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Fomites and Infection Control Charles P. Gerba Departments of Soil, Water and Environmental Science and Epidemiology and Environmental Health Univeristy of Arizona Tucson, AZ Conflict of Interest Statement Clorox - Research funding and consulting GOJO Industries – Research funding and consulting Purethread – Research funding Allied Bio Science – Research funding Waterlogic – Research funding 2 Objectives How are common infections transmitted? The role of hands in spreading microbes. The difference between cleaning and hygiene Germ geography –where the germs are Interventions to prevent the spread of microbes Disinfectants – what’s new Percentage of Disease Due to Transmission Route Person to Person Animal to Human Drinking Water ?% ?% ?% ?% ?% ?% Aerosols ?% Food Fomite Recreation Life in the 21st Century Most of our time is spend indoors (80 - 90%) More people work in offices than ever before We travel more than ever before We spend less time cleaning than the last generation (50% less than 50 years ago) We are less clean (e.g. laundry practices) We spend more time in public places We are more mobile and have more electronic equipment (e.g. cell phones, ipods) We share more common surfaces (fomites) with more people than ever before in history Cleaning vs. Hygiene Cleaning is the removal of unwanted matter Hygiene is reducing the risks of infection 6 Role of Fomites in Transmission of a Disease Person picks up pathogen through contaminated fomite Pathogen falls on fomites e.g. phone, computer Person touches nose or eyes with contaminated fingers and becomes infected with pathogen Sick person sneezes, coughs and pathogens fall on fomite or get aerosolized 7 Mouthing Events in Children (per hour) -81 times under two years -42 times two thru five years -A child swallows the about of dirt on six kitchen floor tiles per day Hand Contact in Adults Adults hour touch their face 15.5 times per 2.5 eyes 5 nose 8 lip Germ Geography Identifying Critical Control Points Home/Work/Play/Shopping Coliform Bacteria and E. coli Coliform bacteria and E. coli are found in feces and their presence on surfaces indicates contamination by feces and the potential presence of disease causing microorganisms Germs at Home 2 Geometric mean per cm or per mL Enteric Bacteria (Coliforms) in the Home by Location 7 6 5 4 3 2 1 0 -1 -2 Sponge Kitchen Sink Bath Sink Cutting Board Kitchen Floor Bath Floor Bath Counter Toilet Seat The Importance of Cleaning Tools in the Spread of Germs Germs in Your Laundry Exposure from Laundry Changes in practices in the U.S Hot water used only 5% of the time. Most use cold water Only 12 minute wash Dry for only 30 minutes Occurrence of Coliforms and Fecal Coliforms in Wash Water After Laundering Fecal Coliform Coliform Arithmetic Arithmetic Average Average Type of Clothing Washer Load Underwear 5.2 x 106 Jeans Per Item Washer Load Per Item 4.5 x 105 5.6 x 105 7.4 x 104 7.2 x 105 1.07 x 105 1.5 x 104 2.24 x 103 Bath Towels 1.2 x 106 1.77 x 103 <1.6 x 104 ND Feces in the Laundry Average pair of underwear contains 0.1 grams of feces Rotavirus and adenovirus 1010-11 virus per gram of feces Salmonella 1010 per gram of feces Hospital Scrubs Summary of Heterotrophic Plate Count for different classifications of scrubs Type of scrub Number of garments Average CFU/sq cm Range CFU/sq cm Unwashed hospital 18 180 5 - 473 Homelaundered 26 143 1 - 848 Hospitallaundered 20 4 1 - 27 New disposable 16 16 1 - 118 New cloth 10 35 1 - 145 20 Bacteria in Home Laundered Scrubs GRAM NEGATIVE Enterobacter cloacae Klebsiella pneumoniae Klebsiella oxytoca Raoultella terrigena Pantoea species Serratia rubidaea GRAM POSTIVE Staph. lugdunensis Micrococcus luteus Curtobacterium luteum Sanguibacter incohoensis Scrubs Hospital-laundered scrubs had significantly fewer (p=0.044) HPC bacteria than home-laundered scrubs Ten percent (3/29) of unwashed scrubs tested positive for E. coli Mold commonly found on all