By Rick Mullen
Maintenance Sales News Associate Editor
Speaking to a group of cleaning industry professionals recently, Dr. Rosie D. Lyles, MD, MHA, MSc, outlined pertinent facts and techniques to combat what she calls public enemy No. 1 — infectious pathogens.
The objectives of her educational session were:
• To learn key terminology associated with environmental cleaning, disinfection and best practices;
• To learn how cross-contamination occurs and understand its implications for public health; and,
• To improve understanding of environmental cleaning and disinfection strategies for preventing the spread of infections on hard and soft surfaces.
“I want to make sure you know the key terminology associated with environmental cleaning, disinfection and best practices, to include pathogens that you have to deal with on a daily basis,” Lyles told the audience. “Why do we clean? We clean for numerous reasons. One reason we clean is for appearance. No one wants to work in an environment where there is dirt, etc.”
Lyles alluded to a survey that showed 70 percent of parents think school restrooms reflect the quality of a school. In addition, one-third of the people surveyed said they have left a place of business because the restroom smelled like urine. Furthermore, 55 percent said they would give a positive or negative review of a business based on restroom cleanliness.
Lyles said cleaning must be done, not only for appearance, but also for health reasons.
Again, citing a study, Lyles said, “Most cleaning professionals are fully aware of the importance of cleaning for appearance and for health. However, only half the respondents believe that their staff is aware of the risks associated with the spread of infectious pathogens in the restroom setting, which is not good. Also, 68 percent said their staff does not understand, or only somewhat understands, the difference between cleaning, sanitizing and disinfecting.”
Lyles defined “cleaning” as removing the dirt and germs from objects and surfaces, while “sanitizing” lowers the number of pathogens on surfaces and objects to a safe level, as judged by public health standards.
“Disinfecting is the only one that actually kills the bacteria and pathogens, and that is what is needed in the facilities in which you work, whether hospitals, schools, etc.,” she said.
Lyles emphasized the importance of proper hand washing as a way to help prevent the spread of infectious pathogens. If a person does not wash his or her hands before exiting a restroom, he or she can deposit harmful bacteria or germs on the next surface touched, such as a doorknob.
“For example, MRSA (methicillin resistant Staphylococcus aureus) bacteria can remain on a surface for up to seven months at a time,” Lyles said. “So, the next person who touches the contaminated surface can get a staph infection. It is like a bad chain reaction.”
Lyles said there are two basic ways to break the chain. One is for people to take ownership of their own health by cleaning their hands properly. Secondly, the restroom, in this example, should be cleaned and disinfected.
Lyles displayed a graphic that indicated the chain of infection includes six different links: pathogen, reservoir, portal of exit, means of transmission, portal of entry, and the new host.
Lyles said each link has a unique role in the chain and each can be interrupted by various means, including such prevention activities as hand washing, cleaning/disinfection, vaccinations and interventions to stop outbreaks.
“Bad” pathogens include MRSA, norovirus, influenza and rhinovirus. Lyles said the most serious pathogen is MRSA. This pathogen was once only found in health care environments, but has mutated into the community setting.
Lyles displayed the following information about MRSA:
• MRSA is a type of staph bacteria found on the skin and in the nose that is resistant to antibiotics. More than 90,000 Americans get potentially deadly MRSA infections every year and, in 2005, nearly 19,000 Americans died from MRSA infections;
• MRSA spreads primarily through skin-to-skin contact and contact with surfaces that have come into direct contact with the bacteria; and,
• To contain and prevent the spread of MRSA infections, the U.S. Centers for Disease Control and Prevention (CDC) recommends cleaning and disinfecting all surfaces that are likely to come in contact with pathogens, which could include toilet seats and restroom sinks.
“Norovirus, meanwhile, is more like a stomach flu,” Lyles said. “You have explosive diarrhea and forceful vomiting where it can come through the nose.”
According to the CDC:
• Norovirus is a highly contagious virus that is the No. 1 cause of gastroenteritis in the United States;
• It causes an average of 800 deaths, 71,000 hospitalizations, 400,000 emergency room visits, 1.9 million outpatient visits and 21 million total illnesses each year;
• It takes as few as 18 virus particles to cause a norovirus infection and, once infected, a person is capable of infecting many others; and,
• Once a norovirus outbreak occurs, it can be difficult to contain, so it is important to have a prevention plan in place that includes cleaning and disinfecting surfaces with U.S. Environmental Protection Agency (EPA)-registered products that have label claims to kill norovirus.
“I call influenza a very ‘sneaky’ virus, because it picks on the most vulnerable of our population — children and older adults,” Lyles said.
