Tori Whitacre Martonicz is the editor of 

.  She has been a writer and editor for over 30 years, and she has an MA and BA in English Composition/Literature from the University of Akron in Akron, OH. She lives in Ohio with her husband; son; 2 tiny dogs, Selena Brigid Sophia and Doctor Danger Dog; and a big black cat, Freya. She loves reading, writing, gardening, and spending time with her loved ones.

Since COVID-19 is here to stay, are health care workers apathetic to the effect of influenza? The last 2 flu seasons were “rather aberrant,” says William Schaffner, MD, medical director of the National Foundation for Infectious Diseases, said in an interview with 

). “Two years ago, there was no flu. Well, that was because we were all locked up. Children are the great spreaders of the influenza virus in our population, and they were all at home.”

Schaffner continued, “Last year, we had an influenza season that started up in December and [went] into early January as though it were going to be a moderately severe season. And then the bottom fell out! Influenza just plummeted and then, surprisingly, it lingered for a long time, and we were getting cases of flu beyond April and into May. So we’ve had 2 aberrant seasons, both of them less impactful than usual.”

Two milder-than-usual flu seasons, plus a population worn out with relentless worries about COVID-19, may have created an apathetic attitude about flu for some individuals. “Recent memory on the part of the general public is a little bit dim on influenza now,” Schaffner said. “We’re going to have to remind them that this is also an illness that we have to take seriously.”

The public may not be the only ones who need a refresher course. Although health care workers seem to be more aware of the importance of influenza prevention thanks to the COVID-19 pandemic, “they have expressed high levels of frustration, burnout, and fatigue with interventions which can lead to subsequent challenges with implementation,” Kate Grusich, a public affairs specialist for the Centers for Disease Control and Prevention (CDC), said in an interview with 

However, she added, “The pandemic has highlighted the role of core infection prevention and control (IPC) practices like hand hygiene and environmental disinfection and led to renewed efforts to improve these practices.” The last few years have been extremely instructive. “Lessons learned about the importance of ‘source control’ is one specific example that will likely continue to pay dividends for prevention efforts for other respiratory viruses, including influenza viruses,” she said.

Influenza in a medical institution “has a different epidemiology and effects compared to influenza in the community,” causing more complications and mortality, warn investigators for the Transgovernmental Enterprise for Pandemic Influenza in Korea, who published a guideline on flu prevention and control in health care settings.

Roughly 0.3 to 0.8 cases of flu occur per 100 hospitalized patients, the researchers say. When an outbreak happens in a health care institution, the attack rate increases to 0.7% to 20%, and can rise to more than 30% in the ward where the outbreak began. In a long-term care facility with many elderly patients, they add, the attack rate can leap to 70%. The risk gets higher for the staff, too, of course, with an attack rate of 11% to 59%.

However, the study authors cite research that found when “aggressive” infection control measures were used, such as vaccination, reporting and monitoring respiratory symptoms, and “exclusion from work” for the symptomatic, the attack rate for health care workers was maintained at less than 2%.

The key is to cast a wide protective net. Preventing the spread of pathogens, like influenza viruses, in health care settings depends on implementing sets of interventions to “build redundancy” and improve effectiveness, Grusich says. Interventions like early recognition of patients with acute respiratory illness who might have influenza and the use of recommended personal protective equipment are important. She says the use of facemasks by symptomatic patients for source control, although recommended as part of standard precautions for people with respiratory symptoms for years, is also an important intervention that has been used for COVID-19 patients in health care settings, and should be applied to all patients with respiratory symptoms in health care settings.

The Occupational Safety and Health Administration (OSHA) recommends, among other things, encouraging sick workers to stay home; using airborne infection isolation rooms; making sure HVAC systems in patient rooms, procedure rooms, and examination rooms are functioning properly; and limiting the transport of infectious patients throughout the facility (instead, conduct exams and procedures at the bedside). However, OSHA warns, pandemic flu is always a concern for health care employers, and advises that a pandemic flu plan “should be based on a ‘worst-case’ scenario.”

As Grusich indicates, it’s not a matter of simply covering bases but covering them using redundant measures. The “cornerstone of influenza prevention,” she said, is annual vaccination. Here again, COVID-19 has stolen nearly all attention. That’s one reason Schaffner is concerned. “[In] the fall of 2021, as we were starting to vaccinate for influenza, there had been so much attention [given] to [the] COVID-19 vaccine that I had to reintroduce the notion of influenza to [individuals] and remind them [it] was another nasty respiratory virus [for] which we have vaccine. And I felt I was starting from scratch,” he said.

Certainly, the steps people took to prevent COVID also helped prevent flu. And Grusich noted only slight reductions exist in the estimated percentages of children and adults who received the influenza vaccine this past season compared with the 2020-2021 season. “However, the estimated percentage of pregnant [individuals] who received [an] influenza vaccine during this past season was substantially lower than [in] the [previous] 2 seasons,” she said, adding the reasons for lower influenza vaccination coverage in children, pregnant individuals, and nonpregnant adults are unknown.

“Despite best efforts, flu vaccination in the US has remained under 50% for most seasons, although it has slowly been rising.”

