On January 31, 2020, the US Department of Health and Human Services declared the COVID-19 situation a public health emergency.1 Nearly year and a half later in June 2021, the Occupational Safety and Health Administration (OSHA) issued the COVID-19 Emergency Temporary Standard (ETS) CFR 1910.502.2 The ETS requires employers in all healthcare settings to develop and implement a COVID-19 Plan to identify and control COVID-19 hazards in order to protect workers when treating suspected or confirmed COVID-19 patients This blog post will focus on the cleaning and disinfection requirements of the ETS.
Employers must conduct a hazard assessment of the entire workplace to identify and understand where COVID-19 hazards might exist and what controls must be implemented to minimize the risk of COVID-19 transmission. High risk areas, tasks, and occupations must be identified in the assessment. This includes the identification of high-touch surfaces. Facilities are expected to follow both the CDCs “Guidelines for Environmental Infection Control in Healthcare Facilities” for standard practices for cleaning and disinfection of surfaces and equipment as well as the COVID-specific recommendations found in the CDCs “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic”. The latter guidance calls for the following:
- Equipment that cannot be dedicated to the patient room is to be cleaned and disinfected per manufacturer’s instructions for use (IFUs) between every patient.
- Ensuring that environmental cleaning and disinfection procedures are followed consistently and correctly.
- Use of an EPA-registered disinfectant from EPA’s List N. Appropriate disinfectant formats include ready-to-use sprays, concentrates, and wipes.
- Delay room entry for terminal cleaning until time has elapsed for enough air changes to remove potentially infectious particles. After this time, EVS personnel can enter the room wearing a facemask (for source control) along with a gown and gloves. Eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products.
- No-touch devices (NTDs) can be used as an adjunct to terminal cleaning. UV, electrostatic sprayers, and foggers are examples of NTDs.
Furthermore, the ETS requires that employers have cleaning and disinfecting policies and procedures. The cleaning frequencies to be included in the policies are outlined below:
- High-touch surfaces are to be cleaned at a minimum of least once per day and when visibly soiled. However, I recommend increased frequency for high-touch surfaces to reduce transmission risk of not only COVID-19 but other pathogens as well.
- After an aerosol-generating procedure on a person with suspected or confirmed COVID-19, clean and disinfect the surfaces and equipment in the room or area where the procedure was performed.
- In other areas, when a COVID-19 positive person has been in the workplace within the last 24 hours, clean and disinfect any areas, materials, and equipment that have likely been contaminated.
- Ensure that employees have sufficient time during their work shift to perform the required cleaning and disinfection activities.
To avoid costly citations, you may wish to familiarize yourself with the OSHA Inspection Procedures.3
When will the OSHA ETS end? In all likelihood, when the public health emergency is declared over, the ETS will “end” with the many of the elements being absorbed into other existing OSHA standards such as the general respiratory protection standard.
1. U.S. Department of Health and Human Services. Determination that a Public Health Emergency Exists [internet]. [cited 2021 Aug 21]. Available from https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx
2. Occupational Safety and Health Administration. COVID-19 Emergency Temporary Standard. COVID-19 Healthcare ETS [internet]. [cited 2021 Aug 21]. Available from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.502
3. Occupational Safety and Health Administration. Inspection Procedures for the COVID-19 Emergency [internet]. [cited 2021 Aug 21]. Available from https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-02_CPL_02.pdf
The COVID-19 pandemic has brought unprecedented changes to healthcare throughout the world. Fraught with high volumes of patients and paucity of resources and testing, combined with personal protective equipment (PPE) and staffing shortages the past year has taught the healthcare community lasting lessons in resilience. The rapidly advancing knowledge around the SARS-CoV-2, the virus that causes COVID-19, has also prompted a shift in the standard of care. In the face of such multifaceted challenges, the world of Infection Prevention and the capacity to monitor and prevent healthcare-associated infections (HAIs), changed.
How, why, and what changes have occurred?
Stevens et al described the impact on HAI prevention efforts as notable due to diversion of human resources for surveillance and case identification, process measures for prevention of HAIs (such as hand hygiene), mitigation resources (lack of real-time feedback), and the lack of adequate supplies of PPE for traditional HAIs resulting in potential increased risk of cross-contamination.
The transmission of SARS-CoV-2 lacked clarity, but was described to spread via aerosol and surface contamination in 2020. Infection prevention resources were critical in this environment of uncertainty, both for adequate disinfection of surfaces, but also for appropriate use of PPE. Although the overall risk of surface contamination resulting in transmission of SARS-CoV-2 was ultimately deemed to be low, effective disinfection practices were still necessary, adding to the workload burden of already overstretched infection prevention teams.
Furthermore, the level of illness of patients affected by COVID-19 combined with the limited PPE resources, resulted in changes in patient care that could be unpredictable at times. In clinical care settings for example, the long length of hospital stay, particularly in the intensive care unit (ICU), was accompanied by longer durations of support devices, such as endotracheal tubes, central venous catheters (CVCs), and urinary catheters. The longer duration of which increased the numbers of opportunities for in the failure of executing process measures to prevent HAIs.
