Introduction

We were all hopeful this summer was going to bring the end of the COVID-19 pandemic and we could get back to life as we once knew it. We may be done with this virus, but it certainly is not done with us as variants continue to stoke the flames. Although we are still in the thick of this pandemic, the optimist in me likes to think that we should start to think about the future, beyond COVID-19. This pandemic changed everything including the way we clean and disinfect our facilities. In this post, I will highlight practices that can be discontinued and those that should be hard-wired.

Extreme Cleaning and Disinfection

Early in the pandemic, before much was known about the SARS-CoV-2 virus and how it was transmitted, extreme cleaning was a common occurrence – both inside and outside of healthcare facilities. Some have referred to this as “Hygiene Theatre,” which is the act of increasing hygiene protocols that may make patients, visitors and workers feel safe, but has no real correlation to lowering the risk of infection. An unprecedented awareness and focus on infection prevention including hand hygiene and cleaning and disinfecting catalyzed across healthcare. Healthcare workers banded together in their shared responsibility for infection control practices to protect patients and each other.

Over time, as more was learned about the virus, the CDC de-emphasized the importance of cleaning and disinfection, citing low risk of transmission from environmental surfaces. This is generally true, however, the risk does increase when a COVID-19 positive patient is present and is shedding the virus into their immediate environment. Hopefully, by now, we have all stopped extreme cleaning. However, continued diligence to cleaning and disinfection is still necessary as it plays an imperative role as part of a holistic strategy to protect patients, visitors, and staff from other pathogens that are easily transmitted via surfaces.

While we are still in the midst of a global pandemic, enhanced cleaning and disinfection protocols that align with Centers for Disease Control and Prevention guidance and the Occupational Safety and Health Administration Emergency Temporary Standard (OSHA ETS) requirements. I like to think of enhanced cleaning and disinfection as somewhere between our routine processes and extreme cleaning and disinfection — it’s the “happy middle.” Frequent disinfection of high-touch surfaces should be included in these enhanced measures.

It is important to apply the lessons learned during this pandemic. This is an opportune time for Infection Preventionists (IPs) to collaborate with Environmental Services (EVS) to assess whether the cleaning procedures they’ve adopted at the onset of the pandemic still serve the facility’s needs and meet regulatory requirements.

COVID-19: Not the Only Pathogen of Concern

Over the past year and a half, with our focus on a single pathogen — SARS-CoV-2, other pathogens have gone under the radar. One that is highly concerning is drug-resistant Candida auris (C. auris). Several facility outbreaks have been reported in the U.S. and case counts have nearly doubled during the pandemic.1,2 This pathogen can survive for prolonged periods on environmental surfaces, including portable equipment. Its primary route of transmission is contact with contaminated environmental surfaces, including medical equipment, fomites, and from person-to-person such as from unclean hands. One recommended strategy to reduce the risk of transmission of a broader range of pathogens, like C. auris, is a horizontal and standardized approach to cleaning and disinfection.3 Even a pathogen like Clostridioides difficile can be managed under a horizontal approach as many of today’s sporicidal disinfectants have great surface compatibility for everyday use.

Everyone Plays a Role in Cleaning and Disinfection

This pandemic highlighted the importance of a sanitary healthcare environment to keep patients, visitors, and staff safe. While we don’t want to slow down their cleaning and disinfecting efforts, it is time to give some tasks back to the cleaning professionals. For example, early in the pandemic when supplies were limited, nurses took on occupied daily room cleaning to conserve personal protective equipment (PPE). Now that PPE supplies have normalized, EVS should perform this task. This begs the question, what should nurses continue to do?

At least once per shift in their assigned patient rooms, nurses should clean and disinfect high-touch surfaces, including medical equipment — particularly the high-touch surfaces like control panels. We don’t hesitate to clean our hands frequently, but it’s important to note that our hands are only as clean as the environment around us, so it is important to routinely clean and disinfection surfaces as well.