Why do some individuals not get vaccinated against influenza? Schaffner said a myth he’d like to dispel is the idea “that because we do not have a perfect match between the vaccine and the circulating virus, the influenza vaccine’s not good. ‘We don’t need to get it.’ That’s a very dangerous concept. Even [if] there’s not a good match, there’s often sufficient protection so the recipient is protected against the most serious aspects of influenza.” These aspects include hospitalization, intensive care unit admission, and death.

For health care workers specifically, he said, “By getting the vaccine, we are not only protecting ourselves—it’s a 

. We don’t want to give our infection to our patients! It’s important that we do everything as a professional and ethical responsibility to prevent the transmission of our virus to our patients.”

According to results of a CDC survey of 2,391 health care personnel, 76% of health care workers reported getting flu shots in the 2020-21 season. That was fewer than the previous season (81%), although not statistically significant. Vaccine coverage was highest among those working in hospitals (92%) and lowest among workers in long-term care facilities (66%).

“One of the things that accelerated change in hospitals and large health care systems was the vaccine became mandatory,” Schaffner said. “And that concept has not been embraced in the long-term care industry. I think because there’s so much turnover in personnel, industry leaders are concerned [whether] they’ll have enough [staff] working if they insist on vaccination. That’s what I keep hearing.”

The CDC survey results showed physicians, nurses, and pharmacists had the highest coverage (91.3%, 90.3%, and 90.3%, respectively). Interestingly, receipt of a COVID-19 vaccine was the second strongest factor correlated with higher influenza vaccination coverage. Also interesting: 10.5% of respondents said they got vaccinated “to reduce flu’s impact on the health care system during the COVID-19 pandemic.”

Vaccination coverage was lowest among health care workers whose employers neither required nor recommended vaccination. “Before mandates, there were clear distinctions among [individuals] depending upon their professional background. Pharmacists were the best vaccinated. Over time, the doctors [were] second, but the nurses were always in third place. The literature is full of this. Nurses express more concern for one reason or another about vaccination, which is a matter of double concern because our nurses have the most contact with patients. You would want them to be vaccine advocates rather than vaccine cautious,” Schaffner said.

The main reasons health care workers gave for not getting a flu shot were “I do not need the vaccination” (17%), “I might experience side effects or get sick from the vaccine” (12%), and “I don’t think the vaccination is effective in preventing flu” (12%).

“Some health care providers don’t like needles. Some are concerned the vaccine isn’t good. They’re concerned about—and this is not trivial—side effects. Well, [most individuals] who get [the] influenza vaccine may have a sore arm for a few hours or a day, but it’s unusual. And [if] we look at experience, we don’t have a big spike in absenteeism for reasons of side effects when we get these vaccines,” Schaffner said.

But physical adverse effects are not the only thing worrying health care workers. Schaffner said they may be concerned about “adverse effects in the sense that if they’re not working, they won’t get paid. There are lots of single health care workers out there, and [for] single moms, that’s a real threat to their home economics. And there [are], among younger women who are health care providers, lingering concerns about reproductive issues. Of course, influenza vaccine is recommended for [anyone] who’s pregnant.

Research has shown that workplace vaccination promotions, such as on-site clinics, can boost vaccination numbers. Convenience can be one of the best-selling points for flu vaccination, because economic concerns include not wanting to come in on an unpaid day to get the vaccine. “You can’t penalize people for getting vaccinated,” Schaffner says. “You have to provide the vaccine during work time.” That means also for the people who work at night or on weekends. “You may actually have to, in certain circumstances, bring the vaccine 

In the CDC survey, most of the respondents (up to 87%) agreed or strongly agreed with statements such as “Flu vaccine is safe” and “If I get a flu vaccine, people around me would be protected.” Positive attitudes toward the safety and effectiveness of the vaccine were strongly associated with higher vaccination coverage. On the other hand, approximately half of health care workers disagreed with the statement that “flu is a serious threat to their health.”

The flu virus is notoriously mutable, providing new challenges every year. Can we know—or guess—what this coming flu season will be like? “The CDC long ago discovered that predicting flu was a very [iffy] business, Schaffner says. “So I won’t predict that but I will tell you that in Australia, they’ve had a fairly brisk influenza season. It doesn’t always predict what will happen during 

 winter, but it is a cautionary note. So if we needed another reason to be vaccinated, there it is. We don’t know what comes, so we hope for the better and prepare for the worst. And preparing for the worst is, ‘let’s all get vaccinated.’”

Baek JH, Seo YB, Choi WS, et al. Guideline on the prevention and control of seasonal influenza in healthcare setting. 

. 2014;29(2):265-280. doi:10.3904/kjim.2014.29.2.265

Occupational Safety and Health Administration. United States Department of Labor. Employer guidance reducing healthcare workers’ exposures to seasonal flu virus. Accessed Aug. 15, 2022. 

https://www.osha.gov/seasonal-flu/healthcare-employers

USAFacts. US coronavirus vaccine tracker. USAFacts.org website. Updated August 3, 2022. Accessed Aug. 15, 2022. 

https://usafacts.org/visualizations/covid-vaccine-tracker-states/

Centers for Disease Control and Prevention. Influenza vaccination coverage among health care personnel — United States, 2020-21 influenza season. Updated October 7, 2021. Accessed Aug. 15, 2022. 

https://www.cdc.gov/flu/fluvaxview/hcp-coverage_1920-21-estimates.htm

Articles

Because of mask-wearing and social distancing, numbers of influenza cases have been down the last 2 years. However, experts say numbers this year could  go back up numbers in prior years. The public and health care workers alike need a nudge to get vaccinated. 

