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New Technology in Environmental Cleaning and Evaluation

New Technology in Environmental Cleaning and Evaluation. William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology

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New Technology in Environmental Cleaning and Evaluation

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  1. New Technology in Environmental Cleaning and Evaluation William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill and UNC Health Care, Chapel Hill, NC

  2. DISCLOSURES • Consultation and Honoraria • ASP (Advanced Sterilization Products), Clorox • Grants • CDC, CMS

  3. New Technology in Environmental Cleaning and EvaluationObjectives • Understand the pathogens for which contaminated hospital surfaces play a role in transmission • Review new technologies and practices to improve environmental disinfection • Discuss available options for evaluating environmental cleaning • Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

  4. New Technology in Environmental Cleaning and EvaluationObjectives • Understand the pathogens for which contaminated hospital surfaces play a role in transmission • Review new technologies and practices to improve environmental disinfection • Discuss available options for evaluating environmental cleaning • Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

  5. www.disinfectionandsterilization.org

  6. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs • There is increasing evidence to support the contribution of the environment to disease transmission • This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment/equipment

  7. EVIDENCE TO SUPPORT THE CONTRIBUTION OF THE ENVIRONMENT TO HAIs • Microbial persistence in the environment • In vitro studies and environmental samples • MRSA, VRE, Ab, Cd • Frequent environmental contamination • MRSA, VRE, Ab, Cd • HCW hand contamination • MRSA, VRE, Ab, Cd • Relationship between level of environmental contamination and hand contamination • Cd

  8. EVIDENCE TO SUPPORT THE CONTRIBUTION OF THE ENVIRONMENT TO HAIs • Person-to-person transmission • Molecular link • MRSA, VRE, Ab, Cd • Housing in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease • MRSA, VRE, Cd, Ab • Improved surface cleaning/disinfection reduces disease incidence • MRSA, VRE, Cd

  9. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI • Study design: Retrospective cohort analysis, 2005-2006 • Setting: Medical ICU at a tertiary care hospital • Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge • Results (acquisition of CDI) • Admission to room previously occupied by CDI = 11.0% • Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:201-206

  10. RELATIVE RISK OF PATHOGEN ACQUISITIONIF PRIOR ROOM OCCUPANT INFECTED * Prior room occupant infected; ^Any room occupant in prior 2 weeks infected. Otter , Yezli, French. ICHE. 2012;32:687-699

  11. KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION • MRSA • VRE • Acinetobacter spp. • Clostridium difficile • Norovirus • Rotavirus • SARS

  12. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

  13. ENVIRONMENTAL CONTAMINATION ENDEMIC AND EPIDEMIC MRSA Dancer SJ et al. Lancet ID 2008;8(2):101-13

  14. ENVIRONMENTAL SURVIVAL OF KEY PATHOGENS ON HOSPITAL SURFACES Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 and Kramer A, et al. BMC Infectious Diseases 2006;6:130

  15. FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES No significant difference on contamination rates of gloved hands after contact with skin or environmental surfaces (40% vs 45%; p=0.59) Stiefel U, et al. ICHE 2011;32:185-187

  16. ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

  17. ACQUISITION OF MRSA ON HANDS/GLOVES AFTER CONTACT WITH CONTAMINATED EQUIPMENT

  18. TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO IV DEVICE AND TRANSMISSON OF PATHOGEN

  19. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

  20. ACQUISITION OF C. difficile ON PATIENT HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES AND THEN INOCULATION OF MOUTH

  21. New Technology in Environmental Cleaning and EvaluationObjectives • Understand the pathogens for which contaminated hospital surfaces play a role in transmission • Review new technologies and practices to improve environmental disinfection • Discuss available options for evaluating environmental cleaning • Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

  22. TECHNOLOGIES TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES • New surface disinfectants • Improved hydrogen peroxide • Electrochemically activated saline solution • “No touch” terminal disinfection • UV light: UV-C or pulsed xenon • Hydrogen peroxide systems: Vapor or aerosol • Portable devices: UV, steam • “Self disinfecting” surfaces • Heavy metal surface coatings: Silver, copper • Sharklet pattern • Germicide impregnated surfaces: Triclosan

