Environmental Hygiene: What We Know from Scientific Studies

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- Comprehensive interventions and educational programs are helpful
Fitzgerald, et al. (2011) suggest that education of EVS personnel, introduction of a cleaning checklist, and viewing of an educational video by EVS staff only slightly increased cleaning performance.  Face-to-face reporting of cleaning results was well received by EVS staff, further developed a collaborative relationship between Epidemiology and EVS, and contributed to increased cleaning performance. 

McCracken, et al. (2010) suggest that use of a programmatic approach incorporating products, tools and processes, enhanced staff training and engagement, staff surveys and objective environmental hygiene monitoring tools can improve environmental hygiene practices, efficiency, sustainability and staff satisfaction. 

Jean, et al. (2010) investigated if a protocolized double terminal clean performed by especially trained environmental services personnel was effective in reducing the number of MDRA-culture positive rooms and if this intervention would facilitate control of the outbreak. They found that a multidisciplinary intervention involving administration, environmental services, nursing, and infection control resulted in a reduction in MDRA contaminated surfaces and cases. 

Carling, et al. (2008) said that because of significant opportunities in hospitals to improve the cleaning of frequently touched objects in the patient's immediate environment, the information obtained from such assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feedback to the environmental services staff, to improve cleaning and disinfection practices in healthcare institutions. They emphasized that improvements in disinfection cleaning can be achieved in most hospitals without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.

Goodman, et al. (2008) evaluated the adequacy of discharge room cleaning and the impact of a cleaning intervention on the presence of MRSA and VRE on environmental surfaces in intensive care unit (ICU) rooms. The intervention consisted of a change from the use of pour bottles to bucket immersion for applying disinfectant to cleaning cloths; an educational campaign; and feedback regarding adequacy of discharge cleaning. The black-light mark was removed from 44 percent of surfaces at baseline, compared with 71 percent during the intervention. The intervention increased the likelihood of removal of black-light marks after discharge cleaning, controlling for ICU type (medical vs. surgical) and type of surface. The intervention reduced the likelihood of an environmental culture positive for MRSA or VRE (proportion of cultures positive, 45 percent at baseline vs. 27 percent during the intervention. Broad, flat surfaces were more likely to be cleaned than were doorknobs and sink or toilet handles. They said Increasing the volume of disinfectant applied to environmental surfaces, providing education for environmental services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination.

Eckstein, et al. (2007) concluded that simple educational interventions directed at housekeeping staff can result in improved decontamination of environmental surfaces. Such interventions should include efforts to monitor cleaning and disinfection practices and provide feedback to the housekeeping staff.

- Technology could aid manual cleaning efforts
Otter, et al. (2011) suggest that technology-driven advancements in commercially available products may aid cleaning; these products include microfiber cleaning materials, the use of adenosine triphosphate (ATP) analysis for the assessment of surface hygiene, new chemical disinfectants, and area decontamination methods such as vaporized hydrogen peroxide systems and ultraviolet radiation to supplement conventional terminal disinfection.

UV Light
Umezawa, et al. (2012) evaluated a newly developed portable pulsed ultraviolet (UV) radiation device for its bactericidal activity in comparison with continuous UV-C, and investigated its effect on the labor burden when implemented in a hospital ward. The use of pulsed UV in daily disinfection of housekeeping surfaces reduced the working hours by half in comparison to manual disinfection using ethanol wipes. The new portable pulsed UV radiation device was proven to have a bactericidal activity against critical nosocomial bacteria, including antimicrobial-resistant bacteria after short irradiation, and was thus found to be practical as a method for disinfecting housekeeping surfaces and decreasing the labor burden.

Nerandzic, et al. (2012) investigated a hand-held room decontamination technology that utilizes far-ultraviolet radiation (185-230 nm) to kill pathogens, examining the efficacy of disinfection using the device in the laboratory, in rooms of hospitalized patients, and on surfaces outside of patient rooms (i.e. keyboards and portable medical equipment). They found that In hospital rooms that were not pre-cleaned, disinfection with the device significantly reduced the frequency of positive C. difficile and MRSA cultures. While the technology rapidly kills C. difficile spores and other healthcare-associated pathogens on surfaces, the presence of organic matter reduces the efficacy of far-UV radiation, possibly explaining the more modest results observed on surfaces in hospital rooms that were not pre-cleaned.

Rutala, et al. (2010) evaluated the effectiveness of a UV‐C–emitting device to eliminate clinically important nosocomial pathogens in a contaminated hospital room. The device was effective in eliminating vegetative bacteria on contaminated surfaces both in the line of sight and behind objects within approximately 15 minutes and in eliminating C. difficile spores within 50 minutes.

Boyce, et al. (2011) investigated the ability of a mobile UV-C light unit to reduce bacterial contamination of high-touch environmental surfaces in patient rooms and reported significant reduction in  aerobic colony counts and C. difficile spores on contaminated surfaces.