Preventing Influenza in the Health Care Setting

Health care environmental professionals meet in Orlando, Florida, from October 3-5, 2022, The Association for Health Care Environment (AHE) annual conference, 

AHE Exchange, AHE Conference & Solution Center

, is being held on October 3-5, 2022, in Orlando, Florida.

) reached out toRock Jensen, Association for Health Care Environment (AHE) advisory board president, and the administrative director of support services for Yuma Regional Medical Center, for his insights on what AHE hopes the attendees gain from their experience.

What is AHE’s focus for this year’s annual conference?

At the conference this year, we celebrate and embrace the opportunities to provide greater insight, education, and certifications to our members.

®: Would you please describe the educational opportunities at this year’s AHE conference?

We have spent years at AHE developing signature certification programs for AHE members. The only national industry organization to provide this. We set up education opportunities and classes at the conference location, that take place days before the conference even officially begins this year to be able to provide these classes during in-person settings where members can engage with trainers and enhance their educational opportunities. This year before the conference, we are offering the Certificate in Master of Infection Prevention and our CSCT (Certified Surgical Cleaning Technician) Train the Trainer workshop. We also offer the AHE CHESP (Certified Healthcare Environmental Services Professional) review sessions and exam prep course. This certification is the gold standard for environmental services leaders.

Other online courses being offered are….

Employee Engagement: Going the Extra Mile

Essentials of Infection Prevention of Environmental Hygiene

Foundations for Success in Environmental Services Management

The Lean Management System in Health Care

Ultimate Scores for the Ultimate Experience

Disinfectants: The Essentials of Evaluation and Selection

Our focus from the advisory board of AHE has been to put in place programs and education that will allow members to be seen as the thought leaders providing insight and expertise, along with our infection prevention leaders, in providing safe and healing environments for our patients, visitors, and staff. This education not only ensures they have the tools, such as our extensive practice guidance, but also certifications validating that understanding and expertise.

AHE has also partnered with The Ohio State University to create the first academic certificate in health care environmental services within a hospitality management program. The program is operated through The Ohio State College of Education and Human Ecology. Students in this college are studying hospitality management alongside existing health care professionals. The program consists of 12 credit hours (3 courses and an internship).

AHE is also involved with the Small and Rural Sustaining Initiative to spread quality Improvement. They are driving applications for scholarships and training to health care EVS teams in rural areas. So far in 2022, over 198 applications have been received and accepted.

Finally, AHE through the programs I’ve noted are using them to influence health care professionals and help decrease infections while improving patient satisfaction across the spectrum. To help accomplish this, AHE is collaborating with key government infection prevention organizations such as the Centers for Disease Control and Prevention and becoming a standard setter and influencer in the creation of health policies across all health care settings.

The Association for Health Care Environment (AHE) annual conference brings together those individuals passionate about environmental hygiene. Rock Jensen, the AHE president for the board of advisors, describes to ICT® the goals of this year's conference.

2022 AHE Conference Highlights Environmental Education

’s) wide-ranging coverage of the infection prevention and control world. Everything from interviews with known opinion leaders, to the news that infection preventionists and other health care professionals can use on their jobs.

Sepsis: Earlier Detection With New Clinical Surveillance Tool

A sepsis diagnosis is expensive and deadly, and early detection and treatment are key to saving lives. However, sepsis is not always easy to diagnose early, so a new advanced analytics surveillance tool can increase the chances of an improved outcome.

How to Obtain Better Hand Hygiene Adherence: Ideas From Health Care Workers on the Floor

Many studies have been done on how to increase hand hygiene adherence. However, ICT

 decided to go to the source and ask the health care workers themselves why they do not always follow hand hygiene.

Inpatient and Outpatient Clinics Must Monitor Fomites as Part of IPC Protocols

Thorough cleaning and disinfection reduce the role fomites play in the spread of disease.

Investment in Environmental Services Saves Money and Lives, Boosts Morale: An Example From Geneva

Environmental services teams (EVS) are crucial players in ensuring patient satisfaction and combating health care–associated infections, yet, too many EVS teams are invisible. They deserve recognition, and this article by environmental hygiene experts explains why and how to give appreciation effectively.

How infection preventionists communicate with those individuals with whom they interact is a tightrope of how to do it well and effectively. Read this article from readers' favorite, Heather Saunders, MPH, RN, CIC, to find out how to not fall off that tightrope in her second of 3 series on the 3'Cs of how to be a successful IP.

Take 5 minutes to catch up on Infection Control Today’s highlights for the week ending September 30.


Weekly Rounds: Sepsis Surveillance Tool, Monitoring Fomites, and More

September is National Sepsis Month, and when a patient is in septic shock, it kills 34% of the time. Sepsis is a deadly, expensive, and difficult to diagnose medical condition, and often the clues within the medical record do not come together for early detection.

One tool many hospitals use is the standard systemic inflammatory response syndrome-triggered electronic health record (EHR) alerts that aid in detection. However, the detective work is still mostly by time-consuming retrospection because the information the EHR alerts send are often wrong or misleading, and health care professionals (HCPs) end up with alert-fatigue and do not pay attention to the signals. However, what if the alerts were more accurate and more often gave earlier information to those HCPs who need the information? 

