Originally published by Healthcare Facilities Today

The outbreak of COVID-19 has been a wake-up call for public health and healthcare officials alike. This respiratory disease, caused by a coronavirus, SARS-CoV-2, is a reminder of the importance of infection prevention efforts and the need for continued vigilance.

While the overall risk for contracting COVID-19 in the United States is low, it’s important to not discount that this current influenza season is quite severe, and that flu is a much more likely threat. Attention has mostly been focused on this new outbreak, but millions of Americans have already been battling respiratory illnesses and influenza for weeks. Based off preliminary data, the U.S. Centers for Disease Control and Prevention (CDC) is estimating that for the 2019/2020 flu season (October 1, 2019–February 15, 2020), there have been between 29–41 million flu illnesses and between 16,000 and 41,000 flu-related deaths. 

The spread of both COVID-19 and flu-related illnesses remind us of the critical role of infection prevention. Everything from vaccines to personal protective equipment (PPE) to hand hygiene and environmental disinfection, play a vital role in helping prevent the spread of infections. It’s easy to view flu and even COVID-19 prevention in the context of only PPE, but we can’t discount the critical role of environmental bioburden.

When people with respiratory infections cough or sneeze, the infectious droplets land on surfaces and objects, which contaminates them. These respiratory viruses, especially coronaviruses, are not environmentally hardy, meaning they are easy to kill via standard disinfection practices with EPA-registered disinfectants for enveloped viruses.

However, the challenge is if too much of the attention is on PPE, some may neglect the environmental component to disease prevention. When infected people fail to wash their hands or cover their cough, the environmental disinfection component to infection prevention is the stopgap, making it imperative to preventing the spread of infection. 

In fact, the CDC guidance for SARS-CoV-2 notes that “products with EPA-approved emerging viral pathogens claims are recommended for use against SARS-CoV-2. If there are no available EPA-registered products that have an approved emerging viral pathogen claim for SARS-CoV-2, products with label claims against human coronaviruses should be used according to label instructions.”

There are several products with EPA-approved emerging viral pathogen claims that are available for surface disinfection against SARS-CoV-2, including Clorox Healthcare^® Bleach Germicidal Wipes.

What we can take away from these recommendations and the concerns regarding respiratory illnesses, including both COVID-19 and the flu, is that disinfection remains a critical component to infection prevention and we already have the tools to combat such respiratory viruses.

Hospitals and healthcare facilities are working to ensure they are ready for possible patients with respiratory illnesses and part of these measures include ensuring the right products are available, training staff to use products currently, and monitoring environmental disinfection compliance.

From cleaning high-touch surfaces and workstations to using dedicated medical equipment, environmental infection prevention is a foundational piece to disease control. Shortages of PPE is a concern during this respiratory virus season and while hospital supply chains work to acquire adequate supplies, this is the time to hone in on environmental measures. 

Just like our practices during flu season, we can ensure routine cleaning is being done in high-risk areas like emergency department waiting areas. Rounding and asking staff (both clinical and environmental services) their processes is helpful to engage that reminder of environmental cleanliness during respiratory virus season.

CDC guidance pushes us to also execute routine environmental cleaning and disinfection for patients in isolation, so now is the time we ensure those practices are as efficient and effective as possible. Make sure privacy curtains are laundered appropriately to avoid contamination — linens play a bit role in environmental infection control! 

Moreover, beyond educating staff on the proper screening and isolation for those with respiratory symptoms, we can also remind them about the power of a single disinfecting wipe and that cleaning is not limited to what is done by environmental services staff.

I always encourage frontline staff to grab a disinfecting wipe and wipe down their work areas as a routine practice to end their shift. Desks, keyboards, counters and phones are all high-touch items that can act as transmission mechanisms for respiratory viruses. Waiting rooms can easily be neglected, so it’s important to make sure there cleaning of high-touch surfaces. More so, don’t forget routinely remove those objects that can’t be cleaned, like magazines. 

Environmental disinfection is a key part of preventing both influenza and even COVID-19. We all have a role in prevention and with the right products and training, it is possible for everyone to take responsibility and play their part. Practice makes perfect and given the severe flu season and potential spread of SARS-Cov-2, now is the time for facilities to focus on environmental disinfection efforts to ensure preparedness and effectiveness against such respiratory viruses. 