Lyles listed some facts about influenza:
• Influenza (flu) is a contagious respiratory illness caused by influenza viruses. About 5 to 20 percent of U.S. residents get influenza, and more than 200,000 people are hospitalized from flu-related complications each year;
• The flu can spread from person to person through the air from up to six feet away via the droplets formed from coughs or sneezes or when people touch contaminated surfaces and then touch their own mouth or nose;
• Studies have also shown that flu viruses can survive on hard surfaces (e.g., stainless steel, plastic) for up to 48 hours and on soft surfaces (e.g., cloth, fabric) for up to 12 hours; and,
• To prevent the spread of flu viruses in school and business restrooms, the CDC recommends regularly cleaning to remove visible soil followed by disinfecting frequently touched surfaces (e.g., door handles, counters, light switches) with a chlorine bleach solution or EPA-registered disinfectant with a label claim to kill flu.
The final “bad” pathogen Lyles discussed is rhinovirus — the common cold virus. Some facts:
• Rhinovirus causes 30-50 percent of all common colds and is responsible for more cases of human illness than any other infectious agent. There are over 1 billion colds in the U.S. each year;
• Viruses that cause colds can spread from infected people to others through the air and close personal contact. Infections can spread through contact with stool or respiratory secretions from an infected person. This can happen when you shake hands with someone who has a cold, or touch a doorknob that has viruses on it, then touch your eyes, mouth, or nose. Airborne transmission is also possible. Rhinoviruses can survive on surfaces for several hours; and,
• To prevent the spread of rhinovirus, frequently clean and disinfect commonly touched surfaces using an EPA-registered disinfectant with a rhinovirus claim. Cough or sneeze into a tissue or your elbow and avoid coughing or sneezing into your hand.
Again, Lyles emphasized the jumping off point for preventing the spread of infectious pathogens is for people to learn and practice proper handwashing techniques. She also said sick people should remain at home, to help prevent spreading harmful germs to their fellow workers.
Human, Animal And Environmental Reservoirs
According to Lyles, the reservoir of an infectious agent is the habitat in which the agent normally lives, grows, and multiplies. Reservoirs include humans, animals and the environment. The reservoir may or may not be the source from which an agent is transferred to a host.
The three classifications of reservoirs are:
• Human reservoirs: Many common infectious diseases have human reservoirs. Carriers commonly transmit disease because they do not realize they are infected, and consequently take no special precautions to prevent transmission. Symptomatic persons who are aware of their illness, on the other hand, may be less likely to transmit infection because they are either too sick to be out and about, take precautions to reduce transmission, or receive treatment that limits the disease;
• Animal reservoirs: Humans are also subject to diseases that have animal reservoirs. Many of these diseases are transmitted from animal to animal, with humans as incidental hosts. Several newly recognized infectious diseases in humans, such as Ebola infection and SARS, are thought to have emerged from animal hosts, although those hosts have not yet been identified. Animal reservoirs are not typically a significant reservoir in public spaces; and,
• Environmental reservoirs: All facilities are different and each can pose unique infection prevention challenges, but in any commercial setting, whether it is a hotel, office, school, airplane and even a hospital; public restrooms represent one of the biggest infection prevention challenges and areas with the greatest potential to serve as a reservoir for infectious agents.
Due to their function and constant use, visible dirt and bodily fluids such as urine, vomit and feces are all common in the restroom. For example, every time a toilet is flushed, it releases a plume of aerosolized droplets that can carry bacteria to other restroom surfaces like floors, walls and handles.
Lyles said from the perspective of facility maintenance, the most important reservoir of infectious agents is the physical environment.
In discussing environmental reservoirs, Lyles pointed to the now famous outbreak in 1976 of what was then a “mystery disease” that infected members of the American Legion. The sickness became know as Legionnaires’ Disease.
According to www.emedicine.medscape.com, “The Legionella bacterium was first identified in the summer of 1976 during the 58th annual convention of the American Legion, which was held at the Bellevue-Stratford Hotel in Philadelphia. Infection was presumed to be spread by contamination of the water in the hotel’s air conditioning system. The presentation ranged from mild flu-like symptoms to multisystem organ failure. Of the 182 people infected, 29 Legionnaires died.”
According to the CDC, Legionella is a type of bacterium found naturally in freshwater environments, like lakes and streams. It can become a health concern when it grows and spreads in human-made water systems such as hot tubs that aren’t drained after each use, hot water tanks and heaters, large plumbing systems, cooling towers and decorative fountains. Home and car air-conditioning units do not use water to cool the air, so they are not a risk for Legionella growth.
On animal reservoirs, Lyles said, “If you are pregnant and you have a cat, you can get an infection called toxoplasmosis. (Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii that can threaten the health of an unborn child.) You can get the infection from handling soil or cat litter that contains cat feces infected with the parasite.
“To break the chain, wash your hands and make sure you clean and disinfect.”
Lyles said cross-contamination occurs when bacteria and viruses are transferred from one surface to another, as in her earlier example of a people who do not wash their hands properly, thus depositing bacteria on restroom surfaces.
Another example of cross-contamination is when a briefcase or a woman’s purse is placed on a bathroom floor and then moved to a sink counter. In this way, germs on a floor can be transferred to the purse or briefcase and then to the sink.
