DISINFECTION OF ENVIRONMENTAL SURFACES IN · PDF filedisinfection of environmental surfaces in healthcare: ... norovirus & other non-enveloped viruses ... what about ebola virus?

SYED A. SATTAR, PhD

PROFESSOR EMERITUS OF MICROBIOLOGY

DEPT. OF BIOCHEMISTRY, MICROBIOLOGY & IMMUNOLOGY

FACULTY OF MEDICINE, UNIVERSITY OF OTTAWA, OTTAWA, ON, CANADA

DISINFECTION OF ENVIRONMENTAL

SURFACES IN HEALTHCARE: WHY, WHERE,

HOW AND WITH WHAT?

DISCLOSURE

FUNDING FROM PUBLIC & PRIVATE SOURCES

ADVISOR/CONSULTANT TO NUMEROUS COMPANIES,

GOVERNMENTS & INTERNATIONAL AGENCIES

MEMBER, BOARD OF DIRECTORS, VIROX TECH. (CANADA)

2SATTAR, ICAN CONF., HARARE, ZIMBABWE, NOV. 2014

ANY MENTION OF PRODUCTS & SERVICES IS FOR INFORMATION PURPOSES

ONLY & DOES NOT CONSTITUTE AN ENDORSEMENT BY ME OR MY UNIVERSITY.

WHAT IS THE ISSUE?

LIFE-STYLE/DEMOGRAPHIC CHANGES & GREATER

EXPOSURE & VULNERABILITY TO PATHOGENS

FASTER TRAVEL, LONGER LIFE, IMMUNOSUPPRESSION

REDUCED PROSPECTED FOR DRUGS & VACCINES

WELCOME REVIVAL OF INTEREST IN ENVIRON. CONTROL

DISINFECTANTS BACKBONE OF ENVIRON. CONTROL

INCREASING CONCERNS OVER DISINFECTANT USAGE

HUMAN & ENVIRONMENTAL SAFETY OF CHEMICALS

TESTING & LABEL CLAIMS OF MARKETED PRODUCTS

A CRITICAL LOOK AT CURRENT SITUATION

SATTAR, ICAN CONF., HARARE, ZIMBABWE, NOV. 2014 3

DEFINITIONS

MICROBICIDE: ANY PHYSICAL OR CHEMICAL AGENT THAT

CAN KILL MICROBES

INCLUDES ‘DISINFECTANTS’ & ‘ANTISEPTICS’

ALSO CALLED ‘GERMICIDE’ IN NORTH AMERICA & ‘BIOCIDE’ IN EUROPE

NEITHER TERM IS SUITABLE

FOCUS HERE ONLY ON DISINFECTANTS TO DECONTAMINATE

HIGH-TOUCH ENVIRONMENTAL SURFACES (HITES)



USES OF MICROBICIDES

FOOD

PRODUCTION

ENVIRONMENTAL

SURFACES

SEWAGE & BIOMED.

WASTE

MICROBICIDES

SWIMMING

POOLS MEDICAL, DENTAL

& VETERINARY

SETTINGS

CONSUMER DEVICES (E.G.,

CONTACT LENSES)

SKIN & MUCOUS

MEMBRANES

HYGIENE &

FOMITES

DRINKING

WATER

AIR

VACCINES

PHARM. & OTHER

INDUST.

BIOFILMS

AGRICULTURE


>5,000 REGISTERED

DISINFECTANTS IN U.S.

>60% USED AGAINST

HUMAN PATHOGENS

ABOUT 275 DIFFERENT

TYPES OF ACTIVES; ~14 IN

>95% OF MARKETED

PRODUCTS

ANNUAL SALES OF >BILLION

DOLLARS & INCREASING

6

DISINFECTANT USE DISINFECTANTS USED IN INSTITUTIONAL &

INDUSTRIAL SETTINGS IN THE U.S.(MODIFIED FROM FU ET AL. 2007)


INTERRUPTING ENVIRONMENTAL SPREAD OF PATHOGENS

CONTAMINATION

SURVIVAL ON

PRIMARY VEHICLE

PATHOGEN

TRANSFER TO

SECONDARY

VEHICLE(S)

INOCULATION

INFECTION

(DISEASE)

CLEANING, ANTISEPSIS,

DISINFECTION &

STERILIZATION

INTERRUPTION

EN

VIR

ON

ME

NTA

L F

AC

TO

RS


INTERRUPTION OF PATHOGEN TRANSFER FROM

METAL DISKS TO FINGERPADS(SATTAR ET AL. AEM 59:1579-1585, 1993; ICHE 15:751-756, 1964)