Memarzadeh, et al. (2010) note that although UVGI is microbiocidal, it is "not ready for prime time" as a primary intervention to kill or inactivate infectious microorganisms; rather, it should be considered an adjunct. Other factors, such as careful design of the built environment, installation and effective operation of the HVAC system, and a high level of attention to traditional cleaning and disinfection, must be assessed before a healthcare facility can decide to rely solely on UVGI to meet indoor air quality requirements for healthcare facilities. More targeted and multiparameter studies are needed to evaluate the efficacy, safety, and incremental benefit of UVGI for mitigating reservoirs of microorganisms and ultimately preventing cross-transmission of pathogens that lead to healthcare-associated infections.

Nerandzic, et al. (2010) describe a mobile, fully-automated room decontamination technology that utilizes UV-C irradiation to kill pathogens, examining the efficacy of environmental disinfection using this device in the laboratory and in rooms of hospitalized patients. They concluded that the UV-C device significantly reduces C. difficile, VRE and MRSA contamination on commonly touched hospital surfaces.

VHP
Chmielarczyk, et al. (2012) confirmed the importance of rigorous infection prevention and control measures, combined with VHP decontamination in controlling an outbreak of multidrug-resistant Acinetobacter baumannii (MRAB).

Pottage, et al. (2012) assessed the resistance of meticillin-resistant S. aureus to VHP in comparison with commercially available biological indicators loaded with spores. During the exposure period the recovery of MRSA from the coupons was between 1.5 and 3.5 log(10) higher than the recovery of G. stearothermophilus spores (P<0.05). This greater resistance may be due to the production of catalase which could break down the hydrogen peroxide, resulting in a reduction of the effectiveness of VHP. These findings highlight that the reduction achieved with a commercially available biological indicator cannot always be extrapolated to other micro-organisms. It must be recognized that although gaseous decontamination is the final step of the decontamination process, pre-cleaning of surfaces must be carried out to reduce the microbial loading being exposed.

Havill, et al. (2012) concluded that both HPV and UV-C reduce bacterial contamination, including spores, in patient rooms, but HPV is significantly more effective; UV-C is significantly less effective for sites that are out of direct line of sight.

Falagas, et al. (2011) conducted a literature review on the effectiveness of airborne hydrogen peroxide as an environmental disinfectant and infection control measure in clinical settings. Before the application of any cleaning intervention, 187/480 of all sampled environmental sites were found to be contaminated by the studied pathogens in nine studies that reported specific relevant data. After application of terminal cleaning and airborne hydrogen peroxide, 178/630 of the sampled sites in six studies and 15/682 of the sampled sites in 10 studies, respectively, remained contaminated. Four studies evaluated the use of hydrogen peroxide vapor for infection control. This was associated with control of a nosocomial outbreak in two studies, eradication of persistent environmental contamination with MRSA and decrease in C. difficile infection in each of the remaining two studies.
Davies, et al. (2011) examined three gaseous decontamination technologies for their suitability in reducing environmental contamination with C. difficile: gaseous hydrogen peroxide, chlorine dioxide and ozone; air decontamination and UV-based technologies were also briefly described. The researchers concluded that while there is a role to play for these new technologies in the decontamination of ward surfaces contaminated with C. difficile, the requirement for both a pre-clean before use and the limited 'in vivo' evidence means that extensive field trials are necessary to determine their cost-effectiveness in a healthcare setting.

Chan, et al. (2011) assessed the efficacy of a hydrogen peroxide vapor decontamination, examining the baseline bacterial counts in high-touch zones within wards and evaluated the efficacy of cleaning with a neutral detergent followed by either hydrogen peroxide vapor decontamination, or a manual terminal clean with bleach. They found that dry hydrogen peroxide vapor room decontamination is highly effective on a range of surfaces, although the cleanliness data obtained by these methods cannot be easily compared among the different surfaces as recovery of organisms is affected by the nature of the surface.

Manian, et al. (2011) found that routine terminal cleaning and disinfection of hospital rooms vacated by Acinetobacter baumannii complex -positive patients may be associated with a significant number of ABC- or MRSA-positive room surfaces even when up to 4 rounds of C/D are performed. The addition of HPV treatment to one round of cleaning and disinfection appears effective in reducing the number of persistently contaminated room sites in this setting.

Holmdahl, et al.  (2011) conducted a head-to-head in vitro comparison of a hydrogen peroxide vapor (HPV) system and an aerosolized hydrogen peroxide (aHP) system and concluded that one HPV generator was more effective than two aHP machines for the inactivation of G. stearothermophilus BIs, and cycle times were faster for the HPV system.

Otter, et al. (2010) used hydrogen peroxide vapor (HPV) to decontaminate an entire ICU in an attempt to eradicate undetected environmental contamination during outbreaks of multidrug-resistant Gram-negative rods (MDR-GNR). Surface sampling identified GNR, including MDR strains, on 10 (48 percent) of 21 areas cultured after intensive cleaning but before decontamination with HPV, and on no areas after HPV. No new cases of Acinetobacter were identified for approximately three months after HPV.

Ray, et al. (2010) found that environmental decontamination using VHP combined with comprehensive infection control measures interrupted nosocomial transmission of MDR A. baumannii in an LTACH.