The increased use of prone positioning, even amongst non-ventilated patients, may have negatively impacted visible access to many dressings and device sites for several hours per day. Finally, with PPE limitations, many adjustments were made to decrease required trips and time spent in patient rooms, such as transitioning intravenous medication pumps to outside of patient rooms. Such changes may have positively impacted PPE utilization rates, but may have carried negative counterbalances with increased risks of HAIs due to lack of direct visualization, longer tubing with possible increased risks of contamination, and potential preference for more durable catheters, such as CVCs to minimize risk of dislodgement or need for new access placement. Finally, it was would be remiss to not acknowledge that all of the above were further augmented by the fear and anxiety that resulted from the many unknowns and struggles faced by healthcare workers, and may have increased the risk for error.
What was the result?
The data is still evolving, but increased rates of HAIs have been reported. Amongst the critically ill, one study showed a 46% increase in HAIs, with ventilator-associated pneumonia (VAP) and central line associated bloodstream infections (CLABSIs) as leading causes. Interestingly, within this group, only the intubated patients were noted to have HAIs. A review similarly showed several studies with increased CLABSIs amongst patients with COVID-19, as compared to those without. Moreover, a study of CLABSI data from the National Health Safety Network as similarly demonstrated a 28% increase in CLABSI from early in the pandemic. Of interest, Clostridiodes difficile rates have decreased in some studies, without concurrent decreases in antibiotic use, highlighting that strong infection prevention measures including environmental cleaning and use of PPE and handwashing remain critical in the prevention of nosocomial spread of this infection.
So, where do we go from here?
We must recognize the impact the pandemic has had on healthcare, with rapid changes in practice, high work burdens with increasing burnout, and the need to move forward. Hardwiring our HAI prevention practices to ensure consistency in both the best and worst of times is critical. Considering how to identify, implement and amplify the positive innovations and changes throughout the field is necessary. Of paramount importance is ensuring robust infection prevention teams have adequate resources for surveillance, mitigation, education and quality improvement.
Thank you to all of the tireless Infection Prevention teams, continuing to strive to provide the safest care for our patients and healthcare teams around the world!
In the past year or so, I’ve read about a number of outbreaks of carbapenem-resistant Acinetobacter baumanii (commonly abbreviated to CRAB) that highlight the threat from this particular antibiotic resistant pathogen. Before describing those in more detail, a little about CRAB.
Like bacteria in the Enterobacteriaceae family, A. baumannii is a gram-negative bacterium that can also develop resistance to carbapenem antibiotics. It is part of the Moraxellaceae family and is the most important species causing human infections within that family. The most common resistance genes found in A. baumannii include those that code for New Delhi metallo-beta-lactamase (NDM) and oxacillinase (OXA) enzymes, both of which chemically degrade carbapenem antibiotics. The high levels of resistance mean that the infections caused by CRAB in the bloodstream, lungs, wounds, and urinary tract increasingly require the use of last-line antibiotics such as colistin, polymyxin B and tigecycline.
The first reports of CRAB infections appeared in the early 1990’s but reports have increased steadily since then. Around 800 articles have been published since 1999, and outbreaks have been reported globally.
The serious global threat of CRAB
In the CDC’s first Antibiotic Resistance Threats report issued in 2013, multi-drug resistant A. baumanii is listed as a “Serious Threat.”1 Carbapenem resistance is not specifically mentioned. In the 2019 report, CRAB is specifically listed as an “Urgent Threat,” the highest threat level.2 This report estimates that in 2017, there were 8,500 cases in the U.S., resulting in 700 deaths and a significant cost to the health system of $281 million. The one piece of good news is that rates have declined by 25% since 2011. That said, WHO’s June 2021 Global Antimicrobial Resistance and Use Surveillance System (GLASS) report “depicts a dire scenario” noting that a median of 66% of A. baumannii causing bloodstream infections are carbapenem-resistant.3
The challenges of controlling and preventing and controlling CRAB infections
In the first half of 2020, New Jersey, an outbreak at a hospital in New Jersey highlighted the importance of consistently implementing comprehensive infection prevention and control (IPC) measures, especially if patients are intubated and ventilated.4 In the outbreak, 34 patients were infected or colonized with meropenem-resistant A. baumanii infections, 80% of which occurred during the facility’s surge in COVID-19. Of these patients, 25 were intubated and mechanically ventilated and ultimately, 20 with infections were identified. Due to personnel and equipment shortages, space constraints and the high number of critically ill patients admitted during the COVID-19 surge, this hospital understandably had to adopt alternative mitigation measures. As a result, intentional and unintentional changes in IPC measures may have contributed to the outbreak.
A regional outbreak that occurred in May 2021 in California highlights how the infection can rapidly spread between facilities.5 Of 52 NDM-CRAB cases, 43 cases were reported in a single county across multiple facilities including acute care hospitals, two skilled nursing facilities, and a long-term acute care hospital. A further 17 probable NDM-CRAB cases were epidemiologically linked to these cases or facilities. Genome sequencing of 17 isolates pointed to a common source of exposure. This outbreak emphasizes the need for active surveillance including screening new patients being transferred from facilities experiencing outbreaks and placing them on contact precautions while awaiting results.