Nurses aren’t the only healthcare workers, so you are probably wondering, what should other staff members do? Much like the nursing staff, they too should ensure that their work spaces are clean. Remember, EVS is only required to clean any given area once per day, and we must question if this is enough given the high traffic in hospitals. All staff should clean and disinfect work spaces at least once per shift as well as clean and disinfect any patient care equipment after each use. With many EVS department’s short staffed, it’s important that office workers do their part by cleaning and disinfecting their desk areas and high-touch items such telephones and printer control panels.

Conclusion

A sanitary environment is key to infection prevention and control efforts, regardless of pathogen. Hopefully, the next normal for cleaning and disinfection in healthcare will mean more collaboration among disciplines as well as more appreciation for IPs and EVS professionals.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

1. Pan-American Health Organization. (2021). Epidemiological Alert: Candida auris outbreaks in health care services in the context of the COVID-19 pandemic – 6 February 2021. [Internet]. [Cited 2021 Sep 13]. Available from https://www.paho.org/en/documents/epidemiological-alert-candida-auris-outbreaks-health-care-services-context-covid-19
2. CDC. (2021). Tracking Candida auris. [Internet]. [Cited 2021 Sep 13]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
3. Wenzel R, Edmond M. Infection Control: The Case for Horizontal Rather than Vertical Interventional Programs. International Journal of Infectious Diseases. 2010; S3-5.

Hospitals at the Breaking Point

As the Delta variant of SARS-CoV-2 continues to sweep the country, we are seeing peak numbers of cases since the beginning of the pandemic. Hospitals are feeling the weight of this spike as the infected make their way into acute care settings, filling beds. Facilities around the country are experiencing such a demand for healthcare services that it has overwhelmed their ability to provide. Entire healthcare systems and even states have been forced to activate Crisis Standards of Care, which ultimately results in the difficult task of determining who receives care and who does not. The current situation in northern Idaho is a prime example of this as hospitals are at max capacity resulting in patients seeking care across the border in Washington and overwhelming their system.1

The healthcare situation, already bleak, could soon get worse. The unfortunate reality is that SARS-CoV-2 isn’t the only respiratory pathogen currently circulating in our communities. As respiratory illness season knocks at the door, illnesses such as influenza, respiratory syncytial virus (RSV), rhinovirus, and others will add stress on an already strained healthcare infrastructure. We have already seen a glimpse of unusually high numbers of illnesses with the uptick in RSV cases beginning in April 2021 accompanying the relaxation of COVID-19 precautions.2 Health experts fear the reality of a “twindemic” this year with the prediction of a severe flu season and the potential of increased coinfections.3 This all points to the fact that it is likely only going to get worse before it gets better.

Keeping Prepared this Respiratory Illness Season

The past year of the pandemic has taught us how difficult it is for patients to receive the care they need when healthcare facilities face countless challenges including staffing shortages, burnout, and limited resources. As facilities and staff carry on through the difficult circumstances brought about by the pandemic, there is a need to step beyond the singular focus on COVID-19 and proceed with an approach to deal with the countless threats on the horizon. Currently, perceptions on the modes of respiratory virus transmission are shifting, and with that new information there must be a willingness to adapt and prepare with the necessary tools to fight back. More than ever, it is imperative that healthcare workers act as stewards of infection prevention to protect the vulnerable and help stop the spread of respiratory illnesses in healthcare.

In preparation for what could be a long winter ahead, consider adopting the following practices in your facility:

While navigating these trying times, we applaud healthcare workers for all their efforts and hope that these suggestions can help ease the burden and lessen the impact felt by the healthcare industry. First and foremost, we want healthcare workers to take care of their own physical and mental well-being so they can continue to care for others. Over the next several months through the respiratory illness season, comfort and safety will come as deliberate efforts are made to help reduce the spread of pathogens and protect the health of patients, staff and loved ones.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