 (Blessing), an integrated health system in Quincy, Illinois, was searching for an answer and selected 

 to more quickly identify and treat patients with sepsis or sepsis shock—up to 6 hours earlier—leading to possibly better patient outcomes.

a hospitalist and the chief quality and safety officer for Blessing Health spoke with 

about sepsis and describe how Blessing Health using this new innovation to manage information to pinpoint patients at risk of sepsis and save patient lives easier and faster.

: What is sepsis, and why is it so deadly?

Sepsis is the body's response to an infection. The body triggers a chain reaction, and that reaction can damage your own tissues. If left untreated, it can progress to septic shock, which is when the blood pressure drops, which can lead to severe organ problems and even death. If we intervene and give early treatment with antibiotics and IV fluids, it improves the chances for survival. But without treatment, sepsis can lead to tissue damage and even death.

Would you please describe the POC Advisor’s role?

 Point of care (POC) Advisor is a clinical decision support tool. What does that mean? Clinical decision support tools take data, usually from our electronic medical records, and turns it into actionable information to help the clinicians decide about a patient's care. They take over some of the routine tasks and can recognize changes in vital signs, changes in labs, and then warn the clinicians of potential problems or prompt suggestions for the clinical team to consider. In this case, the tool searches our medical record for signs and symptoms of possible sepsis, and then alerts the nurses and doctors taking care of the patient that sepsis might be present.

: Please walk us through the Blessing Health collaborative approach.How does the POC Advisor fit in?

 Blessing has been working with a multidisciplinary sepsis committee for more than a decade. The surviving sepsis campaign came out with international guidelines back in 2004. Then in 2011, we revamped our multidisciplinary team, and it has met monthly ever since. It's currently led by a fulltime registered nurse sepsis care coordinator. The committee meets and collaborates to produce standardized evidence-based order sets. We have a nurse-driven sepsis screening protoco; we have a nurse-driven testing, order-set protocol. We have a code sepsis alert that can go off that can get clinicians to the bedside quickly to assess the patient, implemented technology to assess fluid responsiveness in our patients. All of these different interventions have allowed us to demonstrate significant improvement in our sepsis core measure and our sepsis mortality. But we still have opportunity in the population of patients who don't have sepsis on admission. They're admitted to the hospital for other reasons, and then they develop sepsis. So POC Advisor will provide one more layer to helping our clinicians recognize when a patient is starting to develop signs and symptoms of sepsis, especially on our medical-surgical floors, and then give an alert to our clinicians, so they can make timely decisions.

: Do you have an infection preventionist on staff, and now does that individual interact with the POC advisor?

 The role that would be closest to what you're referring to would be our sepsis coordinator. She's a registered nurse, and she's in charge of our sepsis program. She chairs our sepsis committee meetings. She's developed a lot of the tools that I mentioned before, but she's the one right now piloting with the POC Advisor, getting all the alerts on any patient inhouse who fires a risk for possible sepsis. Then she's reaching out either looking in the EMR or reaching out to the bedside staff to investigate to confirm if sepsis is present, and then to notify clinicians that the alert suggests possible sepsis and when the patient needs more of a workup.

: How is this new approach making an impact at Blessing Health?

 It's early to come to any conclusions about outcomes. But I think [POC Advisor] is one more layer. It's a tool that can alert our staff to be aware that there appear to be some changes in that patient, whether it's vital signs or labs or new signs or symptoms of infections. Like I said, the population that we hope to impact the most is those who aren't admitted with sepsis. We don't know that they have sepsis, and then they develop signs and symptoms after admission. So that's the population that we're targeting.

: Of the patients with sepsis, do more come to the hospital with that diagnosis or with another unrelated diagnosis?

Most of our cases, though, would come in with a known diagnosis of sepsis, and they're recognized and treated in the emergency room. Then there's a smaller group of patients who come in, and they might have pneumonia or an infection, or they might not, but then they develop or start to exhibit signs of [sepsis] later, and those are the ones who are a little harder to capture.

Videos

A sepsis diagnosis is expensive and deadly, and early detection and treatment are key to saving lives. However, sepsis is not always easy to diagnose early, so a new advanced analytics surveillance tool can increase the chances of an improved outcome. 

Every medical professional knows the importance of hand hygiene (HH). It is the first and most critical defense against the chain of infection. So why is HH adherence so difficult to maintain in health care facilities? Countless meth­ods have been devised to encourage and require adherence: apps on cell phones, video cameras, computer programs, stick­ers, and other small tokens of positive feedback, and most often, infection pre­ventionists (IPs) among health care work­ers (HCWs) noting who followed required HH guidance and who did not.

But why do HCWs, knowing how important it is, not perform the appro­priate HH procedures every single time it is endorsed or required by their facilities? 

) went to IPs and asked, “What keeps you from per­forming HH, and what do you think keeps other HCWs from consistently adhering to HH requirements?”

Leslie Bozigian Curtin, RN, CMIP, former assistant director of nursing and infection preventionist at Sumter East Rehab, has been in the health care field for 40 years. “To break the chain of infection, you have to have an infective agent, a method of transmission, and a susceptible host. Then you must have [a] method of getting the agent to the susceptible host. So anytime you can break any one of those links in the chain, you will break the infection process. The easiest way to do that is HH,” she said.