Finally, an outbreak at a hospital in Israel shows how A. baumanii can persist in the environment.6 Three wards were terminally cleaned with bleach and UV before becoming wards for COVID-19 patients only. Two weeks after reopening, five cases of CRAB infection or colonization were identified, all belonging to the same meropenem-resistant clonal lineage. Three were acquired in a single ward, which prior to COVID-19 had been used to cohort CRAB patients. Epidemiological investigation revealed that the ward’s medication room had not been terminally cleaned and was identified as the source of CRAB. The hospital implemented several measures which stopped the outbreak. The ward in question was closed to new admissions, terminal cleaning repeated, and the medication room closed permanently. CRAB patients were cohorted in a single unit and staff were not permitted to care for CRAB-negative patients until they had left the cohort area and removed all PPE (which included a disposable gown over COVID-19 PPE coveralls.
Preventing transmission of CRAB and other multi-drug resistant organisms
These three outbreak reports paint a picture of the seriousness of CRAB and why the CDC has declared it an “Urgent Threat.” Although in the U.S., cases were steadily decreasing prior to the pandemic, we won’t know how the pandemic has impacted CRAB and other MDRO rates until more data is analyzed and released. In the meantime, these five actions can help to help prevent transmission of CRAB and other MDROs:
- Conduct active surveillance and screen new patients from outbreak facilities
- Test for CRAB and MRDOs through public health labs or the CDC’s AR Lab Network AR Lab Network
- Implement contact precautions along with standard environmental and personal infection control measures
- Communicate a patient’s MDRO status to receiving facilities
- Report carbapenem-resistant organisms and other MDROs to local and state health departments
One final point to note is that if a disinfectant has an EPA-approved claim against A. baumanii, it will most likely not be carbapenem-resistant strain. However, these disinfectants should still be effective against CRAB as drug resistance is not expected to change a bacterium’s susceptibility to disinfectants.
1. Antibiotic Resistance Threats in the United States, 2013. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf Accessed July 19, 2021
2. Antibiotic Resistance Threats in the United States, 2019. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf Accessed July 19, 2021
3. Global antimicrobial resistance and use surveillance system (GLASS) report 2021. Geneva: World Health Organization; 2021. License: CC BY-NC-SA 3.0 IGO.
4. Perez S et al. Increase in Hospital-Acquired Carbapenem-Resistant Acinetobacter baumannii Infection and Colonization in an Acute Care Hospital During a Surge in COVID-19 Admissions — New Jersey, February–July 2020. MMWR / December 4, 2020 / Vol. 69 / No. 48
5. Regional Outbreak of Highly Drug-resistant Carbapenemase-producing Acinetobacter baumannii May 2021. California Department of Public Health. http://publichealth.lacounty.gov/acd/docs/HighlyDrugResistantCarbapenemaseProducingAcinetobacter_baumannii.pdf Accessed July 19, 2021
6. Gottesman T et al. An outbreak of carbapenem-resistant Acinetobacter baumannii in a COVID-19 dedicated hospital. Infection Prevention in Practice. 2021 Mar; 3(1): 100113.
COVID-19 infections caused by the delta variant are surging in much of the United States and globally, just as countries are continuing to open and get back to some level of normal. In the United States, the end of the summer will mark the return to school for millions of kids. Similarly, many businesses are considering how or whether to have workers return to offices and if so, on what schedule. And all over the country, restaurants, movie theaters, concert venues and other entertainment venues are continuing to welcome back customers. As they do so, they continue to implement a range of infection prevention measures recommended by the U.S. Centers for Disease Control and Prevention (CDC) which include among others, promoting vaccination, improving ventilation, regular hand hygiene, wearing of masks, cleaning and disinfecting, COVID-19 testing, and case investigation and contact tracing of employees.
CDC guidance on cleaning and disinfecting non-healthcare facilities has been updated periodically to reflect the current state of evidence, but the general principles and practices have remained the same.1 Although the risk of COVID-19 transmission from surfaces is low, it’s important to remember that other disease-causing bacteria and viruses can also be spread this way. Consequently, regular cleaning and disinfection is important to help keep your facility users healthy.
The most common questions asked about cleaning and disinfecting facilities to help prevent COVID-19 are how often and when. Based on current CDC guidance, cleaning with products containing soap and detergents can decrease the risk of infection from surfaces. Disinfection with an EPA-registered List N disinfectant may further reduce the risk of pathogens. If a COVID-19-positive person has been in the facility within the previous 24 hours, then the facility should be cleaned and disinfected. It’s worth remembering that the EPA expects that all List N disinfectants will kill COVID-19 virus variants, including the Delta variant, which is currently responsible for most of the infections in the United States.
However, there are other situations where more regular cleaning and disinfection may be necessary:
- In high-traffic areas in shared spaces where surfaces could be touched regularly by multiple people. These criteria could apply to many school settings.
- If COVID-19 transmission rates in the community are high. With the current Delta variant surge, this may apply to many parts of the country. In the CDC’s COVID-19 Integrated County View tracker, you can find the level of community transmission for any county in the U.S., classified as low, moderate, substantial and high.2
- If there are low vaccination rates in your community. In the same COVID-19 tracker, you can find out the vaccination rates in any county in the U.S.