“Every time you put your briefcase or your bag on the floor, and then go home and put it on your bed, you are actually bringing bacteria into your home,” she said. “The abundance of high-touch surfaces and objects in public settings make it easy for patrons, and even cleaning professionals, to move illness-causing pathogens from one surface to another.
“Also, cleaning tools and equipment can become contaminated during the cleaning process, so it is important not to clean multiple areas with the same supplies. Dirty cloths, sponges and mops can spread viruses and bacteria.”
In discussing susceptible hosts, Lyles said effective infection prevention and control is vital in all types of facilities, but is especially important in settings where building occupants or visitors are at greater risk for infection.
“For example, long-term care facilities and their residents are at inherently increased risk of infection,” she said. “Regular person-to-person contact and contact with objects and surfaces in the facility is an integral part of residential care, but it is also a primary risk factor for acquiring and spreading pathogens.
“In college and university settings, high levels of social interaction and close proximity to others make it significantly easier to spread germs. The combination of stress, lack of sleep and poor eating habits often leave students with weakened immune systems. Young adults are also among the least likely to take precautions to prevent illness, meaning students are especially vulnerable to infection.”
Breaking The Chain Of Transmission
Lyles outlined four basic steps for facilities to follow to help prevent the spread of germs that could impact public health:
• Identifying your enemy;
• Reduce the reservoir;
• Target transmission; and,
• Reduce host susceptibility.
“The enemy is MRSA, influenza, norovirus, etc., and we are at war right now,” Lyles said. “Thorough handwashing, cleaning and disinfection is the first line of defense against familiar threats and new challenges.
“You can’t always predict what type of germs will walk through the door; therefore, cleaning professionals need proven products that have extensive kill claims and broad surface compatibility.”
She offered the following tips:
• Select products specifically formulated and EPA-registered to kill some of the most contagious and hard-to-kill pathogens. Bleach and hydrogen peroxide-based products are especially effective; and,
• Disinfectants with short kill times and a wide range of kill claims provide the best value, since they do a lot with less, in a short amount of time.
For hard surface disinfection, Lyles suggested, “Pre-clean surfaces first to remove debris and bodily soils such as urine, feces and vomit, and then use an EPA-registered disinfecting product to kill germs.
“Pay particular attention to disinfecting frequently touched surfaces such as faucet handles, countertops and doorknobs which need to be disinfected at least once a day.
“Ready-to-use disinfecting wipes can offer an easy solution for disinfecting high touch surfaces because they are pre-moistened to deliver the proper concentration of active ingredients every time they are used.
“Remember, it’s important to always refer to the product label and follow manufacturer’s instructions for use and contact time, or the length of time the disinfectant needs to remain wet on the surface to properly kill pathogens. Different products have different contact times for killing certain pathogens.”
When it comes to soft surface sanitation, Lyles said organisms can persist on porous surfaces from several hours to as long as three months.
She offered three steps to improve soft surface sanitization:
• Routinely launder washable curtains, bedding, linens, employee uniforms and other soft surfaces in your facility;
• Use an EPA-registered product to kill bacteria on soft surfaces between laundering and on soft surfaces that cannot be laundered; and,
• Encourage good hand hygiene practices by staff during and between routine cleanings.
“No matter what type of facility you work in, whether it is a hotel, office, school, or long-term care facility, there are contaminated soft surfaces that need attention,” Lyles said. “Carpets, upholstered furniture, mattresses, curtains and bedspreads, just like all hard surfaces, are potential reservoirs of harmful bacteria that can cause infection.
“If left unaddressed, contaminated soft surfaces can pose a risk of infection and can undermine any hard surface disinfection routines your facility may have as well as put building occupants and staff at risk.
“As I said earlier, encourage good hand hygiene practices for your staff during and between routine cleanings. You must train them over and over again in this area.
“Everyone in a facility needs to understand his or her role and responsibilities and follow established infection prevention protocols, which is why training must be a key component of any program. Successful training programs should clearly outline expectations, including what needs to be cleaned, who is responsible for cleaning and disinfecting certain areas and when and how those areas should be cleaned.
“Training efforts should also be designed to help employees get a better understanding of why certain protocols are in place. Sharing basic information on the difference between cleaning and disinfecting, why paying attention to contact times is important and other basic information is a helpful part of driving compliance. Remember, infection prevention is everyone’s responsibility.”
In conclusion, Lyles suggested the following steps:
• Make sure staff members understand the terminology associated with environmental cleaning, disinfection and best practices;
• Know your enemy and implement protocols to guard against MRSA, norovirus, influenza and other important pathogens;
• Explain how cross-contamination occurs, why it has important implications for public health and how to prevent it in your facility; and,
• Environmental cleaning and disinfection strategies are only effective if they are implemented correctly and consistently. Invest in ongoing training and education to ensure staff understand the important role they play in preventing the spread of germs on hard and soft surfaces.
“I would advise you to implement all of these steps, because they are all very important and very crucial. Please remember to use EPA-registered products that will kill bacteria or viruses,” Lyles said.