Why Isn’t Hand Hygiene Consistently Performed?

Tracy M. Field, RN, corporate infection preventionist for Ecumen, a long-term care organization, told 

 she sees HH not per­formed, especially in long-term care (LTC) facilities, despite technological advances. “Things have come a long, long way. In the 30 years I’ve been in health care, one of the biggest things that has developed is the placement of hand sanitizer. They have those wall units right at the patient rooms, right at the resident rooms. They have these strategic placings of solution everywhere. But even though those are there, I still see [HCWs] walk by them,” she said.

The first barrier to HH adherence is familiarity with the patient, Field told 

. “We live and work with these [patients] whom we love very much. We’re their family, and they’re our family. When you feel like you love this [patient], you take care of them every day; you don’t look at them as infectious. You might skip [HH] because it’s not like the hospital…and this [patient] in front of you is not super sick. It’s a different situation. In senior care, HH is just as important: all we can do for infection prevention. But there is this sweetness about the care we give [due to familiarity]. I see that as a big barrier,” she said.

Field also explained the second barrier: complacency. In an LTC facility, an HCW may think, “‘I took care of this person every single day [in the past] week; I know they’re not sick.’ The HCW comes back 2 days later, [and the patient has] COVID-19 or norovirus. And the HCW was already exposed. There’s this kind of complacency where the HCW thinks, ‘Oh, I take care of these [patients] all the time. They’re not sick.’ I see that thought as a barrier for senior care,” she said.

Other reasons for improper HH that came up in the discussions with IPs were staffing challenges and lack of time. In these situations, the HCW tries to get everything done, and HH is the easiest and first guideline to be overlooked. “Staff shortages are so overwhelming that you’re frazzled and frustrated,” Field said. 

However, Field explained these feelings are no excuse. “[HCWs] complain they don’t have time. [However,] I don’t think [HCWs] can argue they don’t have time to wash their hands or…use hand sanitizer…It is not that we don’t have time. Our mind has gotten so loaded with wearing the mask, wearing eye protection, putting on a gown, and so on for these rooms. It’s an overload of intense situations that is bogging HCWs down. We lose that laser focus, and you fall back and miss some steps,” she said.

Curtin tells her HCWs to perform HH in the following situations:

Before you go into any other room on the unit

If you go into someone’s room and deliver a tray

After providing care requiring gloves, you must take your gloves off and wash your hands again

 also asked Laura Miller, MD, MPH, FAAFP, the main reason she sometimes finds herself not following HH procedures. Miller is an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota in Minneapolis. “I think number 1 is time and so many different things in our cognitive spaces. We’re in and out of different locations with patients and care teams. There’s a lot of things going on [and] a lot moving parts happening,” Miller said.

Miller said another reason for poor HH adherence is lack of access to hand sanitizer. It may not be refilled or in the right place. “That’s a big gap I have noticed, and it is certainly something that could be actionable. We have come a long way now that we are in the era of hand sanitizer solutions readily available. We’ve transitioned to having [hand sanitizer] alongside hand washing stations. It is handier and more useful to have hand sanitizer solution available instead of hand washing [stations] because it takes so much more time and space to [wash].”

Additionally, according to Miller, simply remembering to do HH may be difficult “especially in more emergent and urgent

situations, when you’re trying to get in the emergency department [because] your patient is not doing well in the hospital.” She went on to say, “When you’re in obstetrics, and you’re having a crunch in your time, it’s hard in the moment to stop when you have something more urgent in front of you.”

 about sticky and/or smelly hand sanitizer or soap. “There have been times when a refill pack or something is different…so I’m going to avoid that one.” She also mentioned allergies or dermatologic effects from hand sanitizer solution. Being alcohol based, it is a drying agent that may cause severe and chronic skin issues.

However, Curtin said there is no excuse for lack of HH adherence; even children know to wash their hands well and often.

No matter their reason for improper HH, her admonition to HCWs is always the same: “You can’t wash your hands or use hand sanitizer too many times.”

Many studies have been done on how to increase hand hygiene adherence. However, ICT® decided to go to the source and ask the health care workers themselves why they do not always follow hand hygiene.


Henry G. Spratt, Jr, PhD, is the senior microbiologist and professor in the Department of Biology, Geology, and Environmental Science at the University of Tennessee at Chattanooga. His microbial ecologically based research, which now focuses on the presence of viable pathogens in clinic environments, has resulted in over 110 presentations at conferences and over 25 publications.

David Levine, PhD, DPT is a professor and the Walter M. Cline Chair of Excellence in Physical Therapy at the University of Tennessee at Chattanooga. His research includes public health epidemiology, control of clinical infectious disease, and Ehlers-Danlos syndrome. He has

Susan McDonald, EdD, OTR/L, is an associate professor and director of the occupational therapy program at the University of Tennessee at Chattanooga. Her research includes clinical infectious disease, Ehlers-Danlos syndrome, and educational research. She has more than 15 publications and has given more than 75 conference presentations.

Meredith Rippy, BS, earned her degree in preprofessional biology at the University of Tennessee at Chattanooga in 2022. Her research involves surgical patient care, psychological variables associated with COVID-19 vaccination, and viability of pathogens on occupational therapy instruments. Her research has resulted in 2 publications and 17 presentations.