1. Baker M. ‘Their Crisis’ is ‘Our Problem’: Washington Grapples with Idaho Covid Cases. The New York Times. 2021 Sep 13 [cited 2021 Sep 24]; Available from: https://www.nytimes.com/2021/09/13/us/coronavirus-hospitals-washington-idaho.html
2. RSV National Trends. Centers for Disease Control and Prevention. 2021 [cited 2021 Sep 24]. Available from: https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html
3. Upcoming Flu Season Will Likely Be Severe. University of Pittsburgh Health Sciences. [cited 2021 Sep 24]. Available from: https://www.upmc.com/media/news/083121-roberts-flucovid-medrxiv

Children Are at Higher Risk of Respiratory Illness This Year

The high rate of COVID-19 circulation in the U.S. as we head into winter leads to concerns, again, about a possible “twindemic” of flu and COVID-19. Unlike last year though, if the “twindemic” arrives, it may hit children the hardest. Adults have been eligible for vaccination for months, and many are still working from home and limiting social interactions. But millions of kids have returned to school for in-person learning, and children under 12 years old are not yet eligible for COVID-19 vaccination. And already, dozens of schools have had to shut down due to outbreaks of COVID-19. The majority of states do not have mask mandates for schools, and several states have banned mask mandates, leaving schools with higher risks and fewer options to keep kids safe.

Current U.S. School Closures Caused by Outbreaks of COVID-19 (September 2021)

Outbreaks of COVID-19 in schools will continue until the pandemic can be brought under control through greater population immunity. The Delta variant is currently responsible for more than 99% of infections of SARS-CoV-2,1 the virus that causes COVID-19. The American Academy of Pediatrics publishes a weekly report tracking SARS-CoV-2 infections in children. Currently, the level of community transmission of SARS-CoV-2 in the U.S. is high,1 with 300 cases per day per 100,000 residents. In the first week of September alone, almost 250,000 infections were reported in children.2

The bottom line: Unlike last year, children increasingly are getting sick from COVID-19. Right now, children represent our most vulnerable segment of the population because of limited vaccine coverage and greater social interactions as a result of being back in school. In addition, unique challenges brought on by the pandemic, such as missed vaccinations and fewer pathogen exposures due to social distancing measures, may put them at higher risk for other respiratory illnesses as well.

Children are more likely than adults to be infected with multiple respiratory viruses at once

Prior to the pandemic, researchers at the Cleveland Clinic conducted a study to see how frequently people are infected with more than one respiratory virus at the same time. Among a sample of over 1,000 respiratory infections, almost 1 in 5 children were infected with more than one virus at the same time.3 Children were infected with multiple viruses 6 times more frequently than adults were. The reason for this is simple: young children do not have the immune experience that adults do; their immune systems have not encountered as many viruses as adults have. This increases the chances that kids will get infected with multiple viruses at the same time.

This summer, we observed off-season outbreaks of a common and sometimes serious respiratory disease, respiratory syncytial virus (RSV). The high levels of community transmission of SARS-CoV-2, the coming cold and flu season, in addition to other respiratory pathogens like pertussis (the bacterium that causes whooping cough), will increase the likelihood of co-infections in children this year. Even last year, with schools and businesses closed and influenza circulation brought to historically low levels, as many as 3.2% of, or 1 in 30, children infected with SARS-CoV-2 were infected with influenza at the same time.4

We are entering another uncertain flu season

“Reduced population immunity due to lack of flu virus activity since March 2020 could result in an early and possibly severe flu season” — Centers for Disease Control and Prevention (CDC).

In the U.S. currently, influenza cases are higher this year than at the same time last year. As we have started our reopening process, respiratory viruses like RSV have returned as well. Delayed vaccinations during the pandemic, combined with children going back to school, have placed children in an unusually risky position. While it is true that children are generally more protected from severe outcomes from COVID-19, influenza and other co-illnesses may put them at greater risk of hospitalization and death.

We must use every tool we have to protect children this year

Since flu viruses can live and spread to people from surfaces for up to 48 hours, and SARS-CoV-2 can live on surfaces from hours to days,5 CDC recommends routing cleaning and disinfecting of frequently touched surfaces such as desks, toys, door knobs, and faucets and counters in restrooms.6 We recommend using disinfecting wipes on high-touch and frequently used surfaces throughout the day, and more thorough disinfecting at night using electrostatics.