Dr. Saskia v. Popescu is a paid consultant for Clorox Healthcare.

In the ever-changing world of healthcare and infection prevention, there’s always a hot topic or new approach to an old problem. 2020 is sure to keep us on our toes with increasing emerging infectious disease threats like COVID-19 caused by the virus SARS-CoV-2, growing antimicrobial resistance, and the expansion of medical care and procedures to outpatient settings.

As an infection preventionist (IP), below are some themes I anticipate will be critical for infection prevention and environmental hygiene in 2020:

• Tackling emerging antimicrobial-resistant organisms — As antimicrobial-resistant organisms such as Candida auris (C. auris) emerge, hospitals and healthcare facilities must develop strategies for rapid detection, isolation, and prevention, including effective environmental disinfection. This year will be one in which the industry must work to understand new and emerging resistant organisms. While these pathogens challenge antimicrobial response efforts, they will also require IPC to adapt through foundational disinfection practices. As antimicrobial-resistant organisms become more prolific and common in U.S. hospitals, guidance will come from the U.S. Centers for Disease Control and Prevention (CDC) and researchers. For example, with C. auris, the CDC has published a list of Environmental Protection Agency (EPA)–registered hospital-grade disinfectants effective against C. auris, including Clorox Healthcare^® Hydrogen Peroxide Cleaner Disinfectants, and if none of these products is available, the EPA recommends using an EPA-registered hospital-grade disinfectant effective against Clostridioides difficile spores. In conclusion, it is vital that healthcare facilities engage in enhanced cleaning or stay aware of additional measures that the CDC is suggesting to stop the spread of pathogens that contribute to antimicrobial resistance.
• Implementing infection prevention programs in outpatient settings — Today’s healthcare practice is increasingly pushing procedures to outpatient centers. However, it is critical that these types of facilities also have strong infection control programs akin to those found in acute-care facilities. Regulatory oversight is beginning to look at this issue and requirements are changing, which means facilities need to establish plans to incorporate infection prevention processes, such as staff training, into these previously overlooked outpatient settings. Routine rounding, risk assessments, and even staff surveys can help identify those opportunities to improve patient and healthcare safety in these unique healthcare environments. Outpatient settings need to take infection control just as seriously as their acute-care counterparts.
• Investing in preparedness — From the recent COVID-19 outbreak in China to the Ebola outbreak in the Democratic Republic of Congo in 2019, emerging infectious diseases are increasingly becoming a part of the infection prevention playbook. In the U.S., the funding for the tiered hospital approach to special pathogens is set to expire, which means hospitals will have to start investing in preparedness. The tiered hospital approach was set into place following the 2014 Dallas Ebola cluster to ensure there were designated hospitals with enhanced measures to treat patients with special pathogens, like Ebola or SARS-CoV. This includes all preparedness measures, from personal protective equipment to environmental disinfection in areas where a patient with an infectious disease might be. Infection prevention programs play a critical role in preparing for future outbreaks, like COVID-19, and that means considering screening practices in triage and the importance of the i3 strategy (identify, isolate, and inform). Given the current outbreaks across the world, these topics have to be re-addressed in 2020.
• Actively fighting flu instead of bracing for impact — Too often, hospitals and health facilities have approached flu season as a “brace for impact” situation, responding to cases and increases in severity as it intensifies. The 2019-2020 flu season is still going strong making it imperative for IPs to continue to actively fight flu through preventative measures instead of being reactionary. Healthcare facilities must focus on working with staff, so they are working proactively on the frontlines to prevent its spread and rapidly identifying and isolating patients with suspected cases. Moreover, for pediatric settings, it is vital to continue to emphasize the importance of hand hygiene and enhanced disinfection as children more often spread respiratory infections through contact.
  
