. In fact, there is an entire industry focused on helping to ensure that cleaning professionals get what they need to do their job well. IICRC, ISSA, and AHE are just a few examples of organizations with this goal in mind.
While your employer is ultimately responsible for making sure you are educated and trained, here are some basics to help get you started. You can use this information to talk to your employer about what’s important, and potentially even as a starting place for a “new cleaner” training guide for your facility.
What is the difference between cleaning, sanitizing, and disinfecting?
- Cleaning is the physical removal of unwanted matter, including dirt, dust, soil and some pathogens.
- Sanitizing is the killing of bacteria, and is most often applicable in food service.
- Disinfecting destroys or inactivates both the bacteria and viruses (like SARS-CoV-2) on hard, nonporous surfaces.
Does cleaning always need to be done before disinfecting?
No. Cleaning and disinfecting can be done at the same time if these criteria are met:
- The surface is free of visible soil.
- The product is a “one-step” cleaner disinfectant, which means the product is both a cleaner and disinfectant.
How can I be sure I’m using a product that kills “xyz” germ?
- Check the back label on the product. If the product has an EPA Registration number and says that it kills “xyz” germ then you can be confident that the product works. Just make sure to also read the directions for use, including the dilution ratios if appropriate, on the label and follow them in practice.
- For SARS-CoV-2, the virus that causes COVID-19, make sure you are using an EPA-registered product on list N.
- Never mix cleaning products! This is important for efficacy AND safety.
What else is important to understand about the product, and where can I get the information?
- What the contact time is — see the product label
- What Personnel Protective Equipment (PPE) and precautions are needed to protect you from:
- The product — see the product label
- The contaminants (e.g., SARS-CoV-2) in the environment — check with your employer and the CDC website.
- How to store and dispose of the product safely — see the product label
- Mixing/dilution information — see the product label
What else do I need to know to clean and disinfect properly?
- Know what you are responsible for and how often you should be cleaning and disinfecting. Ask your employer for clarity if not clear.
- Focus on preventing cross contamination — this is what happens when germs are inadvertently spread from one area to another. Here are some best practices to help avoid cross contamination during cleaning and disinfecting:
- Always clean from top to bottom so the dirt, dust and pathogens that fall down will get cleaned up as you move lower.
- Always clean from clean to dirty to avoid spreading germs from dirty areas to clean areas.
- Fold each cloth until it is the size of your hand. After each use, find a clean side of the cloth to use on the next surface.
- Know what jobs require the professional custodial/EVS team (e.g., blood and body fluid clean-up) and call them when needed instead of doing it yourself.
COVID-19 has presented us with quite a challenge to say the least. Fortunately, there have also been a few “silver linings” along the way. One is the knowledge and skills about cleaning and disinfecting properly that few had before. If you have been asked to take on additional cleaning and disinfecting responsibilities as part of your current role, as in any profession, education and training on how to do the job right are essential. This will not only help ensure goals of the job (e.g., to reduce the spread of germs in the environment) are achieved, but to also ensure that the job is done safely.
Late last year I wrote about The Good and Bad News of Antibiotic Resistance…in a Post-Antibiotic Era. The Centers for Disease Control and Prevention (CDC) had just published the second “Antibiotic Resistance Threats in the United States” report, calling for continued aggressive actions to prevent infections, improve antibiotic stewardship, and stop the spread of resistance when it does develop.
And then COVID-19 happened.
On the surface there doesn’t seem to be much of a connection between COVID-19 and antibiotic resistance. After all, COVID-19 is caused by the virus SARS-CoV-2 and antibiotics are not used to treat viral infections, right? Well, unfortunately, that may not be the case. Initial data from Wuhan identified that antibiotics were used in approximately 53% of patients with non-severe disease and more than 90% of patients admitted to the hospital or the ICU. Since then, there have been multiple reports and scientific papers highlighting the high use of antibiotics to treat COVID-19 patients. Given that antibiotic use is a main contributor to antibiotic resistance, the treatment of COVID-19 infections may have an impact on the growing antibiotic resistance problem.
Why are COVID-19 patients receiving antibiotics?
COVID-19 patients are receiving antibiotics to treat secondary bacterial lung infections and hospital acquired infections. In some cases, they are also being used as a last resort effort. Empiric therapy for suspected bacterial infection in COVID-19 patients, which is recommended by the WHO, may be complicating the issue as non-specific antibiotics are prescribed prior to identifying the specific bacteria causing the infection. Although this approach may be necessary at this time, it is counter to the antibiotic stewardship best practice of conducting microbial analysis before prescribing antibiotics and could be contributing to an increase in “antimicrobial pressure” on pathogens to become resistant.