This year, it’s not just about COVID-19. The conditions of the pandemic have put children at an increased risk of illness from bacterial and viral pathogens. Vaccination, hand hygiene, wearing masks, staying home when ill, and routine cleaning and disinfection are all going to be needed together to keep kids in school, healthy, and safe.

Download the K–12 Environmental Cleaning and Disinfection Protocol Guide

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

REFERENCES

1. CDC Covid Data tracker. Centers for Disease Control and Prevention. Retrieved September 20, 2021, from https://covid.cdc.gov/covid-data-tracker/#variant-proportions.
2. Children and covid-19: State-level data report. American Academy of Pediatrics. Retrieved September 20, 2021, from https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/.
3. Mandelia, Y., Procop, G. W., Richter, S. S., et al. (2021). Dynamics and predisposition of respiratory viral co-infections in children and adults. Clinical Microbiology and Infection, 27(4).
4. Dao, T. L., Hoang, V. T., Colson, P., et al. (2021). Co-infection of SARS-COV-2 and influenza viruses: A systematic review and meta-analysis. Journal of Clinical Virology Plus, 1(3), 100036.
5. Wißmann, J. E., Kirchhoff, L., Brüggemann, Y., et al. (2021). Persistence of pathogens on inanimate surfaces: A narrative review. Microorganisms, 9(2), 343.
6. How to clean and disinfect schools to help slow the spread of flu. Centers for Disease Control and Prevention. Retrieved September 20, 2021, from

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:

This guidance can help facility managers assess the risks of transmission from surfaces and develop appropriate cleaning and disinfecting plans and protocols.  

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.


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.

Back to school will be a lot different this year

For some, the difference may be subtle: bottles of hand sanitizer and disinfecting wipes on the supplies list, making sure children have their lunch and a face mask before heading to the bus. For others, there may be intense anxiety about sending their kids back to school before they have been vaccinated for COVID-19. The concern about our children getting sick at school has never been higher – but the threat of illness-causing germs at school is in fact, old news.

Before COVID-19, back to school meant increased risk of exposure to illness-causing germs in school-aged children

When I was a child, back to school meant I was going to get sick — a lot. I caught strep throat, a common illness caused by the bacteria Streptococcus pyogenes, 7 or 8 times each year. I felt like I spent more time home sick from school than I did at school. To prevent this, my parents eventually had my tonsils removed, which I then proudly brought to school for show-and-tell. Turns out, I was not alone — there are an estimated several million cases of strep throat each year1. Streptococcus pyogenes can be spread by children who have no symptoms and can be acquired by touching contaminated droplets on surfaces. I often wonder — if my school had disinfected surfaces more frequently, could I have been at school more, and at home in pain less?

In addition to strep throat, there are many other illnesses that children contract during the school year. Each year, colds result in an average of 189 million missed school days2. Respiratory syncytial virus, or RSV, has made headlines recently for outbreaks in the southern U.S. this summer. RSV can be serious, and results in 58,000 hospitalizations of children under 5 each year3.   

Some pathogens can outlive the entire school year on surfaces

E. coli, a bacterium found in feces that causes gastrointestinal illnesses, can survive on surfaces for up to 300 days4. If a sick child brings it to school on the first day, E. coli can survive the entire school year on surfaces. One study found that up to 59% of desks in a school were contaminated with fecal matter5. Norovirus, another pathogen that causes gastrointestinal illness, is a common source of outbreaks in schools that may result in closures and can require costly cleaning measures.

Normally, hand hygiene would be an effective measure for preventing illnesses from pathogens picked up from surfaces. But kids being kids, have a hard time following and practicing hand hygiene, and they touch more surfaces than the average adult. In fact, 4 out of 5 children don’t wash their hands with soap after using the bathroom, and children touch and retouch up to 300 surfaces in 30 minutes6,7. As a result, teachers are exposed to 7 times more bacteria per square inch of surface than doctors5. That’s a lot of opportunities for pathogens to spread, that can cause illnesses and missed school days for students and teachers.  