- If the wearing of masks by unvaccinated people is low, or hand hygiene is infrequently practiced.
- If your facility is frequently used or occupied by people at a higher risk for severe illness, such as older people, those with chronic health conditions, or those who have long experienced systemic health and social inequities.
This guidance can help facility managers assess the risks of transmission from surfaces and develop appropriate cleaning and disinfecting plans and protocols.
1. U.S. Centers for Disease Control and Prevention. Cleaning and Disinfecting Your Facility. Every Day and When Someone is Sick. Updated June 15, 2021. https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html Accessed August 4, 2021.
2. The County Tracker is part of the CDC’s COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home Accessed August 4, 2021.
After two long years, we finally got to meet together again. Albeit only virtually, it was great to be in the “same room” with the over 3,300 participants from across the globe - many of whom are new to the profession. This blog post will summarize my top two favorite sessions from the 2021 annual APIC conference.
The Joint Commission (TJC) Office Hours
Sylvia Garcia-Houchins, TJC Director of Infection Prevention & Control (IP&C)
In this practical session, a hierarchical approach to infection control (IC) standards (pictured below) was reviewed. The speaker advised participants, when creating or revising IC-related policies, to apply this hierarchy as it will “always get you to the right answer.”
It was interesting to learn that only three evidence-based guidelines are required and they are 1) CDC or WHO Hand Hygiene, 2) CDC Standard Precautions, and 3) CDC Transmission-based Precautions. Beyond these, healthcare facilities may adopt any other evidence-based guidelines (EBG), national standards, or consensus documents of their choosing. Of note, the speaker stated that to be considered an EBG, that the document must have a reference list.
Last, participants were advised to download a copy of the program-specific Centers for Medicare and Medicaid Services (CMS) State Operations Manual which offers day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. Be thoughtful in regards to facility policy content as TJC will hold facilities accountable during surveys to ensure they are doing what they say they will do. For example, if your policy says you follow Association for the Advancement of Medical Instrumentation (AAMI) standards as opposed to CDCs for high level disinfection, you must be compliant with AAMI standards. Of note. AAMI guidelines have no reference list.
Pre-Conference Workshop: IP&C in Long-Term Care (LTC) - The Future is Now
Deb Burdsall, PhD, RN-BC, CIC, FAPIC; Assistant Adjunct Professor, University of Iowa College of Nursing; Manager, Baldwin Hill Solutions LLC, Infection Prevention for Long-Term Care
Teri Hulett, RN, BSN, CIC, FAPIC; Infection Prevention Consultant, Infection Prevention Strategies LLC
Buffy J. Lloyd-Krejci, DrPH, MS, CIC; Owner, IPC Well, LLC; Infection Preventionist
This day-long session was kicked off by calling out the elephant in the room: IP&C in LTC was an issue before the pandemic. In fact, 82% of LTCFs surveyed between 2013 and 2017 were cited for an IP&C deficiency. Infections are the most frequent cause of transfers and readmissions to the hospital. Two very important topics covered in this workshop were 1) Process surveillance and 2) Enhanced Barrier Precautions (EBP). For more information on the latter, see my June HICPAC Hub blog post. Regarding process surveillance, it is the review of staff practices with the purpose to identify whether staff implement and comply with IP&C policies and procedures. It is also required by CMS. Not only do IPs need to perform outcomes surveillance (e.g., healthcare-associated infections), they need to collect data and act on the findings around processes that can lead to infections. A good example is to observe cleaning and disinfection practices and to provide timely feedback to frontline workers.
At the session closing, new IPs who started in the profession during the pandemic were cautioned to be mindful that the IP&C practices observed were not best practices. Reuse of single-use personal protective equipment is a great example. For more on the CMS infection control requirements for LTCFs, see my blog post titled “New CMS Requirements for Long-Term Care Facilities – Are You Ready?”
I will conclude with a reminder inspired by Simon T. Bailey in the closing plenary session: Never forget that you all are diamonds – created under pressure and it is your time to shine!
Let’s grab a cup of coffee next year in Indianapolis, Indiana!
COVID-19 has suddenly and dramatically shifted infection prevention efforts in places from the home to public spaces, workplaces and businesses large and small. Many of these new behaviors are things that should have been common practice in pre-pandemic times. The efforts have been shown to be hugely beneficial not only in the fight against COVID-19, but also against other respiratory viruses, like influenza, which is at a record low this year.
Now as we look towards wide-spread vaccinations and re-openings, the question is what infection prevention strategies need to remain post-pandemic, and when COVID-19 cases become less common, what new behaviors will we keep?
Masks are now an integrated part of our lives – expected across our daily activities – whether you’re running errands, waiting in line, dropping off the kids – don’t forget your mask. A public health intervention has never been so prevalent across the majority of the U.S.
We may move away from behaviors and protocols around masking, but there are fundamental infection prevention behaviors that should stay.
One of the earliest measures was cleaning and disinfection. With any new pathogen, especially a respiratory one where we know fomites (i.e. objects or materials which are likely to carry infection) can play a role, routine cleaning and disinfection is pivotal. Early on we saw consumers wiping down everything that entered their home and spaces they interacted with, including groceries, mail, handles, desks, and packages.