  23. TECHNOLOGIES TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES • New surface disinfectants • Improved hydrogen peroxide • Electrochemically activated saline solution • “No touch” terminal disinfection • UV light: UV-C or pulsed xenon • Hydrogen peroxide systems: Vapor or aerosol • Portable devices: UV, steam • “Self disinfecting” surfaces • Heavy metal surface coatings: Silver, copper • Sharklet pattern • Germicide impregnated surfaces: Triclosan

  24. LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol 70-90% Chlorine 100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

  25. IMPROVED HYDROGEN PEROXIDE (HP) SURFACE DISINFECTANT • Advantages • 30 sec -1 min bactericidal and virucidal claim (fastest non-bleach contact time) • 5 min mycobactericidal claim • Safe for workers (lowest EPA toxicity category, IV) • Benign for the environment; noncorrosive; surface compatible • One step cleaner-disinfectant • No harsh chemical odor • EPA registered (0.5% RTU, 1.4% RTU, wet wipe) • Disadvantages • More expensive than QUAT

  26. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. 2012;33:1159 Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested

  27. Hospital Privacy Curtains(pre- and post-intervention study; sampled curtain, sprayed “grab area” 3x from 6-8” with 1.4% IHP and allowed 2 minute contact; sampled curtain)

  28. Decontamination of Curtains with Activated HP (1.4%)Rutala, Gergen, Weber. 2012 * All isolates after disinfection were Bacillus sp; now treat CP patient curtains at discharge with IHP

  29. Novel Methods of Room Disinfection

  30. EFFECTIVENESS OF UV ROOM DECONTAMINATION Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:1025-1029.

  31. ROOM DECONTAMINATION WITH UV, HP • Issues-Room decontamination time; where the occupancy is high and fast patient turnaround time is critical • Room decontamination with UV is 25 minutes for vegetative bacteria and 50 minutes for C. difficile spores • HP room decontamination takes approximately 2.5 hours

  32. Rapid Hospital Room Decontamination Using UV Light With a Nanostructured Reflective Coating • Assessed the time required to kill HAI pathogens in a room with standard white paint (3-7% UV reflective) versus walls coated with an agent formulated to be reflective to UV-C wavelengths (65% UV reflective) • Coating/painted uses nanoscale metal oxides whose crystal structures are reflective to UV-C • Coating is white in appearance and can be applied with a brush or roller in the same way as any common interior latex paint • Cost to coat walls used in this study was estimated to be <$300.

  33. ROOM DECONTAMINATION USING UV-C WITH A NANOSTRUCTURED UV-REFLECTIVE WALL COATING Rutala WA, Gergen MF, Weber DJ. ICHE 2013;34:527-529

  34. EVALUATION OF A HAND HELD UV DEVICE FOR DECONTAMINATIONNerandzic MM, et al. BMC ID 2012;12 • Design: Assessed a handheld UV device (185-230nm) • Methods: Inoculated surfaces • Results: • Lab surfaces: 100 mJ/cm2 for ~5s reduced C. difficile spores by 4.4 CFU log10, MRSA by 5.4 log10 CFU and VRE by 6.9 log10 CFU • Keyboards and portable medical equipment: 100 mJ/cm2 for ~5s reduced C. difficile spores by 3.2 CFU log10, • Presence of organic material reduced/eliminated lethal effect of far-UV • Conclusion: Rapidly kills HA pathogens but soil reduces efficacy

  35. Room Decontamination with UVRutala, Gergen, Weber. 2013 • Objective: Determine the effectiveness of a UVC device • Method: Study carried out in standard hospital room using Formica sheets contaminated with MRSA, C. difficile • Results: The effectiveness of UVC radiation in reducing MRSA was more than >99.9% within 5 min and the reduction of C. difficile spores was >99% within 10 min • Conclusion: This UVC device (UVDI) allowed room decontamination in 5-10 minutes