Proper cleaning and disinfecting can help bring kids back to school safely — during the pandemic and beyond

Keeping kids healthy and in school ensures that they will all have the best opportunities to learn. Every child deserves to be healthy and safe in their school. We can help achieve this with a Smart Disinfection program. Smart Disinfection means focusing on high touch surfaces — desks, door handles, toys, light switches, and restrooms, prioritizing disinfection of higher risk areas and disinfecting correctly. By implementing Smart Disinfection, we can prevent our children from picking up germs that can make them sick, so that they can stay healthy, stay in school, and live well.

Learn more about Smart Disinfection

Learn more about Smart Disinfection and how to implement Smart Disinfecting practices in your school by following the links to our resources below:

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

REFERENCES

1. Centers for Disease Control and Prevention. Surveillance for Group A Strep Disease. https://www.cdc.gov/groupastrep/surveillance.html (accessed July 19, 2021)
2. Fendrick MF et al. The Economic Burden of Non–Influenza Related Viral Respiratory Tract Infection in the United States. Arch Intern Med. 2003;163(4):487-494
3. Rha B, Curns AT, Lively JY, et al. Respiratory Syncytial Virus–Associated Hospitalizations Among Young Children: 2015–2016. Pediatrics. 2020;146(1): e20193611
4. Wißmann, J. E., et al. (2021). Persistence of pathogens on inanimate surfaces: A narrative review. Microorganisms, 9(2), 343.
5. Gerba, C. P. The Burden of Norovirus in Schools; Cengage Learning, 2016
6. Guinan, M. E.; McGuckin-Guinan, M.; Sevareid, A.; Philadelphia, M.; The Agnes Irwin School, F. Who Washes Hands after Using the Bathroom?
7. Alliance for Consumer Education. Cleaning Definitions - Disease Prevention | Alliance for Consumer Education https://www.consumered.org/programs/health-wellbeing/cleaning-definitions (accessed Feb 14, 2019)

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?

Wearing Masks

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. 

Staying power?

We may move away from behaviors and protocols around masking, but there are fundamental infection prevention behaviors that should stay.

Disinfecting Surfaces

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.

Staying power?

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 Power?

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.

Staying power?

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.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

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

If there were a theme song for the past few months, I think we would all agree it would be something closely resembling Hear Comes the Sun, the classic by the Beatles. The smiles are returning, and it certainly feels like years since the long, cold lonely COVID-19 winter began! However, as a public health professional, I wish we were all singing the 80’s classic Don’t Stop Believin’ by Journey because this epidemiologist wants you holding on to the feeling of hygiene. I want us, though we are excited to re-open, to remember what we have learned and continue to embrace the public health awareness brought on by the pandemic.

But I cannot say everyone agrees. In the past few weeks, the number of articles written to combat “Hygiene Theater” disinfection antics is increasing at an alarming pace.1,2 The pendulum of public opinion is swinging and we are ready to move into the future by returning to the pre-2020 “normal” instead of a “new normal” as I had hoped. As I sit here contemplating how to articulate why I feel strongly we should not return to old behavior, I need to pause to reach for a tissue. I have a cold. This is a strange and rare phenomenon lately, but I have concerns it will soon be a wide-spread experience as more of us begin to re-emerge from our homes and our careful precautions give way to old habits. Instead, my hope is that as we enter a post-pandemic world, we bring forth the lessons we have learned over the past year to create a healthier future for all.

Here’s what we know: COVID-19 can be transmitted on surfaces, but it is unlikely to be the main source of transmission.

We all remember the early days of the pandemic when we would wipe down our groceries, packages, and lived in constant fear of catching the virus. We did this because we did not yet know enough about this emerging pathogen and we wanted to protect our loved ones. We now know much of this was unnecessary as the principal mode of transmission of SARS-CoV-2 is through exposure to respiratory droplets in the air and not through surfaces (or fomites).3 Though some might call this theater, I think it was simply our attempt to mitigate the risk of a very scary pathogen from entering our homes. Similarly, out of this fear and with a hope to restart our economy during a pandemic, our communities and businesses went into disinfection and sanitization overdrive (i.e., Hygiene Theater).

