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.  


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:

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.

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.

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.

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.

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-

In the last few months, it’s emerged that a number of variants of SARS-CoV-2, the virus that causes COVID-19, are circulating globally. Variants arise through a process called mutation where the virus undergoes changes to its genetic structure. The new variants can have characteristics that are different from the original virus. You may see the terms “variant” and “strain” used interchangeably, and in this context, they mean the same thing. 

Currently there are three variants of note: one that emerged in the UK in September 2020 and has now been detected in the US, one from South Africa that was first reported in October 2020, and one from Nigeria that emerged at the end of 2020. The UK and South Africa variants appear to spread more rapidly than the original SARS-CoV-2 virus, but do not appear to cause more severe disease and can still be detected by currently available viral tests. 

In January 2021, the United States Environmental Protection Agency (EPA) issued a statement saying that it expects disinfectants on List N Disinfectants for Coronavirus (COVID-19) to kill all strains of SARS-CoV-2. This is to be expected based on the structure of viruses. Let’s take a look and see why.

Virus classification

Viruses can be split into three classes. Enveloped viruses, large non-enveloped viruses, and small non-enveloped viruses. An enveloped virus is surrounded by a fatty layer which breaks apart very easily making the virus very easy to kill with disinfectants. Non-enveloped viruses have a tough outer coating making them much harder to kill with disinfectants. 

SARS-CoV-2 is an enveloped virus but also contains protein “spikes” that stick through the fatty outer layer, creating a “crown”-like structure — one that you’re no doubt familiar with.

The key point is this: the variant resulting from a mutation in an enveloped virus is still an enveloped virus with the easy to penetrate fatty layer, and therefore equally susceptible to disinfectants as the original. The mutation may slightly change the make-up or characteristics of individual parts, such as the protein spikes, but it does not change the physical structure of the virus. This scientific rationale is the basis for the EPA’s determination that viruses on List N are expected to kill all strains, or variants, of SARS-CoV-2. 

Disinfectant antiviral efficacy in practice

In practice, we can see the fact that different strains or variants of viruses are equally easy to kill when we look at kill claims (or contact times) for influenza A viruses on product labels. There are many variants of this virus including H5N1, H1N1, H3N2. However, when the microorganism claims on a product label include more than one variant of this virus, the kill time (or contact time) is always the same for all variants. The EPA recognized this in 2009 when there was an outbreak of a new strain of influenza A, H1N1. At that time, the EPA ruled that any disinfectant that killed a known strain of influenza A would also be effective against the new strain. 

Many disinfectants can kill SARS-CoV-2 with contact times ranging from 15 seconds to 2 minutes. As EPA suggests, we can expect that List N disinfectants will be effective against all variants of SARS-CoV-2 including the current ones from the UK, South Africa and Nigeria.

What do smallpox, polio, and measles1 all have in common? They have all been successfully eliminated in the U.S. via wide-spread vaccination. After ten long months, the COVID-19 vaccine roll-out is finally happening and we are well on our way to successfully combating another infectious disease.

What will determine if the new vaccines are successful?

Simply put, people need to get vaccinated for a vaccine to be effective. Yes, the vaccine itself must be safe and have high efficacy (i.e., create an adequate immune response in those vaccinated), but ultimately what determines if a vaccine is truly successful at eliminating a disease in a population comes down to herd immunity.

What is herd immunity?

Herd immunity is the act of protection that is provided when enough of a population gains immunity to an illness that it halts transmission. Every infectious disease has a reproduction number or R0 (pronounced “R naught”). This calculation is the average number of people an infected individual will infect in an at-risk (non-immune) population. Inevitably, for any given disease, the R0 calculations can vary widely, but are generally based on three primary characteristics:

  1. How long an individual is contagious while infected
  2. The likelihood of infection per contact between an infectious person and a susceptible person
  3. How often people are encountering one another (contact rate)

With COVID-19, R0 estimates change based on location and population, but some studies calculate it being as high as 5.7 (95% CI 3.8–8.9) .2 So, if I am infected with COVID-19 and interacting with a completely vulnerable group of individuals, on average, I could expect to infect five other people. To reach herd immunity, you essentially need to pass an immunity threshold that makes it so that an infected person has no one to transmit the infectious disease to because no one around them is susceptible (R0 < 1).3

Herd Immunity Blog Post

Why do we need to get vaccinated?