Health care professionals know anything you touch can serve as a reservoir for pathogens. They also know you can transmit or contract a pathogen by coming in contact with a contaminated fomite (inanimate object). As part of our medical education, we were taught fomites can play important roles in the spread of infectious disease.

 Doorknobs and light switches are the usual suspects, but fomites also include countertops, handrails, mobile phones, and clothing.

These items are present in most indoor environments. However, when considering health care facilities, the number and types of fomites increase dramatically, as does the presence of infectious pathogens present in those facilities.

Protocols for the proper disinfection of fomites have been in place for decades. Routine procedures for disinfecting surfaces in health care and other facilities were seriously tested when SARS-CoV-2 appeared in 2020. The spread of COVID-19 prompted questions about its mechanisms of transfer. What was more important to address: person-to-person contact, airborne transfer, or fomite transfer? Not knowing exactly how individuals became infected with COVID-19, early studies suggested the virus could survive on plastic or stainless steel for days, resulting in advice to disinfect everything.

Table. Potential fomites in a neonatal intensive care unit of a children's hospital inpatient clinic

However, even though the COVID-19 virus can survive for days on surfaces, epidemiological data did not support contact with contaminated fomites as the greatest risk for spread of infection. Later studies on the importance of social distancing and mask wearing helped provide a better mechanism to avoid spread of the virus in indoor environments.

 Vaccination is now recognized as the best mechanism to avoid the spread of COVID-19.

Airborne mechanisms are more responsible for the spread of COVID-19 than contact with contaminated fomites, evidence suggests. However, the automatic reaction to disinfect surfaces opened up discussion on fomites as transmission vectors for infectious disease.

For a recent study of a neonatal intensive care unit (NICU) in a local children’s hospital, swab samples were taken from 20 sites in the unit by researchers from the University of Tennessee at Chattanooga’s Clinical Infectious Disease Control (CIDC) Research Unit (

). Results of this study indicated that of the 20 NICU surfaces swabbed, 12 sites (60%) had viable staphylococci and 4 of those sites (20%) had methicillin-resistant 

 However, Centers for Disease Control and Prevention (CDC) guidelines on routine environmental sampling for pathogens in hospitals deemed swab sampling not cost-effective, discouraging its use unless certain criteria (eg, ongoing bacterial infections of unknown etiology) were met.

 As a result, surface contamination of MRSA within this NICU would have gone unnoticed without the work of the CIDC.

Many outpatient clinics also have surfaces that come in contact with patients and act as vectors for infection. The CIDC also conducted studies of selected fomites in a children’s outpatient clinic and physical therapy clinics and looked at devices linked to recovery for hip replacement surgery.

Figure. Inpatient NICU sites with repeated positive swabs for staphylococci

In the children’s outpatient clinic, 72 of 208 (35%) swabs taken over a 6-month period found viable MRSA on the floors and toys that patients played with in the waiting room.

 In general medicine and pulmonary unit rooms of this outpatient clinic, similar levels of contamination were found, with significantly higher levels of MRSA on the general medicine floors than on the pulmonary unit floors (

 In both the inpatient and outpatient clinics, floors are generally not off limits to children sitting or playing. Additionally, any medical instrument in clinic rooms (eg, blood pressure cuff or pen/pencil) that falls to the floor may become contaminated with pathogens present on the floors. Clinics should consider implementing protocols about contact with floors and dropped items.

For outpatient health care workers, including physical therapists (PTs) and occupational therapists (OTs), specific instruments play a critical role in patient therapy. For example, a common therapy in PT clinics is therapeutic ultrasound. This therapy involves not only the ultrasound head but also a coupling gel (usually contained in a bottle) that enhances the efficacy of the ultrasound. In a 2014 study, viable MRSA was observed on nearly 4% of the tips of gel bottles sampled.

 Although viable MRSA was not found on the ultrasound heads, other species of bacteria were found on 35% of the ultrasound heads tested. When ultrasound heads were disinfected using an approved quaternary ammonium-type disinfectant for 30 seconds, only 1 ultrasound head had any living bacteria.9 One option to reduce potential contamination from ultrasound coupling gels would be to use sterilized, single-use packets of gel for each patient.

In a study of physical therapy clinics, 16 of 81 (20%) bottles of lotion and cream used in massage therapy (soft tissue mobilization) had viable bacteria including 

 on the threads of previously opened bottles.

 New bottles of lotion and cream did not have viable bacterial contamination. If protocols are in place to properly disinfect these bottles, risk of infection will decrease.

OTs must be careful with therapy devices that go home with patients, including those for patients recovering from hip replacement surgery. To limit the need for patients to bend over, reacher tools and sock aids help them pick up items from the floor or put their socks on. Both items, particularly during the training period in a clinic, may be shared with other patients.

In a CIDC-sanctioned study of these OT devices, a different tack was taken. By adding living bacterial cultures (

in known quantities to surfaces of these 2 OT devices, the CIDC researchers determined potential survival of the bacteria.

 The reacher tool handles were made of metal, and the sock aids were made of nylon plastic.