% VIRUS TRANSFERRED

TREATMENT

ROTA RHINO POLIO

TAP WATER 5.6+1.1 NOT DONE 3.5+1.5

ETHANOL-BASED

SPRAY 0 0 0

BLEACH

(800 PPM) 0 0 3.6+2.4

QUAT. AMMON. 7.6+2.5 8.4+3.6 5.3+2.4

PHENOLIC 0 3.3+1.9 11.9+6.6


INTERRUPTION OF ROTAVIRUS SPREAD(WARD ET AL., J. CLIN. MICROBIOL. 29: 1991-1996, 1991)

TREATMENT NO. INFECTED %

OF VIRUS NO. TESTED INFECTED

NONE 13/14 93

ETHANOL-BASED

DISINFECTANT

SPRAY 0/14 0

VIRUS IN FECAL SUSPENSION WAS DRIED ON PLASTIC PLATES & VOLUNTEERS

ASKED TO LICK THE SURFACE WITH & WITHOUT DISINFECTION.

DISINFECTANTS ARE A DOUBLE-EDGED SWORD!

TOXICITY FOR WORKER & PATIENT

(DERMATITIS, ASTHMA)

ENVIRONMENTAL HAZARDS

(AIR & WATER POLLUTION, HORMONE DISRUPTION)

LACK OF MATERIALS COMPATIBILITY

(CORROSION, DISCOLORATION)

MICROBIOLOGICAL HAZARDS

(CROSS RESISTANCE, MICROBIAL GROWTH)

CHEMICAL HAZARDS

(FIRES, EXPLOSIONS, MIXING OF INCOMPATIBLES)


DISINFECTANTS & WORKPLACE HAZARDS (MMWR 59; 551-556, 2010)

IN THE U.S. (2002–2007), 401 CASES IN HOSPITAL STAFF; 82% IN FEMALES

HOUSE-KEEPERS (24%) & NURSING/MEDICAL ASSISTANTS (16%)

SYMPTOMS MOSTLY MILD; ONE DEATH FROM ACUTE ASTHMA

EYES MOST COMMON ORGAN AFFECTED (55%)

PREVENTION THROUGH:

(A) EDUCATION (B) USE OF PPE

(C) BETTER EQUIPMENT (D) USE OF SAFER CHEMICALS



WHICH ENVIRONMENTAL SURFACES TO TARGET?

PRINCIPAL CONSIDERATION IS POTENTIAL OF A GIVEN

SURFACE TO HARBOR & ‘DONATE’ PATHOGENS

DURING ROUTINE/CASUAL CONTACT

MUST INCLUDE:

PROBABILITY OF CONTAMINATION WITH PATHOGENS

ABILITY TO ALLOW FOR PATHOGEN SURVIVAL

EASE OF PATHOGEN RELEASE

LOCATION & FREQUENCY OF DIRECT CONTACT WITH HANDS

AND/OR MUCOUS SURFACES

LET’S FOCUS ON PATHOGENS ON HIGH-TOUCH SURFACES

CONTAMINATION VIA:

HANDS

BODY FLUIDS AND SKIN SCALES

WATER & WATER-BASED BIOFILMS

DISINFECTANTS/CLEANERS

AIR

DIRECT TRANSFER TO PATIENTS MAY

OCCUR, BUT MUCH MORE COMMON VIA

HANDS; HAND ANTISEPSIS!


Sci. Am., Sept. 2012

■ GENERALLY, HARD, NON-POROUS SURFACES ALLOW FOR BETTER

PATHOGEN SURVIVAL & RELEASE

■ PROPER & REGULAR DISINFECTION CRUCIAL TO INTERRUPT SPREAD OF

PATHOGENS

WHICH PATHOGENS TO FOCUS ON?

HIGH-PROFILE PATHOGENS (E.G., HIV, INFLUENZA- & SARS VIRUS

SHOULD NOT BE THE TARGETS IN TESTING

LESS STABLE & LESS RESISTANT THAN NON-ENVELOPED VIRUSES

POOR SPREAD VIA CONTAMINATED SURFACES

EXAMPLES OF PATHOGENS FOR GREATER FOCUS:

SPORES OF CLOSTRIDIUM DIFFICILE (SPORICIDAL PRODUCTS)

NOROVIRUS & OTHER NON-ENVELOPED VIRUSES

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE)

ACINETOBACTER BAUMANNII

TARGETING THE MORE RESISTANT SHOULD COVER WEAKER ONES!



WHAT ABOUT CURRENTLY AVAILABLE DISINFECTANTS?