  36. Room Decontamination with UVRutala, Gergen, Weber. 2013 Delivers lethal dose of UV in 5-10 min

  37. UV ROOM DECONTAMINATION: ADVANTAGES AND DISADVANTAGES Advantages Reliable biocidal activity against a wide range of pathogens Surfaces and equipment decontaminated Room decontamination is rapid (5-25 min) for vegetative bacteria HVAC system does not need to be disabled and room does not need to be sealed UV is residual free and does not give rise to health and safety concerns No consumable products so operating costs are low (key cost = acquisition) Disadvantages No studies evaluating whether use reduces HAIs Can only be done for terminal disinfection (i.e., not daily cleaning) All patients and staff must be removed from room Substantial capital equipment costs Does not remove dust and stains which are important to patients/visitors Sensitive use parameters (e.g., UV dose delivered) Rutala WA, Weber DJ. ICHE 2011;32:743-747

  38. HYDROGEN PEROXIDE FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Falagas, et al. J Hosp Infect. 2011;78:171.

  39. ROOM DECONTAMINATION WITH HPV • Study design • Before and after study of HPV • Outcome • C. difficile incidence • Results • HPV decreased environmental contamination with C. difficile (p<0.001), rates on high incidence floors from 2.28 to 1.28 cases per 1,000 pt days (p=0.047), and throughout the hospital from 1.36 to 0.84 cases per 1,000 pt days (p=0.26) Boyce JM, et al. Infect Control Hosp Epidemiol. 2008;29:723-729.

  40. USE OF HPV TO DECONTAMINATE UNUSED MEDICAL SUPPLIES • Design: Before-after study (assessed hydrogen peroxide vapor) • Methods: 5 supply paired items removed patient room after discharge (one cultured before and one after HPV [items placed on metal rack in room]) • Results • 7-9% supplies contaminated with 1 or more MDROs; 16% contaminated with potential pathogens • None contaminated after exposure to HPV; projected cost savings (6 ICUs): $387,055.15 • Conclusion- HPV effectively disinfected the packaging of supply items Otter JA, et al. ICHE 2013;34:472-478

  41. HP ROOM DECONTAMINATION: ADVANTAGES AND DISADVANTAGES Advantages Reliable biocidal activity against a wide range of pathogens Surfaces and equipment decontaminated Demonstrated to decrease disease incidence (C. difficile) Residual free and does not give rise to health and safety concerns (aeration units convert HPV into oxygen and water) Useful for disinfecting complex equipment and furniture Does not require direct or indirect line of sight Disadvantages Can only be done for terminal disinfection (i.e., not daily cleaning) All patients and staff must be removed from room Decontamination takes approximately 2-5 hours HVAC system must be disabled and the room sealed with tape Substantial capital equipment costs Does not remove dust and stains which are important to patients/visitors Sensitive use parameters (e.g., HP concentration) Rutala WA, Weber DJ. ICHE (In press)

  42. SELF DISINFECTING SURFACES Copper coated overbed table Sharklet Pattern Triclosan pen Antimicrobial effects of silver

  43. RCT DEMONSTRATING REDUCTION OF HAIs BY USE OF COPPER ALLOY SURFACES • Design: Randomized control trial in ICUs of 3 hospitals • Methods: Patients placed in rooms with or without copper alloy surfaces • Results: Rate of HAI and/or MRSA or VRE colonization was significantly lower than in standard ICU rooms (0.071 vs 0.123; P=0.020) Salgado CD, et al ICHE 2013;34:479

  44. New Technology in Environmental Cleaning and EvaluationObjectives • Understand the pathogens for which contaminated hospital surfaces play a role in transmission • Review new technologies and practices to improve environmental disinfection • Discuss available options for evaluating environmental cleaning • Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

  45. It appears that not only is disinfectant use important but how often is important Daily disinfection vs clean when soiled

  46. Daily Disinfection of High-Touch SurfacesKundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant (PA) in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

  47. New Technology in Environmental Cleaning and EvaluationObjectives • Understand the pathogens for which contaminated hospital surfaces play a role in transmission • Review new technologies and practices to improve environmental disinfection • Discuss available options for evaluating environmental cleaning • Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

  48. Thoroughness of Environmental CleaningCarling et al. ECCMID, Milan, Italy, May 2011 >110,000 Objects Mean = 32%

  49. Mean proportion of surfaces disinfected at terminal cleaning is 32% Terminal cleaning methods ineffective (products effective practices deficient [surfaces not wiped]) in eliminating epidemiologically important pathogens

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