Po and Carling (2010) note, "Although innovative technologies may play a role in the environmental hygiene armamentarium, their logistical complexity as well as the equipment and personnel costs of these interventions make it imperative that independent or consortium‐sponsored, objectively controlled studies be undertaken to clarify the true role of these technologies. Such studies would be particularly important, given the evidence that improving routine hygienic practice can significantly decrease environmental contamination of “patient zone” surfaces and reduce the transfer of healthcare‐associated pathogens to susceptible patients. Given the considerations above, we also believe that the conclusion by Otter et al. that HPV technology should be considered for routine use to decontaminate patient rooms is premature, and we concur with Boyce et al. that additional investigation of room decontamination processes through well‐designed studies is warranted."

Boyce (2009) notes, "Further investigations of the hydrogen peroxide dry‐mist system, hydrogen peroxide vapor systems, and other room decontamination processes, such as the use of gaseous ozone, are warranted to establish the role of such technologies in terminal disinfection of patient rooms and the impact of such technologies on pathogen transmission."

Barbut, et al. (2009) concluded that in-situ experiments indicate that the hydrogen peroxide dry-mist disinfection system is significantly more effective than 0.5 percent sodium hypochlorite solution at eradicating C. difficile spores and might represent a new alternative for disinfecting the rooms of patients with C. difficile infection.

Otter (2009) reports that during a 22-month period at a 500-bed teaching hospital, 1,565 rooms that had housed patients infected with multidrug-resistant pathogens were decontaminated using hydrogen peroxide vapor. Hydrogen peroxide vapor decontamination required a mean time of 2 hours and 20 minutes, compared with 32 minutes for conventional cleaning. Despite the greater time required for decontamination, hydrogen peroxide vapor decontamination of selected patient rooms is feasible in a busy hospital with a mean occupancy rate of 94 percent.

Boyce, et al. (2008) concluded that HPV decontamination was efficacious in eradicating C. difficile from contaminated surfaces, and that further studies of the impact of HPV decontamination on nosocomial transmission of C. difficile are warranted.

As Rutala and Weber (2011) summarize, "There is now ample evidence that no-touch systems such as UV-C light or HP can reduce environmental contamination with healthcare-associated pathogens. However, each specific system should be studied and its efficacy demonstrated  before being introduced into healthcare facilities. Importantly, only a single study using a before/after design has been published that demonstrated that such a system can reduce healthcare-associated infections. Additional studies assessing the effectiveness of no-touch room decontamination systems are needed to further assess the benefits of these technologies. In addition, cost-effectiveness studies would be useful in aiding selection among the different room decontamination technologies and specific systems. Last, if additional studies continue to demonstrate a benefit, then widespread adoption of these technologies (e.g., as a supplemental intervention during outbreaks, after discharge of patients under contact precautions, and on a regular basis in special rooms [e.g., operating rooms]) should be considered for terminal room disinfection in healthcare facilities."

- Self-sanitizing surfaces could supplement manual cleaning
Proper and thorough environmental cleaning is a necessity for pathogen removal. But there are some interesting high-tech solutions on the horizon, such as so-called "self-sanitizing" surfaces. As Kingston and Noble (1964) observe, "It might help to reduce the spread of some infectious diseases is surfaces which are liable to bacterial contamination could be treated so as to make them able to kill organisms subsequently deposited on them." Metals such as copper and silver have long been investigated for their antimicrobial properties, and even newer technologies such as titanium dioxide-containing surfaces are gaining interest among researchers. 

As Weber and Rutala (2012) note, "In the past several years, another method of reducing contamination of room surfaces has emerged: self-disinfecting surfaces. Such surfaces have also been called 'self-sanitizing' and because microbial killing requires direct contact with the surface, the term 'contact killing' has also been used." Weber and Rutala (2012) review these technologies, including copper, silver, triclosan, quaternary ammonium salt, engineered microtopography to inhibit bacterial biofilm formation, and light-activated antimicrobial coatings. They note, "The potential development of self-disinfecting surfaces has tremendous possibilities. Most importantly, the use of such surfaces could minimize the impact of poor cleaning and disinfecting practices during routine and terminal room cleaning and disinfection. However, several cautionary considerations should be noted. First, many of these surfaces have demonstrated only modest killing (<2 log10 reductions in pathogens). Second, the ability of these new surfaces to kill intrinsically more-resistant pathogens, such as C. difficile spores and norovirus, has often not been fully evaluated. Third, the cost of installing such surfaces has not been described. Fourth, only incomplete information is available on the durability of such surfaces and whether their antimicrobial activity is affected by temperature, humidity, the frequency of cleaning, and the presence of organic load. Finally, no studies have been published that demonstrate whether installing such surfaces reduces the incidence of healthcare-associated infections. Although high-touch surfaces have been defined, the relative contribution of individual surfaces to the contamination of the hands of healthcare personnel and to the risk of cross-transmission is incompletely defined. Thus, it is unclear which environmental surfaces and medical devices in patient rooms should or could be coated with a self-disinfecting surface. Nevertheless, continued research in this area to discover means of reducing the impact of environmental contamination in the transmission of healthcare-associated pathogens is clearly warranted."

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