MANY ARE ONLY WEAK BACTERICIDES (LOW-LEVEL)

TEST METHODS FOR MICROBICIDAL ACTIVITY INAPPROPRIATE

LABEL CLAIMS NOT BASED ON WIPE-TESTING!

ACTIVITY FURTHER COMPROMISED DURING FIELD USE DUE TO:

MUCH SHORTER CONTACT TIMES; HIGH VOLUME:SURFACE RATIO

SOIL LOAD AS WELL AS DEMAND FROM APPLICATOR/SURFACE

GENERATE A FALSE SENSE OF SECURITY

MAY INCREASE RISK OF PATHOGEN SPREAD!

GRAPEFRUIT EXTRACT AGAINST C. DIFFICILE SPORES IN INTENSIVE CARE!

HOW GOOD ARE LABEL CLAIMS ON DISINFECTANTS?

OFTEN, CONTACT TIME ON LABELS TOO LONG FOR FIELD USE

NO DIRECTION ON VOLUME:SURFACE AREA

LACK OF CLEAR DIRECTIONS FOR PRE-CLEANING

LONG LISTS OF IRRELEVANT MICROBES

‘BROAD-SPECTRUM’ SHOULD MEAN MORE THAN JUST ACTIVITY

AGAINST GRAM+ & GRAM- BACTERIA

LEGALLY, ‘DISINFECTANT’ CAN MEAN ONLY ‘BACTERICIDE’!

16SATTAR, ICAN CONF., HARARE, ZIMBABWE, NOV. 2014


WHAT ABOUT THE HOUSE-KEEPING STAFF?

CRUCIAL ROLE BUT WITH INADEQUATE RECOGNITION!

LEAST SKILLED & TRAINED WITH FAST TURN-OVER

PRODUCT LABELS OFTEN DIFFICULT TO INTERPRET

LANGUAGE OFTEN A BARRIER; NEED BETTER SIGNAGE

INADEQUATE IN-SERVICE TRAINING & SUPERVISION


% OF VRE-POSITIVE CULTURES FROM 17 ROOMS TESTED (ECKSTEIN ET AL., BMC INFECT. DIS. 2007;7:61)

AFTER

HOUSEKEEPING

CLEANING

AFTER

DISINFECTION BY

RESEARCH TEAM

80

70

60

50

40

30

20

10

0

PE

RC

EN

T P

OS

ITIV

E

BEFORE CLEANING

BEDRAIL

BEDSIDE TABLE

PHONE

CALL BUTTON

TOILET

DOOR HANDLE

DISINFECTION WITH 10% DOMESTIC BLEACH BY HOUSE-KEEPING STAFF STILL LEFT MANY

SURFACES CONTAMINATED; ADDITIONAL IN-SERVICE TRAINING WAS REQUIRED TO

IMPROVE THE PRACTICE.


WHAT ABOUT GOVERNMENT-REGISTERED DISINFECTANTS?

REGISTRATION PROCESS FLAWED & OUT-DATED!

BASED ON UNSUITABLE TEST METHODS & PRODUCT

EFFICACY CRITERIA

LACK OF REGIONAL & GLOBAL HARMONIZATION

DISCOURAGE INNOVATION

THE OECD INITIATIVE


PRINCIPLES OF ‘GREEN CHEMISTRY’(ANASTAS & WARNER, 1998)

20

1. DESIGN SAFER CHEMICALS &

PRODUCTS THAT ARE FULLY

EFFECTIVE WITH LITTLE OR NO

TOXICITY

2. USE SAFER SOLVENTS & REACTION

CONDITIONS

3. DESIGN CHEMICALS & PRODUCTS TO

DEGRADE AFTER USE SO THAT THEY

DO NOT ACCUMULATE

4. MINIMIZE POTENTIAL FOR ACCIDENTS

SUCH AS EXPLOSIONS, FIRES &

RELEASES TO THE ENVIRONMENT

MICROBICIDAL ACTIVITY OF

HOUSE-HOLD CHEMICALS

(E.G., VINEGAR) SLOW & LIMITED

BOTANICALS CAN BE

POTENTIALLY TOXIC

CRITERIA FOR ‘GREEN’

CHEMISTRY (TABLE)

PERSISTENT CHEMICALS TO

BE DISCOURAGED

THE ‘GREEN’ MOVEMENT

DESIRED TRAITS IN A DISINFECTANT


LEAST TOXIC & ENVIRONMENTALLY FRIENDLY (‘GREEN’)

FAST & BROAD-SPECTRUM MICROBICIDAL ACTIVITY

NON-STAINING, NO PUNGENT SMELL & NO VOLATILES

NOT READILY NEUTRALIZED BY SOIL LOAD

HIGH MATERIALS COMPATIBILITY

EASY TO USE WITH CLEAR LABEL DIRECTIONS

GOVERNMENT REGISTERED(?)