What types of antibiotics are being prescribed?
There have been reports of the use of azithromycin, amoxicillin, tetracycline, doxycycline and teicoplanin (which is a last-resort antibiotic used to treat methicillin-resistant Staphylococcus aureus (MRSA) infections). Azithromycin has been shown to cause antibiotic resistance in some bacteria, such as Streptococcus pneumoniae. Drug-resistant Streptococcus pneumoniae (S. pneumoniae) is a leading cause of bacterial pneumonia and meningitis in the U.S., and is estimated to cause 900,000 infections and 3,600 deaths in the U.S. each year. It is listed as a serious antibiotic-resistant threat in the CDC 2019 report.
What is the potential impact?
With currently (as of May 27, 2020), almost 1.5 million cases and almost 100,000 deaths from COVID-19 in the U.S. alone, the potential for increased antibiotic resistance is high. While all antibiotic use has the potential to increase antibiotic resistance, so much in such a short amount of time has potentially sped up the process. Without having new antibiotics to replace the ones that no longer work, there could be additional risk of not surviving an infection for both COVID-19 and non-COVID-19 patients now and in the future.
The potential short-term impact was recently summarized in this way by Dr. Julia Gerberding, former CDC director and infectious disease expert: “The challenge of antibiotic resistance could become an enormous force of additional sickness and death across our health system as the toll of coronavirus pneumonia stretches critical care units beyond their capacity.”
In the longer term, an increase in antibiotic resistance threatens the progress that we have made in recent years and undermines current efforts. The CDC’s 2019 report estimated that almost 3 million infections from antibiotic-resistant bacteria still occur in the United States each year, resulting in almost 36,000 deaths. Antibiotic resistance also has a significant economic impact such as extended hospital stays, additional follow-up visits to healthcare providers, and the use of treatments that may be more costly and potentially more toxic. Ultimately, this adds to the burden of high healthcare costs we are already facing.
So what can we do about it?
Time will tell the true impact that COVID-19 will have on antibiotic resistance. However, there are actions we can take today to help offset any additional negative impact we may see. For clinical staff, antibiotic stewardship principles should remain at the forefront of our efforts. For pharmaceutical companies and government, we need to do everything in our power to develop new antibiotics for the future. And finally, for everyone, perhaps the most important and impactful thing we can do is to help prevent infections in the first place. These infection prevention fundamentals, which I believe should also be part of every child’s early childhood education, will help us recover from COVID-19 and combat continued antibiotic-resistance threats. As Kiran Mazumdar-Shaw has said: “Ultimately, the greatest lesson that COVID-19 can teach humanity is that we are all in this together.”
Fundamentals of infection prevention from the CDC:
- Stay home if feeling sick
- Contact your health provider if you think you have COVID-19 (or any other infection). For COVID-19, use the CDC’s self-checker to help you make decisions and seek appropriate care
- Don’t touch your face with your hands
- Perform frequent hand hygiene — especially before eating, cooking, and after interacting with others or in environments where others have been and using the restroom.
- Clean and disinfect commonly touched and shared surfaces frequency
- When respiratory illnesses are a concern, as is the case with COVID-19, stay six feet apart from other people and wear a face covering. Note: Healthcare staff should follow facility protocols for the use of PPE, including proper donning or doffing
To learn more and keep up with the scientific community on this topic, a new website, Secondary Infections, Antibiotic Chemotherapy and Antibiotic Resistance in the Context of COVID-19, was created to be a resource of peer-reviewed publications, preprints, blogs and commentaries on this very important topic. Additionally, you can read the latest insights from CloroxPro here on CloroxPro.com.
As some states begin to ease shelter-in-place restrictions and many shuttered nonessential businesses begin to reopen, our nation’s journey toward our “new normal” has begun. Of course, with COVID-19 still present, it’s a scary time for everyone involved, including building occupants and staff. If you manage a building’s cleaning and disinfection program, here are some guidelines to help you protect people and minimize the spread of SARS-CoV-2, the virus that causes COVID-19.
Step 1: Pre-work
- Inspect the building: As the late John Walker once said, “The difference between a ruin and a building in use is the janitor.” This holds true for many of the buildings that have sat empty for the last few weeks or months—they have also been without their cleaning crew. With this in mind, step one is to inspect the building. A thorough inspection should include looking for areas where mold may have grown (e.g., in the restrooms, kitchens, on walls and in HVAC systems), and surfaces that may have been damaged. Moldy and damaged surfaces should be addressed right away including remediation or replacement if necessary.