types of scrubs 22 Study of Bacteria in Reusable Cleaning Cloths in Hospitals Collected three cloths each from 10 different hospitals in Arizona Tested cloths by wetting in trypticase soak broth and then squeezing out the liquid and testing for total bacteria, coliform bacteria, spore formers, MRSA and C. difficile Average Number of Bacteria in Towels used to Clean Patient’s Rooms (before use) Hospital Total Bacteria Coliforms* 1 2 3 12,600 63 6,310 1 0 2 4 7,943 0 5 6 7 8 9 10 31,622 100,000 1,000 5,012 6,310 398 0 20 0 0 0 25 *E. coli was identified in two towels Effect of Cleaning Cloth Material on Bacteria in the Cloth Organism Total bacteria Coliforms Molds Cotton 1,995 Microfiber 24,547 P-value 0.01 1 1 6 47 0.0002 0.001 Effect of Disinfectant Application Method Organism Total bacteria Coliforms Mold Spores Soaked 2,239 Sprayed 104,713 P-value 0.01 1 1 15 18 2,188 4,074 >0.0001 >0.0001 0.04 Bacteria Identified in Cleaning Cloths Pseudomonas luteola Klebsiella oxytoca Klebsiella pneumoniae Serratia plymuthica Pasteurella pneumotropica Aerommoas hydrophilia Pantoea sp Escherichia coli Conclusions Reuseable cleaning/towels/cloth can contain opportunistic pathogenic bacteria Washing practices can effect microbial loads in reusable cleaning clothes/towels Microfiber clothes contain more bacteria than cotton A wide range of enteric bacterial types are present in cleaning clothes Home Laundering of Professional Clothing Bleach as directed should yield 200 ppm bleach Hot Water Dry for 45 minutes European Washing Machines Wash at ~180 oF – 140 min wash cycle Germs at Work Number of Germs per Square Inch Bacteria in Offices 32 Parainfluenza on Office Fomites Fall 2004 Percentage of Fomites Positive for Parainfluenza 70 60 Conference Rooms 50 Offices 40 Cubicals 30 20 10 0 New York San Fransico Atlanta Chicago Tucson Total Comparison of Offices that Use Disinfectant versus Offices that Don't Use Disinfectant Average Bacteria 1.00E+05 1.00E+04 1.00E+03 1.00E+02 1.00E+01 Don't Use Disinfectant Use Disinfectant Germs at School School Study (Grade K thru 12)- 2009 Figure 1 Top Three Contaminated Sites in All Schools Total Bacteria/approximate 100 cm sq 1.00E+07 4.77E+06 1.70E+06 8.60E+05 1.00E+06 1.00E+05 1.00E+04 Average Toilet Seat 1.00E+03 1.00E+02 Cafeteria Table Computer Mouse Desk Sites with the Highest Percent of Coliforms in all Schools – it’s not the Restroom!! Site Desk Computer Mouse Cafeteria Table Library Table Bathroom Sink Faucets Water Fountain Keyboard Bathroom Paper Towel Handle Percent of sites positive for Coliforms 59 57 55 53 36 33 33 29 Impact of Disinfectant Wipes on Absenteeism -Seattle Study Two school semesters 3rd and 4th graders Intervention Children’s desk wiped with a disinfectant wipe at the end of each school day Results 50% reduction in absenteeism From Bright et al, 2010; J. School Nursing Shopping with Germs Coliform Bacteria in Reusable Grocery Shopping Bags 49% 51% Coliforms Yes No Reusable Shopping Bags E. coli detected in 30% of the bags No Salmonella detected E. coli Isolation from Shopping Carts Maine 80% Atlanta 79% Chicago 70% Tucson 0% Los Angeles 10% Recent study has associated Salmonella and Campylobacter infections in children and placement in shopping carts The Forgotten Fomites Critical Control Points Phone / mobile phone TV remote Computer keyboard Computer mouse Sink taps / handles Sponges / cleaning cloths Laundry 44 Most Common Disinfectants used in Homes, Public Places and Hospitals/Health Care Facitlies Quats (take 10 minutes) Chlorine Bleach Hydrogen Peroxide Occurrence of Coliforms (%) in Your Dentist’s Office phone 64 mouse 53 0 desk 52 63 keyboard faucet handle 67 light handle 0 18 handsets 70 arm rests door knobs 76 50 22 drawer pulls Impact of Hydrogen Peroxide Wipes Sample Site Dental Office Pre intervention Post intervention Keyboard >1.61E+03 (100->2.42E+03) <1 Mouse >1.84E+03 (100->2.42E+03) <1 Dentist chair arm >1.62E+03 (100->2.42E+03) <1 Patient chair arm >3.38E+03 (100->2.42E+03) <1 <1* <1 Receptionist counter tops >1.68E+03 (100->2.42E+03) <1 Bathroom door knob >5.50E+03 (310->2.42E+03) <1 <1* <1 Office phones >2.14E+03 (110->2.42E+03) <1 Office door knobs >1.58E+03 (100->2.42E+03) <1 Dental tool handles Dentist light Quat Wipe / Hand Sanitizer Intervention In an Office Building Add a bacterial virus to the entrance door handle of an office building with 80 persons Collect samples after 2, 4 and 7 hours of fomites and hands 48 The Virus Bacteriophage MS-2 -~23 nm in diameter -single stranded RNA -no lipid layer -similar in shape and size to the cold virus (rhinovirus)vand norovirus -commonly used as a model for disinfectant testing Add bacteriophage to one persons hand?* 80 persons in building *Person did not know hand was contaminated Virus detection on office workers hands/fomites after times indicated. (MS-2 virus was added to one person’s hand at the beginning of the work day) First place virus detected is the coffee break room Intervention + hygiene education 52% of 80 employee’s agreed to participate Impact of intervention on Occurrence of Virus on Employee's Hands Results The number of people with viruses on their hands was reduced 80 to 50%. The occurrence of viruses in communal work areas (fomites) was reduced by more than 80% after four hours and by 70%100% after seven hours UV Dose (µW*sec/cm2) vs. Distance 0 Ft 3 Ft 5 Ft 8 Ft Distance from Ground 217,185 35,604 10,743 2,593 4 Ft 166,152 68,241 42,428 5,133 2 Ft 208,500 64,087 19,879 5,103 0 Ft Distance from Device UV Inactivation of MRSA Log Reduction of MRSA 0.00 0 Average Log Reduction 2.03 3.07 3.46 Standard Deviation 0.52 0.72 0.55 17,594-17,768 4.22 0.48 35,014-35,845 4.20 0.58 Formica UV Exposure (μWs/cm2) 1,193-1,632 5,543-6,370 10,951-12,502 15,762-18,872 30,433-37,032 Fabric UV Exposure (μWs/cm2) 121,155-126,407 236,256-285,395 Average Log Reduction 0.89 2.55 3.17 3.28 3.70 Average Log Reduction 0.39 1.11 Standard Deviation 1.12 0.74 0.07 0.12 0.16 Standard Deviation 0.24 0.24 10,000 20,000 30,000 40,000 -0.50 -1.00 Average Log Reduction Stainless Steel UV Exposure (μWs/cm2) 1,558-1,615 5,788-6,540 11,948-12,637 -1.50 -2.00 -2.50 Stainless Steel -3.00 Formica -3.50 -4.00 -4.50 -5.00 UV Exposure (μWs/cm2) • Results are an average of triplicate experiments using a collimated beam set up Log Reduction of Clostridium difficile spores on stainless steel UV LOG Exposure REDUCTIO (μW/sec/cm N 2) 0 0 4000 2.09 8000 2.57 12000 2.63 16000 3.19 20000 3.21 STD DEV 0.18 0.23 0.2 0.09 0.1 0.62 + Evaluation of combination of UV and H2O2 Combinations of disinfectants UV disinfection for hard surfaces followed by hydrogen peroxide wipe to evaluate if there is any synergy Test organisms: MS2 C. difficile spores Methods for H2O2 and (UV+H2O2) After inoculating, expose the dry tile to varying times and distances of UV (if necessary, for UV and Synergy) After exposure to UV (not applicable for just H2O2), H2O2 was squeezed onto the tile. After covering the tile with liquid and allowing to sit for 50 seconds, the tile was wiped for 10 seconds. MRSA with and without Hydrogen Peroxide Log Reduction Stainless Steel Formica Polyester Control 0.0 0.0 0.0 UV Horizontal 2.9 4.9 0.8 UV Vertical 5.3 4.4 1.0 UV + H2O2 Horizontal > 5.4 > 4.9 > 5.8 UV + H2O2 Vertical > 5.4 4.9 5.8 Stainless steel Formica Key takeaway: H2O2 + UV is more effective than UV alone. The difference is most pronounced on the soft surface. Polyester The Future Self Sanitizing Surfaces • Copper – toxic to many bacteria and viruses. Recent studies show a 40 to 50% reduction in Hospital acquired infections • Titanium dioxide – uses light energy to kill microorganism. A “Thin film reactor” coating • Silinated sanitizers/disinfection . Disinfectants chemically bound to • hard surfaces Summary Fomites will continue play a major role in disease transmission now and into the future Good hygiene is not cleaning more, but focused and targeted use of disinfectants and cleaning tools Questions?