Herd immunity has been a hot topic throughout the pandemic as there are only two ways to truly achieve it: 1) natural immunity via infection and 2) immunity via vaccination. Unfortunately, when it comes to most infectious diseases, natural immunity through active infection might not be enough to offer full protection and any immunity provided could dissipate over time leaving some individuals vulnerable to reinfection. Additionally, waiting for a population to become infected, and therefore immune, can take a very long time and may result in unnecessary deaths and long-term health implications.

One great example of this is chickenpox. Not long ago, parents would purposely expose their children to infectious individuals to ensure immunity was developed at a young age. I can remember vividly being forced on a play date while covered in spots. Unfortunately, to achieve this natural herd immunity, each year, over 10,000 were hospitalized and an estimated 100-150 died. After the vaccine became widely available in the U.S. in 1995, more than 3.5 million cases of chickenpox are now prevented each year.4

How many people need to get vaccinated to achieve herd immunity?

The estimated number of people that need to get vaccinated to achieve herd immunity depends on several factors:

  1. The infectious disease and how contagious it is.
  2. The proportion of people that are susceptible in a population.
  3. The overall effectiveness of the vaccine.

Experts do not yet know what that threshold is for COVID-19. This is because we do not know how many of us already have immunity. Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, estimates that around 75% of the public needs to get vaccinated for herd immunity to provide protection and truly stop the spread of COVID-19.5

How do we learn more about the COVID-19 vaccines and the plan to reach herd immunity?

Concerns over the speed with which these vaccines were developed are warranted. We should all do our due diligence with any new public health intervention. Thankfully, the information on safety is widely available. Here are three comprehensive resources to help address any concerns you, your family, or your staff may have:

What can we do now?

The Centers for Disease Control and Prevention (CDC), in consultation with the U.S. Advisory Committee on Immunization Practices (ACIP), is prioritizing vaccine distribution in a fair and ethical way and continuing to provide transparent updates on the vaccine roll-out plan. While we wait for our turn to be vaccinated, we need to remind our family, friends, and staff to continue to do all the things that we have been doing – wear masks, maintain social distance, avoid indoor and poorly ventilated spaces, wash our hands, and clean and disinfect regularly. We do these things to protect ourselves, but more importantly, to protect others. That is also true of vaccines. We get them to create herd immunity and protect those in our society that are most vulnerable. I, for one, am looking forward to adding another eliminated disease to the above vaccine success list – smallpox, polio, measles, and COVID-19!

References

  1. Measles Elimination [Internet]. Centers for Disease Control and Prevention (CDC). 2020. [cited 2020 Dec 8] Available from: https://www.cdc.gov/measles/elimination.html
  2. Sanche S, Lin YT, Xu C, Romero-Severson E, Hengartner N, Ke R. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. Emerg Infect Dis [Internet]. 2020. [cited 2020 Dec 8] Available from: https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article
  3. Delamater PL, Street EJ, Leslie TF, Yang YT, Jacobsen KH. Complexity of the basic reproduction number (R0). Emerg Infect Dis [Internet]. 2019. [cited 2020 Dec 8] Available from: https://wwwnc.cdc.gov/eid/article/25/1/17-1901_article
  4. Chickenpox (Varicella) [Internet]. Centers for Disease Control and Prevention (CDC). 2020. [cited 2020 Dec 8] Available from: https://www.cdc.gov/chickenpox/about/index.html
  5. Armour, S. Fauci Calls Coronavirus Vaccine a Game Changer, Decries Misinformation [Internet]. The Wall Street Journal. 2020 Dec 8. [cited 2020 Dec 8] Available from: https://www.wsj.com/articles/deborah-birx-and-anthony-fauci-to-discuss-coronavirus-response-11607432098

Within the past three months, there have been more and more articles written about “Sanitization or Hygiene Theater.”1 The concept is based off “Security Theater,” a term which was used post-9/11 to describe the increased TSA measures that, arguably, did little to prevent future attacks.2 The comparison is founded on the notion that all the pandemic-induced cleaning, sanitizing, and disinfecting may be completely unwarranted and even wasteful in terms of time and money. In August 2020, Dr. Emanuel Goldman, a Professor of Microbiology at Rutgers University published a commentary based on comprehensive scientific literature review in The Lancet stating that “the chance of [SARS-CoV-2] transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1–2 h) [is there a risk].” Dr. Goldman goes on to say that “although periodically disinfecting surfaces and use of gloves are reasonable precautions especially in hospitals, I believe that fomites that have not been in contact with an infected carrier for many hours do not pose a measurable risk of transmission in non-hospital settings.”3