- Review applicable (and reputable) guidelines: Below are several U.S. Centers for Disease Control and Prevention (CDC) and Environmental Protection Agency (EPA) resources to get you started:
- General cleaning and disinfecting
- Guidance for cleaning and disinfecting public spaces, workplaces, businesses, schools and homes
- Guidelines and resources to reopen facilities and public spaces
- Interim guidance for businesses and employers to plan and respond to coronavirus disease 2019 (COVID-19)
- Schools, daycare centers, offices or other facility that do not house people overnight
- Institutions of higher education
- Confirm funding/budget: Ensure you have the budget for the required cleaning products and tools, as well as staff required to implement the proper cleaning protocol.
Step 2: Update policies, procedures and protocols
In February, I wrote about how clear and robust policies and procedures are needed to maintain a high-quality cleaning and disinfecting program. This is not only true during times of enhanced concern, but also in the regular day-to-day operations. If there was a silver lining to our current situation, it’s that the importance of cleaning and disinfection is now more widely understood. Below are the fundamental pieces needed to run a high-quality and effective cleaning and disinfection program.
- A written cleaning program policy: Cleaning program policies should outline how often procedures will be reviewed and updated, what procedures should be in place, and the frequency of and situations when employees will receive training and feedback on procedures.
- Clear and detailed everyday preventative procedures: A strong cleaning program has written procedures in place that specify cleaning processes for different areas in your facility.
- Each procedure should include what surfaces need to be cleaned, who is responsible for each area, and the products to be used to clean each surface.
- Other product details should include the directions for use, the contact (or dwell) time, and details on how to avoid cross-contamination.
- Procedures should be updated each time a new product is introduced, or a best practice is identified.
- Include public health basics such as washing hands, staying home when sick and the responsibility of building occupants to help the cleaning and disinfecting team reduce the spread of germs. This should be aligned with the occupants’ management. Actions, such as putting up posters like this example from the CDC, can go a long way to support the work of the cleaning staff.
- Outbreak preparedness procedure: Ensure you have outbreak preparedness procedure in place for when viruses, like SARS-CoV-2, may be present your facility. The outbreak preparedness procedure should be separate from everyday preventative cleaning procedures and cover the extra measures that need to be taken. This includes details on the microbial threat and how it is spread, helping employees understand how to identify the signs and symptoms of the illness of concern, knowing the correct personal protective equipment (PPE) to wear, and additional changes such as products used, frequency of cleaning and disinfecting, or the surfaces that should be disinfected.
- Spotlight on products: Make sure that disinfectants have EPA-approved claims against pathogens that cause the illnesses of concern in your facility. EPA’s list N is a great resource to determine if a product is approved for use against the SARS-CoV-2 virus. The list is updated regularly, but if a disinfectant you use isn’t on the list, check the manufacturer’s website, or contact the manufacturer directly. Given product shortages faced by many manufacturers right now, you may need to switch to a new product. If this is the case, it is even more important to ensure all disinfectants are EPA-registered, approved for use against SARS-CoV-2, and that staff are adequately trained on proper and safe use.
- Educate, train, and engage staff: Ensure cleaning staff are adequately trained on your facility’s cleaning and disinfecting procedures and the outbreak preparedness procedure. Competency should be verified on the use of the products.
Step 3: Execute and recognize
- Reconfirm the funding/budget based on updates procedures and protocols: Adjust the budget created in step one, as needed.
- Do regular check-ins with staff: Make sure staff are meeting the expectations of the program and ask them for regular feedback on how things are going. Adjust procedures and protocols as necessary, as per outlined in the program’s policy.
- Bring awareness: Put all the hard work into practice and help the cleaning and disinfecting team shine as occupants start to reenter the building. One way to help do this is to send a letter to building occupants to share efforts or share the program with leadership to bring visibility to all actions taken to protect employees’ health and safety.
April 6–12, 2020 is the 25th annual National Public Health Week (NPHW) brought together by the American Public Health Association (APHA). NPHW is a week set aside to recognize the contribution of public health workers as well as raise awareness of issues that are important to improving public health within the United States.
