Gaining Added Assurance in Infection Prevention Jim Gauthier, MLT, - - PowerPoint PPT Presentation

Welcome to

Gaining Added Assurance in Infection Prevention

Jim Gauthier, MLT, CIC

Disclosure

Jim is employed by Diversey. His expenses to attend this meeting (travel, accommodation, and salary) are paid by this

• company. Diversey has had no input into this

presentation from a commercial interest.

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Objectives

• Discuss the costs related to bacterial and

viral illnesses

• Discuss effective cleaning and disinfection
• Discuss adjunct (added) steps that can

help keep our facilities safe

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Healthcare Associated Infections (HAIs) increase cost between $28 and $45 billion annually; impacting 1 in 25 patients in the US and 1 in 9 patients in Canada Approximately 227 million days of school are missed annually due to the cold and flu; parents miss more than 123 million work days caring for sick children Each year, 5-20% of the population gets the flu. The flu alone costs U.S. companies $10.4 billion in direct medical expense and $16.3 billion in lost earnings

Illness Costs the US Economy $226B Annually

Source: Internet resources and CDC.

The Value of Clean

• A relatively modest investment in

cleaning and disinfection produces substantial benefits to a business’ bottom line

• Cleaning and disinfection can reduce

absences by up to 46%

• And for healthcare, the prevention of

infection is a matter of financial survival

Source: CDC and http://www.ashkingroup.com/pdfs/Education/Report%20-%20IAQ%20test%20study%202%20-%20children.pdf

Surfaces in Transmission of Illness

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Sick person sneezes, coughs and pathogens fall on fomite or get aerosolized Person picks up pathogen through contaminated fomite Person touches nose or eyes with contaminated fingers and becomes infected with pathogen Pathogen falls on fomites e.g. phone, computer Source: Dr. Charles Gerba

Contamination of Surfaces Happens Quickly

• University of Arizona Study
• Contaminated door knob with a non-pathogenic
• rganism
• After a few hours, they tested 100 surfaces –

light switches, countertops, push buttons, coffee pot handles, faucet handles, phones

Contamination of Surfaces Happens Quickly

60% of surfaces were contaminated! After cleaning with a disinfectant wipe, the

• rganism was removed from more than 80%
• f the surfaces

“The results show that viral contamination of (surfaces) in facilities occurs quickly, and that a simple intervention can greatly help to reduce exposure to viruses” – Charles Gerba

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Key “Germ” Sources in Offices

Number of Germs per Square Inch

Source: Dr. Charles Gerba

Key Germ Sources in Schools

Figure 1 Top Three Contaminated Sites in All Schools

1.70E+06 8.60E+05 4.77E+06 1.00E+02 1.00E+03 1.00E+04 1.00E+05 1.00E+06 1.00E+07 Cafeteria Table Computer Mouse Desk Total Bacteria/approximate 100 cm sq

Source: Dr. Charles Gerba Presentation

When do We Clean in Healthcare?

• General patient rooms
• Once per day, sometimes twice, usually

morning through afternoon

• Operating Rooms
• Between cases, end of day
• Common Public Areas
• Once per day

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When do We Clean in Offices/Schools?

• Generally after hours – late afternoon,

nights

• Contracted services in some cases

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What Can Go Wrong in Cleaning and Disinfecting?

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Germs are Invisible It can be difficult to know if pathogens have been killed. It is impossible to know where the germs are hiding!

Safety Concerns Affect Proper Use Staff is less likely to use disinfectants that can cause eye, skin and respiratory irritation.

Risk from Chemicals

Source: PTS, Virox Technologies, Inc.

Harsh On Surfaces and Assets Some disinfectants can damage assets

Some Products Cause Damage

Disinfectant Dries Before Pathogens Die

Drying time should be greater or equal to the kill time.

Disinfectant Dries Too Fast

Slide Courtesy of Virox Technologies, Inc.

Dry Time vs. Label Contact Time

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Omidbakhsh J AOAC Internat 2010;93(6)1-8 IHP (0.5% H2O2)

Compatibility With Cleaning Tools Efficacy diminishes when disinfectants bind with cleaning tools.