  From the community perspective, in addition to vaccination, we must continue to urge people to stay home when sick, implement correct hand hygiene and regularly clean and disinfect their work areas. Even in the midst of flu season, proactive habits are vital and are as easy as making sure your loved ones are vaccinated (flu shots are still available) or encouraging staff to stay home when sick.
• Improving environmental disinfection practices and reducing human error — Environmental services, the primary department responsible for the safety and cleanliness of a hospital or other healthcare facility, are a critical component of infection prevention and healthcare; however, like many things environmental services can be prone to human error. With rising antimicrobial resistance and attention to healthcare transmission dynamics (i.e., studies showing how patients colonized with MRSA, VRE, or C. diff can easily contaminate their rooms), IPs are trying to improve environmental cleaning and disinfection, as well as addressing the human factor components. Technologies, like ready-to-use and no-touch solutions, have the capacity to improve disinfection compliance without relying solely on the capabilities of personnel.

2020 will be a critical year for infection prevention efforts as hospitals prepare for and respond to the COVID-19 outbreak. These efforts go beyond the normal work that focuses on reducing healthcare-associated infections in a growing healthcare environment. A severe flu season and growing concerns for antimicrobial resistance all shape infection prevention efforts and require a holistic approach to reducing the spread of infectious diseases in healthcare.

Dr. Saskia v. Popescu is a paid consultant for Clorox Healthcare.

Originally published by Contagion Infectious Diseases Today.

As we work towards making health care safer and establishing a stronger role for infection control in patient care, the role of bioburden and environmental contamination is a common conversation topic. The US Centers for Disease Control and Prevention (CDC) recently reported that each year roughly 2.8 million Americans are infected with antibiotic-resistant infections, which result in 35,000 associated deaths. Organisms like vancomycin-resistant Enterococci (VRE), drug-resistant Candida, Methicillin-resistant Staphylococcus aureus, are all considered serious threats in the CDC’s 2019 Antibiotic Resistance Threats Report. 

One conversation that we consistently have in infection prevention is about isolation and screening of patients with multidrug-resistant organisms (MDROs) and/or Clostridioides difficile. What is the role of patients without active infection who are likely just colonized in transmission? Will they shed such organisms and contaminate their environmental surroundings? Such issues are all things that impact isolation and environmental cleaning in health care settings. With this in mind, investigators of a new study, published in Open Forum Infectious Diseases, sought to understand the relationship between environmental contamination and patient colonization with VRE and whether it impacted negative health outcomes. 

To assess this relationship, investigators studied 463 patients in post-acute care in Ann Arbor, Michigan. The patients were assessed from point of enrollment through discharge and then for 6 months. Body and environmental samples were taken at specific temporal intervals to determine patient colonization and environmental contamination, as well as the dynamics of long stays, unplanned hospitalization, and infections which were adjusted for sex/age/race, Charlson’s Comorbidity Index, and physical self-maintenance. 

Understanding the relationship dynamics between patient colonization and environmental contamination for MDROs such as VRE is critical. Not only does it help us to appreciate the transmission dynamics but also alerts us if screening is necessary. Following their analysis, the investigators of this study found that new infection or acquisition of VRE was more likely in patients in contaminated rooms (Odds ratio [OR]: 3.75). The opposite of this relationship was also found; contamination of a room was more likely when the patient had VRE. While this relationship isn’t surprising, it emphasizes the importance of daily environmental cleaning and rapid isolation for those with known VRE infections or colonization.

For those patients or rooms with new VRE acquisition, researchers found that increased length of stay played a critical role (new acquisition OR: of 4.36; new contamination OR: 4.61).

Moreover, contaminated rooms increase the risk for colonization, and both are associated with future adverse health outcomes. New infections were more common in those areas with higher VRE burdens. The authors cite the figures, “15% in the absence of VRE, 20% when following VRE isolation only on the patient or only in the room, and 29% following VRE isolation in both the patient and the room”.

Overall in this study, patients who acquired VRE and became infected with the organism, tended to stay in rooms with VRE contamination. As colonization can increase the risk for future adverse events, the authors emphasized the importance of screening for MDROs on admission.

From the infection prevention perspective, this reinforces the push to screen patients, even if just in high-risk areas like intensive care and oncology units. This study sheds light on the role of environmental contamination in increasing risk of VRE acquisition by patients and how those patients with VRE can easily contaminate their space.