The theme this year is “looking back, moving forward,” which is particularly relevant given the current COVID-19 pandemic. Each day of NPHW is focused on a health topic that is important to improving U.S. public health and identifying ways to make a difference on each. The daily themes this year are Mental Health (Monday), Maternal and Child Health (Tuesday), Violence Prevention (Wednesday), Environmental Health (Thursday), Education (Friday), Healthy Housing (Saturday) and Economics (Sunday). Here is how the APHA is thinking about each day of NPHW in light of COVID-19: http://www.nphw.org/nphw-2020/covid-19.
In honor of NPHW, I’ve begun to look back and think about the focus of my daily work as a public health liaison. The value of cleaning in public health has never been as clear or as relevant in each of the daily themes. Keeping surfaces clean helps to prevent infections by reducing the spread of germs (or pathogens) from person to person through indirect contact. In turn, this is good for mental health, violence prevention, and helps to create healthier homes and environments.
To bring this to light, we don’t need to look much further than the current COVID-19 pandemic. In addition to social distancing, clean hands and clean surfaces work together to help minimize the spread of this virus, as well as many other germs. With an unprecedented public health and economic impact, COVID-19 reminds us of the importance of infection prevention, particularly as we move forward.
COVID-19 has also highlighted the importance of education for professional cleaners to ensure facilities are cleaned properly to help prevent the spread of illness and protect human health. From choosing the correct product for each cleaning job to knowing the proper process to implement, there is much for cleaning professionals to learn and know to ensure cleaning is done safely and efficiently. The industry has made progress with programs such as AHE’s CHEST, ManageMen’s Janitor University, and ISSA’s Cleaning Management Institute, but cleaning professionals are public health workers who deserve quality education and the utmost gratitude. Cleaning correctly, like any other professional skill, requires time, training, knowledge, and practice.
To help keep industry professionals informed and help them navigate this difficult time, CloroxPro has developed a COVID-19 resource page where cleaning and healthcare professionals can access all our educational resources and tools to respond to COVID-19, relevant blog posts on the latest developments in the pandemic, and webinars.
Overall, I am looking forward to hearing about all the NPHW events this week, and also attending the annual APHA meeting in San Francisco October 24-28 (assuming we are able to gather by then). It is my hope that the important role of maintaining clean indoor and built environments will be highlighted during both these public health events as the benefits of cleaning become amplified with further attention to its importance.
Norovirus. You might not know it by name, but you’ve definitely heard about it before. News headlines go something like this, “School closes due to large sudden outbreak, many students and staff sick,” or “Dozens sick after meal at favorite local restaurant.” While the news references “food poisoning,” “gastroenteritis” or even the “stomach flu,” the truth is norovirus isn't really the flu at all.
For those of us who monitor infectious disease outbreak news daily, the culprit at play in these situations can be fairly obvious. This is because norovirus has a unique way of making people sick compared to other germs. Main symptoms of a norovirus infection include diarrhea and vomiting, and ingesting very little (as few as 10 viral particles) is required to make someone sick. This is why norovirus spreads so easily, especially in busy, enclosed environments such as schools and daycare centers, and why so many people can get sick at once. Additionally, norovirus spreads easily by contaminated hands when restaurant and healthcare employees aren’t diligent about hygiene.
Why is norovirus a concern?
Simply said, norovirus is a concern because it causes a lot of illness both domestically and globally, and can even cause death.
In the U.S., norovirus is the leading cause of vomiting and diarrhea. It is responsible for 19 million to 21 million illnesses each year. Almost two million people seek outpatient treatment, and a further 400,000 seek treatment at hospital emergency rooms. Annually, 56,000–71,000 people are hospitalized, and approximately 570–800 die.1 There is no vaccine for norovirus, and because there are many types of norovirus and it mutates quickly, you can get it multiple times in your lifetime.
Furthermore, between 2009 and 2012, almost 3,500 norovirus outbreaks were reported to the Centers for Disease Control and Prevention’s (CDC) National Outbreak Reporting System. Of those, 63% were in healthcare settings, with the overwhelming majority of those outbreaks occurring in long-term care facilities and nursing homes. Restaurants and banqueting facilities accounted for 22% of the outbreaks, while 6% occurred in schools.2 While norovirus is the cause for most of the diarrheal outbreaks on cruise ships, cruise ships account for only 1% of reported norovirus outbreaks.4 From August through December 2019, there were 285 norovirus outbreaks reported to the CDC’s NoroSTAT network, a norovirus surveillance and tracking collaborative.3
How do you know if you have norovirus?
As mentioned, norovirus illness shows up in a unique way so it can be easily identified if you know what to look for.
- The symptoms are the first clue. The most common symptoms of norovirus are diarrhea, vomiting, nausea, and stomach pain.