As a Public Health Professional, I cannot help but pause to contemplate this perspective. On one hand, the CDC confirms that “COVID-19 is thought to spread mainly through close contact from person-to-person, including between people who are physically near each other (within about 6 feet).” Though guidance still encourages “routinely clean[ing] and disinfect[ing] frequently touched surfaces.”4 On the other hand, I have been advocating for better disinfection practices in both healthcare and private settings for my entire career. I see this new world mindset as an incredible public health achievement. Infection Prevention is no longer a term isolated to the four walls of the hospital — we, now more than ever, are all more aware of the need for disinfection within our businesses as employees (or owners), as consumers, and even in our own homes. If you were to travel back to pre-pandemic times (possible via a quick Google search), illnesses such as the flu, common colds, and stomach bugs (gastroenteritis) were already a substantial burden in terms of absenteeism, diminished productivity, and increased healthcare costs.5 Influenza infections in adults alone resulted in an estimated $87 billion per year in terms of healthcare costs, projected lost earnings, and loss of life.6

Even knowing all of this, prior to the pandemic, employees and customers accepted a certain level of risk when it came to the safety of our shared public spaces. Post-pandemic, that accepted trust in the world around us is gone. Deloitte recently published a Safety and Cleanliness Survey7 which demonstrated that in addition to wearing masks and providing hand sanitizer, the top interventions businesses can take to rebuild trust are:

For Customers:

For Employees:

Source: Deloitte Safety & Cleanliness Survey, Deloitte Consulting LLP, 2020

Not only are these practices what we should have been doing all along, it is evident that the public is now looking for consistent displays of safety and cleanliness to trust businesses moving forward. However, as highlighted in the recent CloroxPro blog, Smart Disinfection: Making the Most of Your Disinfectants, it is important to develop a plan for using disinfectants efficiently and effectively. There is undoubtedly a balance that businesses need to find, and “hygiene theater” cannot be the only public health protocol put into practice. Any cleaning and disinfection efforts need to be used in combination with other CDC recommended initiatives, including social distancing, mask wearing, handwashing, staying home when sick, and improving indoor ventilation.4 The idea of Dr. James Reason’s 1990 “Swiss Cheese Model” still holds true today. The safeguards recommended represent the multiple layers needed to protect consumers and employees, alike. As pointed out by the Cleveland Clinic, “when used together consistently, the holes (or weaknesses) in any single layer of protection should be offset by the strengths of another layer of intervention.”8 We have to address every area of potential spread to truly create a safe and healthy environment for all.

References

  1. 1. Thompson D. Hygiene Theater Is a Huge Waste of Time: People are power scrubbing their way to a false sense of security. [Internet]. The Atlantic. 2020 [cited 2020 Oct 6]. p. 1–8. Available from: https://www.theatlantic.com/ideas/archive/2020/07/scourge-hygiene-theater/614599/
  2. 2. Judkis M. Deep cleans and disinfecting mists might not keep us from getting the virus , but they sure make us feel better [Internet]. The Washington Post. 2020 [cited 2020 Oct 6]. Available from: https://www.washingtonpost.com/lifestyle/style/deep-cleans-and-disinfecting-mists-might-not-keep-us-from-getting-the-virus-but-they-sure-make-us-feel-better/2020/09/05/f428b8ee-e965-11ea-97e0-94d2e46e759b_story.html
  3. 3. Goldman E. Exaggerated risk of transmission of COVID-19 by fomites [Internet]. Vol. 20, The Lancet Infectious Diseases. 2020. p. 892–3. Available from: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30561-2/fulltext
  4. How COVID-19 Spreads [Internet]. Centers for Disease Control and Prevention (CDC). 2020 [cited 2020 Oct 6]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
  5. 4. Bramley TJ, Lerner D, Sames M. Productivity losses related to the common cold. J Occup Environ Med. 2002.
  6. 5. Keech M, Beardsworth P. The impact of influenza on working days lost: A review of the literature. PharmacoEconomics. 2008.
  7. 6. Safety and cleanliness – make it or break it. [Internet]. Deloitte Consulting, LLP. 2020 [cited 2020 Oct 6]. p. 1–5. Available from: https://www.deloittedigital.com/content/dam/deloittedigital/us/documents/offerings/offering-20200626-safety-cleanliness-covid.pdf
  8. 7. Return to Work Amid COVID-19 [Internet]. Cleveland Clinic. 2020 [cited 2020 Oct 9]. p. 5. Available from: https://my.clevelandclinic.org/-/scassets/files/org/employer-solutions/covid-19-returning-to-work-guide.ashx