While cleaning and disinfecting have a place, we learned that SARS-CoV-2, the virus that causes COVID-19, is not predominantly transmitted by infected surfaces or objects, unlike other common respiratory pathogens like respiratory syncytial virus (RSV) or influenza. It can and does spread this way, but not as frequently as through respiratory inhalation.
It is important that we continue to practice routine cleaning and disinfection and emphasize that it is one part of a holistic infection prevention strategy. COVID-19 after all, is not the only infectious disease we live with and cleaning and disinfection should be a standard part of our lives.
We can expect to see business take a proactive role in maintaining these efforts by implementing a variety of new disinfection practices, such as leveraging electrostatic technology like the Clorox® Total 360® ProPack Electrostatic Sprayer to disinfect airport terminals or hospitals, handing out hand sanitizers or disinfecting wipes to passengers when they board aircraft or customers when they enter a store, or having restaurant personnel slow the seating process to allow time for all surfaces to be cleaned and disinfected between guests.
Avoiding the Indoors
As we continue to learn more from transmission data, it is now known that clustered outbreaks can occur when people interact together indoors even with masks. This has put an unprecedented spotlight on the health of our indoor environments. There is now enormous emphasis on indoor protocols, including social distancing and air ventilation. These are not new areas of study for epidemiologists, but because of COVID-19, social distancing and air ventilation in public spaces have become priorities in infection prevention among consumers.
Staying away from indoor situations may not be practical for many in their everyday lives, and may not be broadly beneficial for public health, education or small business impact. Like masking, protocols for reduced capacity in indoor settings like restaurants will gradually fade.
Instead we’ll see continual investments in infection prevention efforts like hand hygiene, routine cleaning and disinfecting protocols and staying home when sick. From plexiglass partitions to marked indicators for physical distancing, we’ve seen a lot of emphasis on infection prevention during this pandemic.
Awareness Around Infections
Our awareness of infectious disease and the importance of general infection prevention including hand hygiene and routine cleaning and disinfection.
Early on, the focus was on staying home, masking or staying six feet apart. It was quickly realized that wasn’t enough. COVID-19 prevention requires multiple intervention strategies. Increasing emphasis on all the infection prevention behaviors – masking, physical distancing, hand hygiene, cleaning and disinfection, and avoiding indoor spaces with those outside your household - is what prevents the spread of COVID-19. No single layer of prevention is perfect, but together, they can significantly reduce risk. We know that now.
Using a holistic approach to reducing infectious diseases, whether they be COVID-19 or any other, is one that has definite staying power. While the protocols may change, the holistic nature of infection control will remain the same. Infection prevention efforts are front and center now, not only for infection preventionists like me, but to each and every one of us. We have a real opportunity to change how we treat infections in our everyday life even beyond COVID-19.
Dr. Saskia v. Popescu is a paid consultant for Clorox Healthcare.
About the HICPAC Blog Series
The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in U.S. to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in U.S. healthcare settings. As Infection Preventionists, we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. This blog series will highlight the key discussions at these meetings. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner.
Welcome to the first edition of the HICPAC Hub for 2021. This post will highlight the key topics addressed in the March 4, 2021 meeting which included updates on COVID-19, CDC guidelines, Project Firstline, and the Long-Term Care workgroup.
With the worst of the pandemic behind us (hopefully), the CDC is taking a closer look at which COVID-19 guidance and practices are applicable for future pandemics. They are also investigating the sustainability of both local and regional responses. Issues that have bubbled to the surface are also CDC priorities such as:
- Increase in central line bloodstream infection (CLABSI) rates,
- Health disparities and inequities,
- Staffing and training of healthcare workers, and
- Inappropriate antibiotic prescribing which of course drives antimicrobial resistance. This is particularly concerning at a time when the country - the world actually — is focused on a single pathogen.
With vaccinations underway across the country, the CDC has released updates on post-vaccination activities such as small maskless gatherings with other vaccinated individuals. The CDC did acknowledge that they need to be clearer moving forward to differentiate guidance intended for the public versus that for healthcare workers. A great example was the recent double masking guidance which targeted the general population and not healthcare personnel. The lack of a clearly stated target audience for the guidance caused much confusion among healthcare personnel.
CDC also announced that there will be a work group assembled to focus on rethinking the respiratory illness isolation precautions.
CDC Guideline Updates
Several guidelines for neonatal intensive care units (NICU) as well as the Infection Control in Healthcare Personnel guidelines continue to be updated. On March 8th, HICPAC reopened the public comment period for the following sections of the Healthcare Personnel guidelines:
- Group A Streptococcus,
- Meningococcal Disease, and
Project Firstline Update
CDC’s Project Firstline was launched late last year to educate frontline staff on the fundamentals in infection prevention and control (IP&C). This 2-year pilot intends to address gaps in IP&C knowledge and aims to provide the rationale behind the recommendations. Topics will be timely and will cover the fundamentals, as well as grounded in adult learning theory and provided in bite-sized formats. For example, there are some great short videos on cleaning and disinfection including why it matters and about contact times. Currently, materials are available in English, with Spanish versions to follow. CDC does recognize the need for the materials to be available in other languages too.