Survival of these 3 bacterial species differed on each device. For the plastic sock aids, 7.5% of 

, survival on sock aids was less than 1% after 48 hours. However, when looking at survival of these 3 bacterial species on the metal handle of the reacher tools, the highest percentage of survival at 48 hours was for 

 also survived on the reacher tool handle (4%), but at a lower percentage than for the sock aids. Essentially no surviving 

 was found on the reacher tool after 30 minutes.

Interestingly, results of an earlier study of 

 survival on therapeutic ultrasound heads found close to 25% survival of these cells after 72 hours on the metal surfaces.

 Whether therapeutic devices for PT or OT act as fomites in the spread of infectious disease hinges on disinfection techniques used by the therapists or other end users. Consideration of pathogenic bacteria survival on fomite surfaces should include knowledge of the materials used to make the devices.

Research emphasizes the potential role that fomites play in the spread of infectious disease in inpatient and outpatient clinical environments. This threat is not limited to hospitals; it also spreads via facility floors and any devices patients take home. We should not only ramp up cleaning and disinfection protocols in response to rapidly spreading pathogens such as the COVID-19 virus but also be proactive by minimizing the role fomites play in the spread of infectious diseases.

Zoppi L. What are fomites? News Medical. Updated February 18, 2021. Accessed August 3, 2022.https://www.news-medical.net/health/What-are-Fomites.aspx

Lewis D. COVID-19 rarely spreads through surfaces. So why are we still deep cleaning? 

. 2021;590(7844):26-28. doi:10.1038/d41586-021-00251-4

Science brief: SARS-CoV-2 and surface (fomite) transmission for indoor community environments. Centers for Disease Control and Prevention. Updated April 5, 2021. Accessed August 5, 2022. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html

Jayaweera M, Perera H, Gunawardana B, Manatunge J. Transmission of COVID-19 virus by droplets and aerosols: a critical review on the unresolved dichotomy. 

. 2020;188:109819. doi:10.1016/j.envres.2020.109819

Spratt HG, Levine D, Sinha A, See D. Surveillance of staphylococci presence in and around neonate Isolette beds in a neonatal intensive care unit of a children’s hospital. Abstract presented at: Association for Professionals in Infection Control and Epidemiology Annual Meeting; June 13-15, 2022; Indianapolis, IN.

Guidelines for environmental infection control in health-care facilities. Centers for Disease Control and Prevention. 2003. Updated July 2019. Accessed August 5, 2022. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

Spratt H, Levine D, Hanks J, et al. Colonization of environmental methicillin-resistant 

 in a newly constructed children’s outpatient clinic. 

. 2020;48(8)(suppl):S15-S58. doi:10.1016/j.ajic.2020.06.023

Levine D, Spratt H, Brunton L, et al. Comparison of viable environmental bacterial prevalence and species in outpatient general medicine and pulmonary units. 

 2020;48(8)(suppl):S15-S58. doi:10.1016/j.ajic.2020.06.024

Spratt HG Jr, Levine D, Tillman L. Physical therapy clinic therapeutic ultrasound equipment as a source for bacterial contamination. 

. 2014;30(7):507-511. doi:10.3109/09593985.2014.900836

Spratt HG Jr, Levine D, Bage J, Giles DK, Collier AG. Topical lotions utilized in outpatient rehabilitation clinics as a potential source of bacterial contamination. 

. 2019;35(2):163-170. doi:10.1080/09593985.2018.1441935

Analyzing the Survival Rate of Clinically Pathogenic Bacteria on Occupational Therapy Devices Used During Full Hip Replacement Rehabilitation

. Honors thesis. The University of Tennessee at Chattanooga; 2021.

Spratt HG Jr, Levine D, McDonald S, et al. Survival of 

. 2019;47(9):1157-1159. doi:10.1016/j.ajic.2019.02.019

Alexandra Peters, PhD, is the scientific lead for 

, a global network dedicated to making healthcare safer through improved environmental hygiene. She is based at the University Hospitals of Geneva Infection Control Program and World Health Organization (WHO) Collaborating Center on Infection Prevention and Control and Antimicrobial Resistance. She holds a PhD in Biomedical Science (Global Health track) and an MA in Science and Security. Her areas of expertise include health care environmental hygiene, hand hygiene, and health security.

 is the hospital epidemiologist and director of the Infection Control Programme & World Health Organization (WHO) Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, University of Geneva Hospitals and Faculty of Medicine, Switzerland. He holds honorary professorships at Imperial College (London), Hong Kong Polytechnic University School of Health Science (Hong Kong) and the First Medical School of the Fu (Shanghai). Professor Pittet is also a fellow of the Royal Medical Association (Ireland) and Honorary Member of the All-Russian Scientific Societies of Epidemiologists, Microbiologists and Parasitologists and the French Academy of Surgery and the French National Academy of Medicine.

Author and co-author of more than 500 publications in scientific journals and editor of the first textbook “

Hand Hygiene – A Handbook for Medical Professionals

” (Pittet, Boyce, Allegranzi, edition Wiley-Blackwell, 2017), Professor Pittet is a member of the editorial boards of many prestigious scientific journals, including 

. He is also an editorial consultant for 

 (Editions L'Âge d'Homme, 2014), available in 19 languages and 

 (Editions Nouvelle Imprimerie Laballery, 2021) written by French writer Thierry Crouzet, and the documentary film 

 (Aftermedia 2016, 8 languages) describe Didier Pittet's medical odyssey dedicated to the promotion of hand hygiene worldwide.