It is well established that as length of stay increases, so does the risk for infection, so this study further reinforces this point. The symbiotic relationship between environmental contamination and patient colonization or infection is a lesson we must truly listen to and apply to infection control efforts. More prevalent environmental disinfection, screening, and stringent patient isolation are all steps we can take to break the chain of infection. 

Originally published by Contagion Infectious Diseases Today.

Clostridioides difficile (C. diff) is one of the infections that stops people in their tracks, from infection preventionists to providers and nurses alike. Roughly half a million Americans will contract this bacterial infection every year, and 20 percent will relapse after treatment.

Moreover, 1 in 11 people over 65 years of age with healthcare-associated C. diff will die within one month of their diagnosis. Studies have shown that the cost of managing and treating C. diff infections is quite significant at around $18,000.

On top of these startling statistics, C. diff also poses a challenge because the bacterium is particularly environmentally hardy. When it’s in its spore form, it’s quite resistant to disinfectants and ultimately requires bleach-based products. (Clorox has become the strongest tool in our arsenal to combat C. diff.)

Moreover, even alcohol-based hand sanitizers aren’t enough to get rid of the bug, which requires healthcare workers and patients to use soap and water as a way to get the spores off through friction. 

One recent study from the U.K. sought to test the hardiness of C. diff on hospital gowns and stainless steel, and assess the efficacy of disinfectants. Investigators first wanted to evaluate the role of gowns as fomites in C. diff transmission, as there has been suspicion that they could play an active role.

The research team found that when they applied spores in sterilized water at various concentrations to the surgical gown, the number of recovered spores did not increase over time.

This means that any transmission would occur within the first 10 seconds of contact. And since the gowns are capable of trapping these spores it is a critical reminder to only use them once, and discard immediately after use. 

The second part of the study is the one that has gotten more attention. The investigators sought to treat the gowns with a disinfectant to test its efficacy and whether it would help with the bioburden.

The research team found that after being treated with the 1000 ppm chlorine-based disinfectant for 10 minutes, the gowns still were able to pick up and hold the C. diff spores. This concern over resistance sent shockwaves, and many news outlets picked up on this as an indicator of what’s on the horizon. But an issue with the study was exactly what disinfectant was used.

First and foremost, as an infection preventionist and the first to stand on my soapbox to shout about the perils of antimicrobial resistance, I know that the efficacy of our disinfectants will eventually fail.

The issue with this study is that much of the media coverage speaks broadly of a chlorine-based disinfectant, and goes into little detail about exactly what was used. For my infection prevention peers, you know not all disinfectants are alike, and some just weren’t designed for combatting hardier bugs like C. diff. This is the playbook we live by in healthcare. 

The disinfectant the investigators used was sodium dichloroisocyanurate (NaDCC), which is a pretty stable form of chlorine that can disinfect water, as well as surfaces/objects. But it is not a hypochlorite (like bleach).

The issue I have is that hospitals in the U.S. don’t use NaDCC, but rather sodium hypochlorite (NaOCl), as a disinfectant for C. diff. In fact, the investigators even note that higher concentrations of NaDCC are required (1000 ppm for 10 minutes) to truly kill C. diff spores. 

NaDCC is different than bleach, and has a lower pH, meaning that its antimicrobial capabilities are different. There are benefits to NaDCC in that it has a reserve disinfecting capability, but it’s simply not used as a primary cleaner within the U.S. as it requires larger concentrations. Ultimately, the U.S. Centers for Disease Control and Prevention (CDC) recommend bleach, like Clorox.

So although hospitals in the U.K. stopped using bleach years ago, it’s important to note that this study was not carried out with the same disinfectants that we use in the U.S., and comparing them apples to apples would be misleading.

Although this study sheds light on how easily gowns can become contaminated with C. diff spores, the takeaways regarding types of disinfectants should be taken in context.

This study highlights the need to test disinfectants and continuously monitor their efficacy against microorganisms, especially those that are more environmentally hardy.

It should also be a reminder that the variety of disinfectants and biocides being used is likely to show variation in different regions, and those results are not always comparable to other healthcare regions.