Long-Term Care Work Group Updates
The Long-Term Care (LTC) Work Group continues to make progress on its White Paper to address the new enhanced barrier precautions guidance for MDRO infections (EBP). Multidrug-resistant organism (MDRO) infections disproportionately affect LTC residents. They contribute significantly to morbidity and mortality for residents and high costs for the healthcare system. Standard Precautions are inadequate to prevent transmission of MDROs and Contact Isolation Precautions are impractical in this setting. In comes EBP which fall somewhere between Standard and Contact Precautions. Essentially, with EBP, gown and gloves are recommended for certain residents infected or colonized with novel or targeted MDROs or who have wounds or indwelling medical devices during specific high-touch care activities such as bathing or providing wound care. Gowns, gloves, and alcohol-based hand sanitizer should be available outside of every resident room. While there will be costs up front to implement EBP, savings should be realized through prevention of healthcare-associated infections.
A few action items for IPs include 1) take a moment to review the section of the Healthcare Personnel guidelines that is open for public comment, 2) check out the resources available from Project Firstline, and 3) watch for more to come on EBPs for LTC settings. For additional information the HICPAC meeting minutescan be reviewed once they are posted. We hope that you find these meeting summaries helpful in your day-to-day practice.
While the COVID-19 pandemic appears to be slowing down, the next pandemic is knocking at our door – infections caused by antibiotic resistant organisms (ARO). The post-antibiotic era isn’t coming – it’s here.1 According to Dr. Arjun Srinivasan with the Centers for Disease Control & Prevention (CDC), “The COVID-19 pandemic has created the perfect storm for antibiotic resistance. Prolonged lengths of stay; crowding; and infection control challenges, such as training gaps and shortages in PPE, all contribute.”2 It is estimated that in the next 30 years, deaths caused by AROs will surpass those caused by all cancers combined.3
The two AROs we’ll focus on are Candida auris (C. auris) and Clostridioides difficile (C. diff), both of which are considered urgent threats, according to the CDCs most recent Antibiotic Resistance Threats Report. What these two pathogens hold in common is their ability to cause severe infections, survive in the environment for prolonged periods, and spread easily between hospitalized patients and nursing home residents. In 2018, there were only 323 known clinical cases of C. auris.1 As of November 2020, the total has climbed to 1,595 which represents a nearly 400% increase in just two years.4 Moreover, to demonstrate how quickly the C. auris yeast can spread, in March 2017, a single case of C. auris was identified on a ventilator unit in Chicago. Sixteen months later, C. auris prevalence on the unit was 71%.5
Regarding C. diff, while we have made progress in reducing healthcare-onset rates in recent years, some studies show that these rates may have increased during the pandemic.6 But there are also studies that show a decrease.7,8,9 With the CMS reporting waivers during the pandemic, we may never know the true impact, at least not for a while. Regardless, C. diff remains the most common cause of healthcare-associated infections, more than half of which occur among recently hospitalized long-term care facility residents.1
Deviations from recommended infection control practices during the pandemic, fueled by fear of a novel pathogen, staffing challenges and supply chain challenges may have contributed to outbreaks of these two pathogens. For example, at one facility, a C. auris outbreak involving 35 patients was attributed to such deviations. In addition to missed hand hygiene opportunities, the CDC investigators found incorrect use of PPE and inconsistent disinfection of mobile computers and medical equipment between uses. . However, one of the control measures that helped in stopping this outbreak was enhanced cleaning and disinfection practices.10
Take Action to Prevent the Spread
The importance of infection prevention and control measures cannot be over-emphasized. The strategies to control these two pathogens are similar and include antibiotic stewardship, surveillance, diagnostic testing, transmission-based precautions, hand hygiene, inter-facility communication, and cleaning and disinfection of environmental surfaces and medical equipment. In this final section, we will focus on cleaning and disinfection.
Both of these contact-spread pathogenscan survive for prolonged periods on surfaces. C. auris can survive for weeks and C. diff can survive up to 5 months making cleaning and disinfecting an imperative practice.11,12 Below are some key points around cleaning and disinfection when C. diff or C. auris are present:
- Use products that are EPA-approved against the specific pathogens – C. auris and/or C. diff. For C. auris, do not use a product with C. albicans or fungicidal claims as they may not be effective.13
- If the product does not have a C. auris claim, use a disinfectant with a claim against C. diff spores or a 10% bleach solution. The EPA’s List K of Registered Antimicrobial Products Effective against C. diff Spores shows some products, but may not be complete or up-to-date. It’s best to check the EPA Master Label listing all microorganism claims.14
- Always follow the manufacturer’s directions for product use and application, including the correct contact time.13
- Create daily and terminal cleaning protocols and checklists for patient-care areas, including areas outside the patient room such as radiology and equipment.15
- Daily and terminal cleaning of the patient-care environment and of medical equipment between uses is recommended.13 Special attention should be paid to high-touch surfaces.
- Consider expanding the use of sporicidal agents effective against C. diff spores for daily and terminal cleaning in all rooms on affected units.15
- Consider use of electrostatic sprayer technology, which offers superior surface coverage.16
- Routine auditing of the adequacy of room cleaning is imperative – we can’t manage what we don’t measure.