ENVELOPED VIRUS WITH A SINGLE-STRANDED RNA GENOME

LIMITED PUBLISHED DATA ON FILOVIRUSES SHOW:


WHAT ABOUT EBOLA VIRUS?

SUSCEPTIBILITY TO: 3% ACETIC ACID, 2% PERACETIC ACID, 1%

GLUTARALDEHYDE, ETHANOL-BASED PRODUCTS, 1:10-1:100 DILUTIONS

OF DOMESTIC BLEACH (5.25% SOD. HYPOCHLORITE), & ORGANIC

SOLVENTS (ACETONE, CHLOROFORM, ETHER, METHANOL) AT ROOM

TEMPERATURE WITH A CONTACT TIME OF MINUTES TO HOURS

PRECLEANING REQUIRED TO REDUCE SOIL LOAD

PROPER PPE MUST ALSO BE USED

(KUHN, JH. 2008. INACTIVATION OF FILOVIRUSES AND DISINFECTION PROTOCOLS. CHAPTER 14.

IN FILOVIRUSES. PAGES 297-299. ARCHIVES OF VIROLOGY SUPPLEMENT 20, SPRINGER-

VERLAG, VIENNA, AUSTRIA)


CONCLUDING REMARKS

DEMAND BETTER, FASTER-ACTING & SAFER DISINFECTANTS

SELECT, STORE, USE & DISPOSE OF DISINFECTANTS PROPERLY

DISCOURAGE CLAIMS AGAINST ‘BUG-OF-THE-MONTH’ (‘FEAR-FACTOR’)

ENCOURAGE LABEL CLAIMS WITH WIPING ACTION INCORPORATED

TRAIN & RECOGNIZE HOUSE-KEEPING STAFF BETTER

ICAN SHOULD COORDINATE DISINFECTANT SELECTION & USE

ACKNOWLEDGEMENTS

PROF. SHAHEEN MEHTAR, PRESIDENT, ICAN

PROF. VAL ROBERTSON, PRESIDENT, ICAZ

MRS. NERISER SIBANDA & STAFF OF LUCID EVENTS

MS. YOLANDA GOUWS, STELLENBOSCH UNIVERSITY

MY STAFF & STUDENTS, UNIV. OF OTTAWA, CANADA


FURTHER READING

CARLING & BARTLEY. (2010). EVALUATING HYGIENIC CLEANING IN HEALTH CARE SETTINGS:

WHAT YOU DO NOT KNOW CAN HARM YOUR PATIENTS. AM J INFECT CONTROL. 38: S41-50.

DANCER SJ. (2014). CONTROLLING HOSPITAL-ACQUIRED INFECTION: FOCUS ON THE ROLE OF

THE ENVIRON. & NEW TECHN. FOR DECONTAMINATION. CLIN MICROBIOL REV. 27:665-690.

HUSLAGE K. (2010). A QUANTITATIVE APPROACH TO DEFINING “HIGH-TOUCH” SURFACES IN

HOSPITALS. INFECT CONTROL HOSP EPIDEMIOL 31:850-3.

OTTER JA. ET AL. (2011). THE ROLE PLAYED BY CONTAMINATED SURFACES IN THE

TRANSMISSION OF NOSOCOMIAL PATHOGENS. INFECT CONTROL HOSP EPIDEMIOL 32:687-99.

SATTAR SA. (2010). PROMISES & PITFALLS OF RECENT ADVANCES IN CHEM. MEANS OF

PREVENTING THE SPREAD OF NOSOCOMIAL INFECT. BY ENVIRON. SURFACES. AJIC A38:S34-40.

SATTAR SA & MAILLARD J-Y (2013). THE CRUCIAL ROLE OF WIPING IN DECONTAMINATION OF

HITES REVIEW OF CURRENT STATUS & DIRECTIONS FOR THE FUTURE. AJIC 41;S97-S104.

WEBER DJ ET AL. (2010). ROLE OF HOSPITAL SURFACES IN THE TRANSMISSION OF EMERGING

HEALTH CARE-ASSOCIATED PATHOGENS: NOROVIRUS, CLOSTRIDIUM DIFFICILE, &

ACINETOBACTER SPP. AM J INFECT CONTROL 38:S25-33.



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DISINFECTION OF ENVIRONMENTAL SURFACES IN · PDF filedisinfection of environmental surfaces in healthcare: ... norovirus & other non-enveloped viruses ... what about ebola virus?