This post is part of our "Ask The Pros" blog series for which our internal panel of experts address the latest questions from industry professionals. This month's query,

"It seems like we have a new disinfectant product every week and it's hard to keep up with how and where to use the products. What strategies do you recommend for as little disruption as possible to our current process?"

Introduction

The year 2020 has certainly been a challenging one thus far. The COVID-19 pandemic has created supply challenges in this country that we could not have anticipated that range from U.S. Mint coin shortages to personal protective equipment (PPE) for healthcare workers.  The disinfectant manufacturing industry has also been challenged to keep up with an extraordinary increase in demand.  While production facilities are operating 24/7, supply continues to fall short of demand due to production capacity and raw material shortages.  As a result, many healthcare facilities are having to adjust and adapt to new disinfectants products, whether that means different formats, applications, or actives.  While this may be frustrating, healthcare teams are resilient and they know how to triage.  In response to disinfectant shortages, changes in product and potentially in protocols, we will apply the methodology of triage to the use of disinfectant products in formats that may differ from our usual product. A plan of action can then be developed for the appropriate use of the environmental disinfectants available.

Risk Assessment

The first step when an issue is identified is to assess the risks involved and the potential consequences.  In this case, the issue is that our usual product(s) may be temporarily unavailable, or in limited supply. I recommend downloading and adapting a risk assessment tool from the Centers for Disease Prevention and Control (CDC). Considerations with the risk assessment are:

Once the risk assessment has been completed, the next step is to formulate a plan to mitigate and determine what, if any, safeguards should be put into place.  Your plan should include goals and objectives to tackle high-risk issues. Note that your plan should also address how you will swiftly communicate the change in product and educate staff as the new products come in to your facility. Your vendors may be able to help!

Product Prioritization

Much like the CDC has recommended a strategy to prioritize the use of PPE to preserve supply, consider doing something similar in regards to disinfectants.  I am not proposing cleaning less frequently, but rather to prioritize which products will be used where and by whom.  If you have a limited supply of disinfectant wipes, but you also have some spray bottles of disinfectant, consider prioritizing disinfectant wipes for critical departments, or equipment.  For example, you wouldn’t want to use the spray disinfectant in the ICU where you have patients on a ventilator, so this would be a department in critical need of disinfectant wipes. Another example might be to take the large format disinfectant wipes that Environmental Services (EVS) often use and distribute them to nursing staff for use on the units.  EVS is more accustomed and likely more equipped to utilize different formats of disinfectants such as spray disinfectants, dilutable chemistries and microfibers so consider reserving these formats for them.

If you need help getting started with how to prioritize your products, check out this flow chart (also pictured below) and associated blank and completed risk assessments for reference.

Instructions for Use

Through all of this, it is imperative that the product instructions for use (IFU’s) are reviewed, staff is educated on the IFU’s, and compliance is monitored and enforced by leadership. Healthcare-grade disinfectants registered by the U.S. Environmental Protection Agency (EPA) undergo stringent testing requirements in order to prove their efficacy and safety. For the best results, users should follow the product IFU’s.

For example, Clorox Healthcare® Fuzion, a next-generation sporicidal bleach disinfectant, has an engineered dual-chambered nozzle that combines the active ingredients at the point of dispensing (or spraying).  While highly efficacious, this product is most effective when applied directly to the surface from the bottle itself. If concerned about using sprays but that is all that is available, a better approach would be to consider where use of sprays might be more appropriate, such as in public or common areas after-hours. Finally, until this pandemic is behind us, be sure you are selecting products approved as being effective against SARS-CoV-2, the virus responsible for COVID-19 disease.  You can find these products on the EPA’s List N.

Posts for the Ask The Pros blog series are published every other month. Please submit your cleaning and disinfecting questions to AskThePros@clorox.com for consideration to be addressed in a future edition.

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