These two urgent threat pathogens have many factors in common, which include an affinity for environmental surfaces, including medical equipment and for causing outbreaks. Robust cleaning and disinfecting programs are a key infection control measure.
- CDC. (2019). Antibiotic Resistance Threats in the United States. [online]. [cited 2021 Mar 13]. Available from https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf.
- Medscape Nurses. (2020). CDC Doc Addresses Today’s Pandemic and the Next. [online]. [cited 2021 Mar 13]. Available from https://www.medscape.com/viewarticle/941169.
- WHO. . New Report Calls for Urgent Action to Avert Microbial Resistance Crisis. [online]. [cited 2021 Mar 13]. Available from https://www.who.int/news/item/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis.
- CDC. (2021). Tracking Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
- Chicago Department of Public Health. (2018). 23rd Annual Infection Control Conference: Candida auris Emergence and Containment Efforts in the Chicago Region. [online].[cited 2021 Mar 14]. Available from https://www.chicagohan.org.
- Lewandowski K, Rosołowski M, Kaniewska M, Kucha P, Meler A, Wierzba W, et al. Clostridioides difficile Infection In Coronavirus Disease (COVID-19): An Underestimated Problem? Pol Arch Intern Med. 2021 Feb 26;131(2):121-127.
- Assi M, Doll M, Pryor R, Cooper K, Bearman G, Stevens MP. Impact of COVID-19 on Healthcare-Associated Infections: An Update and Perspective. Infect Control Hosp Epidemiol. 2021 Mar 12:1-9.
- Bentivegna E, Alessio G, Spuntarelli V, Luciani M, Santino I, Simmaco M, et al. Impact of COVID-19 Prevention Measures on Risk of healthcare-Associated Clostridioides difficile Infection. Am J Infect Control. 2020 Oct 5:S0196-6553(20)30891-9.
- Ponce-Alonso M, Sáez de la Fuente J, Rincón-Carlavilla A, Moreno-Nunez P, Martínez-García L, Escudero-Sánchez R, et al. Hospital-Onset Clostridioides difficile Infections During the COVID-19 Pandemic. J.Infect Control Hosp Epidemiol. 2020 Sep 8:1-5.
- CDC. (2021). MMWR Vol. 70: Candida auris Outbreak in a COVID-19 Specialty Care Unit – Florida, July-August 2020. [online].[cited 2021 Mar 15]. Available from https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e3.htm
- Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am. J. Med. 1981; 70:906–908.
- CDC. (2019). Candida auris: Healthcare Professional FAQ.[online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-health-qa.html
- CDC. (2020).Infection Prevention and Control for Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html#disinfection.
- EPA. (nd). Pesticide Product and Label System. [online]. [cited 2021 Mar 19]. Available from https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1.
- CDC. (2019). Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. [online]. [cited 2021 Mar 15]. Available from https://www.cdc.gov/hai/prevent/cdi-prevention-strategies.html.
- Donskey C, Cadnum J, Jenscon A, Livingston S, Li D, Redmond S, et al. (2020). Evaluation of an electrostatic sprayer disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. AJIC, (48):951-954.
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.
A Little About Me
I have been a nurse since 1993 and have worked as an Infection Preventionist (IP) for the past 20 years. Throughout my infection control career, I’ve faced challenges such as the potential weaponizing of smallpox after 9/11, the SARS outbreak in 2003, the H1N1 pandemic in 2009, and the Ebola outbreak in 2014 (just to name a few). I have seen a lot of tragedy and hardship, most of which I never would have dreamed of seeing in a million years.
In 2018, I made a big change in my infection control path. I was afforded an opportunity to join the Clorox Healthcare team as a Senior Infection Preventionist. After completing my first year in my new role, the COVID-19 pandemic was just beginning – a monumental pandemic that we will likely never see again in our lifetimes. In a matter of a few months, COVID-19 spread like wildfire to nearly every continent. We spent most of 2020 in lockdown, and infection prevention became more relevant than ever.
My COVID-19 Pandemic Story
In March of 2020, as part of the emergency response to COVID-19, California Governor Gavin Newsom released an executive order allowing the state of California to commandeer hotels and medical facilities to treat COVID-19 patients. This was termed “Project Roomkey” 2 and local counties were tasked with manning these shelters.1
In my local county, some of these hotels are being used as temporary isolation housing for unsheltered residents. The intent is to reduce transmission in the community from infected persons who are experiencing homelessness or live in congregate or over-crowded settings (e.g., prisons, etc.). Meanwhile, some of the hotels (named Safer Ground sites) are designated for medically fragile persons who meet the above criteria and have not been diagnosed with COVID.2
The other hotels (named Operation Comfort sites) serve as shelters to quarantine or isolate COVID-positive or COVID-exposed individuals who meet the criteria listed above. Project Roomkey takes referrals from hospitals, clinics, prisons, emergency shelters, and homeless outreach teams.
Last summer, I learned through a friend that our local county public health department was looking for nurses to replace the public health nurses at the shelters, who were desperately needed by the county to return to their usual public health roles. With a full-blown pandemic underfoot, I had been chomping at the bit to be able to put my IP skills to work and contribute in a substantive way. I was hired part-time to supervise nurses at the COVID-positive shelters. Since July 2020, I have been working every other weekend with medically fragile COVID-positive individuals in the hotels in an underserved area of East Oakland, California.