If a business is purely using disinfectants for show and more importantly, not using them safely and in accordance with label instructions, then I believe we will all lose sight of the lessons we have learned over the past year.

In this way, I agree with many voicing their concerns publicly. However, we cannot just throw away the public health awareness we have gained over the past year and we cannot make the mistake of thinking COVID-19 is the only pathogen posing a threat to our future health, safety and economy. My optimism on this subject in my November Hygiene Theater Blog still holds true today. We have an opportunity to turn this heightened awareness of germ transmission into actionable infection prevention in our communities.

Over the past year, we have also seemingly forgotten about all the other microbes and pathogens that live and thrive on our surfaces. 

Illnesses such as the Flu have virtually been wiped out by our COVID-19 precautions but as evidenced by my current nasal congestion, they have not gone away and will return to our spaces with us. Norovirus, for example, is a virus that causes vomiting and diarrhea and thrives on surfaces in areas where large numbers of people congregate. Norovirus outbreaks are common and frequently found on cruise ships, in long term care facilities, and in school and childcare settings. You may hear norovirus illness referred to as “food poisoning,” “stomach flu,” or “stomach bug” and because of the large number of variants, we can be infected repeatedly.Close quarters, shared spaces, and high-touch surfaces make it easy for norovirus to spread.

Although the number of norovirus outbreaks have been drastically reduced during the pandemic, norovirus, on average, each year results in over 19 to 21 million cases of vomiting and diarrhea in the United States. It is estimated by the age of five, 1 in 110,000 children will die and 1 in 160 will be hospitalized due to norovirus.4 In 2016, researchers estimated that norovirus resulted in a total of $4.2 billion in direct health system costs and $60.3 billion in societal costs (including productivity loss and income) per year.5

People are ready to return to normal life and we have an opportunity to impact what that looks like.

We must, now more than ever, implement sanitation protocols and base them on risk assessments and scientific evidence. One of the best examples of this is hand hygiene. The simple act of washing our hands more frequently is our first line of defense yet hand hygiene compliance rates are low and we often contaminate surfaces without even realizing it. In fact, nearly 80% of infectious diseases are spread by our hands and the surfaces we touch.6 This is why surface disinfection is such a critical tool in our efforts to break the chain of infection. Our approach to the use of disinfectants and sanitizers needs to be in a way that is not only effective but also efficient. This involves prioritizing places where the risk of pathogen spread is greater, like high traffic, shared spaces, and frequently touched surfaces. By utilizing SMART Disinfection practices (think “work smarter, not harder”), we can target disinfecting higher risk areas to reduce pathogen transmission while also optimizing the use of disinfectants and hopefully preventing concerns of overuse in our communities.

The curtain might be closing on COVID-19 theater, but that doesn't mean our work is done.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

1.       Thompson D. Deep Cleaning Isn’t a Victimless Crime The CDC has finally said what scientists have been screaming for months: The coronavirus is overwhelmingly spread through the air, not via surfaces. [Internet]. The Atlantic. 2021. Available from: https://www.theatlantic.com/ideas/archive/2021/04/end-hygiene-theater/618576/

2.          Anthes E. Has the Era of Overzealous Cleaning Finally Come to an End? [Internet]. The New York Times. [cited 2021 Apr 23]. Available from: https://www.nytimes.com/2021/04/08/health/coronavirus-hygiene-cleaning-surfaces.html

3.          CDC. Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for Indoor Community Environments - Updated Apr. 5, 2021 [Internet]. Centers for Disease Crontrol and Prevention. 2021. p. 5. Available from: https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html