- Secondly, a person usually develops symptoms 12–48 hours after being exposed to norovirus.4 While it may be difficult to know when the first person in a facility was exposed to the virus, there are usually a number of “close-contacts” that will become sick with the same symptoms within the 12–48 hour time frame. This is a tell-tale sign of norovirus: waves of people get sick approximately every 12–48 hours.
- Finally, norovirus illness is short-lived, and for most people only lasts for a 1–3 days.
Additionally, since norovirus and the flu are often confused with one another — as they are both illnesses that spike in the winter months — here is a quick “cheat sheet” of the differences:
How can norovirus be prevented?
Vaccines are the number one way to prevent most infectious diseases, but since a vaccine is not yet available for norovirus, other prevention measures are critical. The best ways to help prevent norovirus from impacting a facility are:
- Practice excellent hand hygiene. Everyone should be carefully washing their hands with soap and water, especially after using the toilet and changing diapers, and always before eating or preparing food.
- Safely handle and prepare food and DO NOT let anyone prepare food or care for others if they are sick. Fruits and vegetables should be washed and seafood cooked thoroughly before serving and eating. Sick food service employees in restaurants, schools, daycares and long-term care facilities should not return to work until at least two days after symptoms, such as diarrhea, stop.
- Regularly and properly clean and disinfect surfaces. Ensure the use of proper cleaning techniques and best practices (e.g., clean to dirty, top to bottom, color coded cloths) and follow label instructions for ready-to-use EPA-registered cleaner disinfectants with efficacy claims against norovirus. Surfaces should stay wet for the contact time listed on product labels, and disposable cleaning cloths should be used, unless using pre-moistened disinfecting wipes. Clean and disinfect all touchable surfaces daily, especially in busy facilities where immunocompromised individuals may be present, such as hospitals, schools, daycares, oncology and dialysis clinics, and long-term care centers.
How to contain a norovirus infection?
If you or someone in your building has been infected with norovirus, the best thing to do is follow the same prevention practices above, which will help to contain the spread. You can also adopt these additional best practices for up to two weeks after the last person has been sick, which is the amount of time it takes for some people to stop shedding the virus in their stool.
- Wear appropriate protection. ServSafe®, the ANSI-accredited National Restaurant Association’s food safety and certification program, recommends that before cleaning up an area where vomiting and diarrhea has taken place, employees should don disposable masks, nonabsorbent disposable gloves, eye protection and aprons.5
In healthcare settings, patients with suspected norovirus should be placed on standard and contact precautions for a minimum of 48 hours after the resolution of symptoms. This means that for anyone entering the area of a norovirus patient should at minimum wear gloves and a gown.
- Wash laundry with precaution. If an item has been contaminated with feces or vomit from someone with norovirus infection and cannot be disposed of, wear gloves and take care not to agitate it too much before placing it in the laundry. Run the washer and dryers on their longest cycles, consider using a laundry sanitizer or disinfectant as an additive, and wash hands thoroughly and immediately after handling a contaminated load. It’s also a good practice to wipe down all touched surfaces with an EPA-registered disinfectant effective against norovirus.
- Increase the frequency of cleaning and disinfecting touchable surfaces. In healthcare settings, the CDC recommends that cleaning and disinfecting should be performed twice daily, with frequently touched surfaces cleaned and disinfected three times daily.6 Following a similar recommendation for non-healthcare facilities is also warranted if norovirus is suspected or confirmed.
1. Centers for Disease Control and Prevention. Preventing Norovirus Outbreaks. https://www.cdc.gov/vitalsigns/norovirus/index.html Accessed Dec 11, 2019.
2. Centers for Disease Control and Prevention. MMWR. Vital Signs: Foodborne Norovirus Outbreaks — United States, 2009–2012 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a3.htm Accessed Dec 11, 2019.
3. Centers for Disease Control and Prevention. NoroSTAT Data. www.cdc.gov/norovirus/reporting/norostat/index.html Accessed Jan 31, 2020.
4. Centers for Disease Control and Prevention. The Symptoms of Norovirus. https://www.cdc.gov/norovirus/about/symptoms.html Accessed Jan 31, 2020.
5. ServeSafe National Restaurant Association. Norovirus: The Notorious Dangers. https://www.servsafe.com/media/ServSafe/Products/Norovirus/Norovirus-The-Notorious-Dangers-Whitepages-(Final).pdf Accessed Jan 31, 2020.