Challenges from the Front Lines
Since an “isolation/quarantine” hotel had never been created or utilized in modern times, we’ve had to continuously learn and adapt to new situations. This often means that our protocols, along with the CDC guidance for COVID-19, is also continuously evolving. Furthermore, as is often the case in public health nursing, we are with faced limited resources. This includes things as simple as having a consistent supply of environmental surface disinfectants. Just about every time I report for duty, we have a different disinfectant which means having to learn the instructions for use, including the contact time. Also, with the supply chain shortages, it means we have to remember to save our empty bottles and trigger sprays for refilling.
As if fighting COVID-19 were not enough, we’ve also had to address the complicated health and social issues our patients face on a daily basis outside of the pandemic, such as mental health and/or substance abuse disorders. My fellow nurses and I must simultaneously monitor our patients’ COVID symptoms as well as any withdrawal or suicidal ideation indicators. Some of our patients also have complex health issues (e.g., diabetes) so we work diligently to coordinate the appropriate care.
Additionally, patients at Project Roomkey come from all types of socioeconomic backgrounds. For low-income community members, having to quarantine for 14 days or stay isolated at a hotel could mean missing a paycheck or risking the next meal for their family. Meeting these patients’ social or other medical needs is not easy when your patient also has an infectious disease like COVID-19. I quickly realized that it’s not the same as working in the hospital outside the pandemic where virtually every resource you need to do your job is on-hand.
In addition to our patients, our nursing staff also come from a variety of backgrounds, which range from new graduates to veteran caregivers. Clinical backgrounds include hospital (ICU, OR, and Medical-Surgical), long-term care, home care, infection prevention and control, behavioral health, public health, and even nurses from academia. What I appreciated this past year was that no one used their specialty to appear superior to anyone else. We simply leaned on each other’s strengths and got the work done.
Finding Inspiration Among the Hardship
Since this work takes place in addition to my regular “day job” with Clorox Healthcare, I’ve had to find inspiration to keep showing up every other weekend. Fortunately, this did not prove to be too difficult as I’ve found great inspiration in both my patients and my coworkers. The most vulnerable in our community needed us during this historic event and as a nurse, I felt that it was my duty to help.
Like me, many of my fellow hotel coworkers took on this work in addition to their “day jobs.” Their dedication motivates me to keep showing up week after week. These amazing individuals not only give their time and skills, but they often donate items to these families in need - things like winter clothing, children’s toys, and games to keep them occupied during quarantine. In addition to nurses, the healthcare team includes nurse practitioners, physicians, mental health providers, substance abuse providers, and pharmacists. Meanwhile, we couldn’t do any of this without the relentless work of the facilities team, housing support staff, housekeepers, cooks and security guards in the hotels. The team collaboration and the comradery of this group has been truly something amazing to be a part of.
Finally, I would be remiss if I didn’t recognize the inspiration provided by all of my fellow IPs out there wherever they have been working during this pandemic. Your dedication to our profession is nothing short of remarkable.
Relief is in Sight
When both the Moderna and Pfizer vaccines were granted Emergency Use Authorization (EUA) from the Federal Drug Administration in December 2020, I was beyond elated to help run the staff vaccination clinic.3 Along with a few of my coworkers, we administered nearly 140 first doses to our fellow shelter workers, which included nurses, medical assistants, housing support staff, housekeepers, cooks, and security guards. I was more than happy to do it all over again four weeks later, too. Being able to offer hope through a vaccine has brought me such joy that I have volunteered to administer vaccinations to the general public as well.
As public health officials, healthcare workers, and members of our community continue to come together to help fight the spread of COVID-19, I’m grateful for the resilience I’ve witnessed first-hand over the past year. This virus is not done with us yet and we are not done fighting, but I have hope for the future. Before the pandemic struck, 2020 had been designated the International Year of the Nurse in honor of the 200th anniversary of Florence Nightingale’s birthday.4 While this may have been lost in the chaos of the pandemic, we nurses will never forget the additional meaning behind this past year.
- Alameda County Public Health Care for the Homeless. Isolation Housing for COVID-19 [nternet]. [cited 2021 Mar 7]. Available from: https://www.achch.org/isolation-housing.html
- Office of the Governor Gavin Newsom. Governor Newsom Issues New Executive Order Further Enhancing State and local Government’s Ability to Respond to COVID-19 Pandemic [internet]. [cited 2021 Mar 7]. Available from: https://www.gov.ca.gov/2020/03/12/governor-newsom-issues-new-executive-order-further-enhancing-state-and-local-governments-ability-to-respond-to-covid-19-pandemic/
- Federal U.S. Food & Drug Administration. COVID-19 Vaccines [internet]. [cited 2021 Mar 7]. Available from: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines
- World Health Organization. Executive Board Designates 2020 as the “Year of the Nurse and midwide.” [internet]. [cited 2021 Mar 7]. Available from: https://www.who.int/news/item/30-01-2019-executive-board-designates-2020-as-the-year-of-the-nurse-and-midwife-