4.          CDC. Norovirus Burden of Norovirus Illness in the U.S. CDC [Internet]. Centers for Disease Crontrol and Prevention. 2020 [cited 2021 Apr 23]. Available from: https://www.cdc.gov/norovirus/trends-outbreaks/burden-US.html

5.          Bartsch SM, Lopman BA, Ozawa S, Hall AJ, Lee BY. Global economic burden of norovirus gastroenteritis. PLoS One [Internet]. 2016; Available from: https://pubmed.ncbi.nlm.nih.gov/27115736/

6.          Healthcare T-C. Gross! Hand hygiene and other germy facts [Internet]. 2018 [cited 2021 Apr 29]. Available from: https://www.tchc.org/blog/2018/12/12/hand-hygiene-and-germ-facts/

Introduction

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:

Conclusion

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.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

  1. 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.
  2. 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.
  3. WHO. [2019]. 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.
  4. CDC. (2021). Tracking Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  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.
  10. 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
  11. 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.
  12. 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  
  13. 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.
  14. EPA. (nd). Pesticide Product and Label System. [online]. [cited 2021 Mar 19]. Available from https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1.
  15. 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.
  16. 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.

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.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

References

  1. 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
  2. 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/
  3. 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
  4.  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-

The COVID-19 pandemic has revealed a number of insights, including the many ways in which schools are important for the health of our children. With the closing of schools to address the spread of COVID-19 infection, a growing body of evidence and expert consensus agree that in-person schooling is critical to the health and development of children. On February 12, 2021, the CDC released updated guidance pushing for reopening schools during COVID-191-2.

What is the basis for the new recommendation that schools can reopen safely?

Many studies have been published recently showing that young children (particularly those in elementary school) are not strong drivers of community transmission of COVID-19. These data suggest that it is possible to reopen schools safely, as long certain mitigation measures are in place to protect teachers, students and school staff. Such measures include physical distancing, wearing masks, improving ventilation, and a focus on effective cleaning and disinfection practices. A recent article in the Journal of the American Medical Association (JAMA) summarized the literature on COVID-19 infection rates in schools3. The authors found that in several schools in the US, school attendance was not associated with increased risk of infection in the school or in the community. Furthermore, in schools with high mask adherence, COVID-19 incidence was lower than in the surrounding community.

What is the new guidance from the CDC?

The new guidance says that schools can reopen safely and provides different strategies to prevent COVID-19 outbreaks based on several factors, including the level of community transmission, the use of COVID-19 testing and screening, and the grade level of the students. For example, elementary schools can be open for some in-person schooling even in communities where COVID-19 transmission is high. By contrast, a high school in a community with moderate COVID-19 transmission may have less in-person schooling.

Overall, the major recommendations for operating schools safely include:

With the above mitigation measures in place, CDC does not recommend that vaccination of teachers, staff, and students be a requirement for reopening. However, CDC does recommend that teachers and staff be given priority for vaccination.

CDC recommends daily cleaning and disinfecting of schools and more frequent disinfecting of high-touch surfaces

As part of a layered mitigation strategy, the CDC has recommended daily cleaning and disinfecting of schools with more frequent disinfecting of high-touch surfaces (such as doorknobs, desk surfaces, sinks and faucets, shared materials, and playground equipment). End-of-day cleaning and disinfecting may still be managed by janitorial or custodial staff members; however, teachers and other school staff will likely need to clean and disinfect high-touch surfaces during the school day. Teachers and other staff should be provided with training, materials, and appropriate personal protective equipment to clean and disinfect safely. General guidance for safe cleaning and disinfecting include:

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.

REFERENCES

1. Centers for Disease Control and Prevention. (2021). Operational strategy for k-12 schools through phased mitigation. Retrieved February 12, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/operation-strategy.html
2. Centers for Disease Control and Prevention. (2021). Operating schools during covid-19: CDC'S CONSIDERATIONS. Retrieved February 12, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html
3. Honein, M. A., Barrios, L. C., & Brooks, J. T. (2021). Data and policy to guide opening schools safely to limit the spread of sars-cov-2 infection. JAMA. doi:10.1001/jama.2021.0374

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