6. Centers for Disease Control and Prevention. Norovirus in Healthcare Facilities Fact Sheet. https://www.cdc.gov/hai/pdfs/norovirus/229110-ANoroCaseFactSheet508.pdf Accessed Jan 31, 2020.
Proactive steps to help prevent the spread of germs in facilities
By now, we are all aware that a novel coronavirus has arrived in the U.S. The 2019 novel coronavirus (COVID-19) outbreak that started in Wuhan, China in December 2019 has infected almost 25,000 people in over 25 countries — including 11 confirmed cases in the U.S. as of February 5, 2020 according to the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). As public health leaders across the world have jumped into action, there is still much to learn about how this outbreak will play out.
While the CDC still considers the risk level to be low in the U.S., concern still exists and many facility managers of schools to businesses are wondering what, if anything, they should be doing. Fortunately, there are simple and proactive steps that can be taken to help prevent the spread of germs in facilities amid concern over COVID-19.
To this end, I recommend a three-part approach to implementing a robust and effective program. It is also important to point out that facility managers can use these same behaviors and practices to prevent the spread of germs every day and in readiness for the next outbreak, even when COVID-19 isn’t a concern.
Part 1 – Public health basics: These activities form the foundation of any public health and infection prevention plan. Cleaning teams likely understand they are responsible for cleaning and disinfecting surfaces, but they may not realize they can also spread germs. Encourage the following behaviors and practices with your staff to help prevent germs from coming into and spreading in your facility:
- Get vaccinated: In the case of COVID-19, it’s not available yet, but staff should be up to date on their vaccines. Learn more about what vaccines the CDC recommends for adults here.
- Keep hands clean: Wash hands frequently with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer if soap and water are not available.
- Cover coughs and sneezes: Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing. Dispose of tissue properly and perform hand hygiene.
- Stay home when sick: Remain at home and avoid contact with others when sick, except if needing to visit a medical provider. Do not travel or go to work while sick.
Part 2 – Environmental stewardship: From common cold and flu viruses to COVID-19, cleaning and disinfection are critical to prevent the spread of germs via surfaces. In fact, almost 80% of infectious diseases are transmitted via contact or touch and surfaces act as reservoirs for germ transfer to hands if they aren’t cleaned and disinfected as cited in The Secret Life of Germs by Philip M. Tierno Jr., Ph.D. If you are doing the job right, you are helping to prevent the spread of pathogens and thus breaking the chain of infection. The following steps will ensure your cleaning and disinfection program has a strong foundation.
- Specify procedures: A strong cleaning program has written procedures in place that specify cleaning processes for different areas in your facility. Each procedure should include what surfaces need to be cleaned, who is responsible for each area, the products to be used to clean each surface. Other product details should include the directions for use, the contact (or dwell) time, details on how to avoid cross contamination by cleaning from clean to dirty. Update procedures each time a new product is introduced or a best practice is identified.
- Products to use: Make sure that disinfectants have EPA-approved claims against pathogens that cause illness or concern in your facility. These may include cold viruses, influenza, norovirus, or MRSA. In the case of COVID-19, the EPA’s Emerging Viral Pathogen policy allows for the quick determination of products that have demonstrated effectiveness against viruses similar to the emerging virus. Check your manufacturer’s website or contact your disinfectant manufacturer if you are unsure of claims.
- Educate and engage your staff: Ensure your cleaning staff are trained adequately on your facility’s cleaning and disinfecting procedures. In addition, engage your employees as engaged employees often have higher performance. For more on developing and sustaining employee engagement, click here.
Part 3 –Ensure ongoing quality and preparedness: Here are two additional practices that facility leaders should tackle to be adequately prepared to prevent illness and outbreaks:
- Written cleaning program policy: Policies are overarching documents that identify key components of your cleaning program. Policies should outline how often procedures will be reviewed and updated, what procedures should be in place, and the frequency in which employees will receive training and feedback on procedures.
- Outbreak preparedness procedure: Ensure you have an outbreak preparedness procedure in place for when outbreaks do impact your facility. Your plan should be separate from your everyday preventative cleaning procedures and cover the extra measures that need to be taken. These include helping employees understand the importance of identifying the signs and symptoms of any outbreak infection, knowing the correct personal protective equipment (PPE) to wear if needed, how germs are generally transmitted, and how to determine if different products need to be used.
Once the behaviors and practices above are in place, facility managers should feel confident in their ability to take on any infectious disease challenge, whether it be COVID-19, a spike in flu rates, or the next new pathogen of concern to come our way.