Quat Binding

Some cleaning tool fabrics, such as cotton and microfiber, are known to bind with quaternary ammonium chlorides (“quats”) Known as “quat binding”

Quat Binding

• Active ingredients (quat) have a tendency to

become attracted to, and absorbed into, microfiber and cotton fabrics

• Cotton fabrics and most microfibers are

negatively charged

• Quats are cationic, or positively charged, and

are attracted to fabric surfaces which are anionic, or negatively charged

• Many non-woven disposable wipes have no

charge, and do not demonstrate binding with quats or other disinfectants

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Quat Binding

• CONSEQUENCE: A portion of the quat

actives become unavailable to disinfect hard surfaces making the disinfection process ineffective!

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Impact of Cleaning Tools on Quat Disinfectant Efficacy

Study Demonstrated:

• Microfiber, cotton and

some disposable wipers bind with quat disinfectants reducing the effectiveness of the disinfectant solution

Boyce JM et al. Quaternary ammonium disinfectant issues encountered in an environmental services department. ICHE 2015;37(3):340-342

Issues Encountered with Dilutables

• Dilution Control Stations may not deliver

compliant disinfectants

• Water pressure and dispenser design can

reduce the effectiveness of dispensers, delivering disinfectants that are out of compliance

Boyce JM et al. Quaternary ammonium disinfectant issues encountered in an environmental services department. ICHE 2015;37(3):340-342

Issues Encountered with Dilutable Quats

• None of the dispensers tested delivered

the 800 parts per million (ppm) of quat active specified on the disinfectant label

• 1 station was inoperative
• 2 stations contained no concentrated

disinfectant

• 7 stations delivered quat concentrations <200

ppm

• 17 stations delivered 200-400 ppm
• 6 stations delivered 400-600 ppm

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Boyce JM et al. Quaternary ammonium disinfectant issues encountered in an environmental services department. ICHE 2015;37(3):340-342

The Importance of Cleaning Tools in the Spread of Germs

Source: Dr. Charles Gerba Presentation

Who? What? When? How?

Without clear roles and responsibilities, equipment and surfaces can be missed.

What Can Go Wrong in Cleaning and Disinfecting?

Roles and Responsibilities: Healthcare

Who Cleans What? When?

Validation

• Are you Confident?
• The job has been completed?
• All areas are in compliance?
• All surfaces are cleaned?
• Procedures are followed?

Inaccessible Means Ineffective

Disinfectants that are out of sight are

• ut of mind.

What Can Go Wrong in Cleaning and Disinfecting?

Inaccessible

• Product Storage
• Product Safety
• HMIS (Hazardous Material Identification System)

rating

• Health
• Flammability
• Physical Hazard
• Best is 0/0/0

The Ideal Disinfectant

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HAI Reduction

What is the Ideal Disinfectant?

• 1. Kill Claims for the most relevant pathogens

Broad spectrum Bacteria and hard to kill viruses

• 2. Fast kill times and acceptable wet contact time

to ensure proper disinfection of surfaces

Fast acting Remains wet

• 3. Safety

Non-toxic and non-irritating to the user or occupant Compatible with surfaces Nonflammable

* Rutala et al. Selection of an Ideal Disinfectant, Infect Cont Hosp Epidem, Vol. 35, No. 7 (July 2014), pp. 855-865

What is the Ideal Disinfectant?

• 4. Ease of Use
• Unaffected by environmental factors, i.e. soil
• Easy-to-use
• Acceptable odor
• Soluble in water
• Stable
• One-step Disinfectant Cleaner
• 5. Other factors
• Economical – Total Cost
• Manufacturer support

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* Rutala et al. Selection of an Ideal Disinfectant, Infect Cont Hosp Epidem, Vol. 35, No. 7 (July 2014), pp. 855-865

Label Claims

• Organisms
• Gram negative/Gram positive/Enveloped

viruses

• Non-enveloped Viruses
• Fungi
• Spores – not as important outside of healthcare

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Effect of Disinfectants on Microorganisms

Organism Type Examples

Bacterial Spores Spore Bacillus anthracis, Clostridium difficile Mycobacteria Bacteria

• M. tuberculosis

Small non-enveloped virus Virus Norovirus, Rhinovirus Fungal spores Fungus Aspergillus, Penicillium, Trichophyton Gram negative bacteria Bacteria

• E. coli, Klebsiella including CRE,

Pseudomonas, Acinetobacter Fungi (Vegetative) Fungus Candida Large Virus (non-enveloped) Virus Adenovirus, Rotavirus Gram positive bacteria Bacteria Staphylococcus including MRSA Enterococcus including VRE Virus (enveloped) Virus HIV, HBV, HCV, Influenza

^Resistant *Sensitive

R^ S*

Adapted from Rutala et al. ICHE 2014;35(7):862

What Can Go Wrong in Cleaning and Disinfecting?