Professor Pittet is the recipient of several national and international honors including a CBE (Commander of the British Empire) awarded by Her Majesty Queen Elizabeth II for services to the prevention of health care-associated infection in the UK (2007), the Society for Healthcare Epidemiology of America Lectureship (2008), the European Society of Clinical Microbiology and Infectious Diseases' Award for Excellence (2009), the American Society for Microbiology (2016), the Robert Koch Award (2017) and the Pasteur Medal (2020).

Since 2005, Professor Pittet has been working closely with the WHO as the lead adviser of the First Global Patient Safety Challenge, whose Clean Care is Safer Care program is active in hospitals in 189 of the 195 United Nations member states. Professor Pittet conducts numerous research projects, in particular concerning the epidemiology, prevention, and control of infections and the development of innovative strategies to improve hand hygiene compliance and the quality of patient care to promote their safety. He is also involved in numerous humanitarian projects. Professor Pittet is also credited with revolutionizing patient care processes in hospitals by replacing hand washing with soap and water with the systematic use of alcohol-based handrubs (ABHR) and spreading this change in practice to health care centers around the world. His work has also involved the donation of a patent-free ABHR solution formulation to the WHO to facilitate its global distribution at lower cost, leading to its inclusion in the WHO list of Essential Medicines in 2012.

In June 2020, Professor Pittet was appointed by the President of the French Republic, Mr. Emmanuel Macron, as president of an independent mission created to assess the management of the COVID-19 crisis and to better address the risks posed by the pandemic and delivered the report of this commission in May 2021. The mission’s primary objective was to assess the relevance, speed, and proportionality of the French response in the management of the health, social and economic crises, in particular in comparison to other countries’ responses.

Few jobs are as important and often as thankless as environmental services (EVS). These teams are key players in ensuring patient satisfaction and com­bating health care–associated infections (HAIs), but many of them are virtually invisible, without professional job titles or presence in the hospital organizational chart. Many health care facilities around the world employ (or outsource) relatively untrained cleaners for low wages. They then demand EVS staff work long hours in relatively demanding conditions and often in contact with dangerous chemicals and fail to recognize the importance of these jobs or understand how this work can disrupt the chain of transmission. As a growing body of evidence demonstrates the hygienic health care environment is important for patient safety,

many institutions still do not consider health­care environmental hygiene (HEH) there needs to be a shift in how facilities view health care environmental hygiene (HEH). The focus of this shift must center on EVS teams.

At the Geneva University Hospitals (HUG) in Switzerland, environmen­tal hygiene holds special importance. Prior to becoming the director of WHO Collaborating Center on Infection Prevention & Control and Antimicro­bial Resistance, the Infection Prevention and Control (IPC) Department led by Didier Pittet, MD, restructured the way cleaning was performed at the hospital, including the practice of hand hygiene. These changes were organized into what would become the World Health Organi­zation (WHO) multimodal hand hygiene improvement strategy, which includes 5 elements: system change, training and education, monitoring and feedback, work­place reminders, and institutional safety climate.

 Ultimately, many of these changes directly affected the EVS teams, reducing cost and staff turnover and improving quality. Although this restructuring was radical at the time, its continued success may provide some guidance for improving HEH programs, especially the challenges facing EVS teams. At HUG, EVS staff have living wages and opportunities for career advancement and remain employed at the hospital for an average of 22 years.

To initiate these changes and avoid the increasingly common outsourcing of EVS staff to an external service provider, HUG conducted an analysis of the HEH program. Resources from overcleaned, noncritical areas were reallocated to more important zones. Non–health care areas such as offices and conference rooms were outsourced to an external service provider, and all health care areas were exclusively cleaned by in-house staff. HUG redeveloped the training system, educating staff not only on cleaning procedures but also on the trans­mission of pathogens and the importance of cleaning itself. Because EVS staff often come from a lower-income demographic, HUG and regional authorities developed national part-time certification programs of 2 to 3 years. Any staff member who desires to improve their knowledge may do so for free. The courses not only cover EVS management but also reading, writing, and other subjects. Individuals participating in the program can attend these courses during their work time; HUG pays for the courses, the hours staff members spend in them, and the cost of additional staffing when individuals are in class. All EVS team managers are hired directly out of the pool of graduates of the certification program. This formula not only motivates the team but also lends legitimacy to the manage­ment, as they have first-hand knowledge of what the job entails.

Because HUG is a public institution, EVS teams have job security once they pass their trial period and can be terminated only for a major transgression or instance of misconduct. EVS staff have the option of joining the union, and the union meets regularly with hospital management.

Results of an international pilot survey on health care environmental hygiene at the facility level

https://www.ajicjournal.org/article/S0196-6553(22)00133-X/fulltext

https://www.infectioncontroltoday.com/view/environmental-hygiene-shows-severe-issues-global-survey

Systematic review on the ability of health care environmental hygiene to reduce health care-associated infections

Environmental services teams (EVS) are crucial players in ensuring patient satisfaction and combating health care–associated infections, yet, too many EVS teams are invisible. They deserve recognition, and this article by environmental hygiene experts explains why and how to give appreciation effectively. 