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Label Claims

• Time to kill Gram positive, negative and

enveloped viruses

• Time to kill non-enveloped viruses
• Time to kill fungus
• Wet Contact Time!

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Keeping Us Safe

• Check the SDS on disinfectants and

cleaners

• Need safe products with minimal residue
• San Francisco Department of the Environment

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Safer Product Discussion

• Good
• Hydrogen peroxide
• Caprylic Acid
• Citric Acid
• Lactic Acid
• Worrisome
• Bleach
• PAA
• Phenolics
• Quats

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How Can We Improve?

• Disinfectant wipes:
• Within patient rooms
• At work stations
• Common eating areas
• Computer labs
• Gyms/Fitness Centers
• Hand Sanitizer
• At work stations
• Common eating areas
• Computer labs

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Who Can Help?

• Healthcare
• Family and Visitors
• Moments for Disinfection by Clinical Staff
• Schools
• Students Gym equipment
• All – keyboards
• Offices
• All!

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Silver Bullet Needs Help!

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Kill Viruses Kill Bacteria

Adjunct (Additive) Technologies

• Adjunct technologies are important, why?
• Manual cleaning is not easily repeatable
• Multiple studies over many years support that, regardless of

effort, rewards, and goodwill, robust manual disinfection is not easily achieved

• Evidence supports that organisms of concern, i.e. antibiotic

resistant organisms, can survive on surfaces for weeks to months

• Additive technologies offer a layer of protection to wipes and

chemicals that help to cover “the gap”

Weber DJ, Kanamori H, Rutala WA. 'No touch' technologies for environmental decontamination: focus on ultraviolet devices and hydrogen peroxide systems. Curr Opin Infect Dis. 2016 Aug;29(4):424-31.

Rutala, 2016 (AHE and APIC)

• Facilities should consider the use of these

adjunct “no-touch” technologies, and should budget for these devices for terminal room disinfection (e.g., after discharge of patients on Contact Precautions).

• What are adjunct technologies?
• Adjunct Technologies are tools used in

addition to existing practices

• These technologies are not a substitute for

manual cleaning. Manual cleaning is always required prior to the use of additive technologies to remove biofilms, dirt, debris, smears and other soils

• These additive technologies are best thought of

as insurance Examples of adjunct technologies are UVC systems, aerosolized hydrogen peroxide, hydrogen peroxide vapor, and some variants

Adjunct Technologies

Adjunct Technologies

• Ultraviolet Light
• Healthcare
• Vapor or Aerosolized Systems
• Healthcare
• Outbreaks?
• Impregnated Surfaces
• Still looking!

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What is Ultraviolet C (UVC) Light

• A form of light, invisible to the human eye
• Has been used to disinfect air and water for many years
• It is most effectively generated by exciting mercury vapor to create

light wavelengths of 254 (253.7) nanometers

• UVC can be used to kill potentially dangerous pathogens, such as

MRSA, VRE, C. difficile and Acinetobacter

• UVC light waves kill pathogens by deactivating their DNA, destroying

their ability to multiply and cause disease

• Ultraviolet technology can be used as an effective, environmentally-

friendly, non-chemical approach to disinfection, but is more effective is surfaces are properly cleaned prior to its application

How UVC Works

The Science of UVC

Ultraviolet – Angle of Incidence

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Distance Matters

• Energy decreases by the square of the distance
• For example:
• Energy at bulb or up to 1 foot = 100 arbitrary units
• Energy at two feet = 25 units (100/4 [the square of 2]),

not 50

• Energy at three feet = 11 units (100/9 [the square of 3]),

not 33

• Energy at four feet = 6.25 units (100/16 [the square of

4]), not 25

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Vapor / Aerosolized Systems

• Excellent efficacy
• Rooms need to be sealed
• Rooms need to be unoccupied
• Time for turnover considerations

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Surfaces

• Impregnated Surfaces
• Quat-siloxane polymers
• Silver citrate
• Surface Composition
• Silver / Silver alloys
• Copper / Copper alloys

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Surfaces

• Not instantaneous (20 minutes to hours)
• Issues if soil present
• Can be hard to clean/disinfect

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Conclusions

• Infections can be costly!
• There are many factors that can affect the

cleaning/disinfection of facilities

• The disinfectant can make a huge

difference!

• Added assurance may be the best

insurance

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Questions?

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