By Sharon Ward-Fore, MS, MT(ASCP), CIC

The first case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 21, 2020.

 A lot has changed since then. People outside of healthcare have become all too familiar with terms usually reserved for epidemiologists and public health professionals such as pandemic, social distancing, hand hygiene, masking, family pods, antibody tests, and quarantine. Healthcare personnel have also learned a thing or two about all of these terms and much more. Infection prevention and control (IPC) teams have been thrust to the forefront to guide staff through these challenging times, sharing their knowledge of personal protective equipment(PPE), disinfection of medical equipment and patient care spaces, and communicating the ever-evolving changes as more information is gained about SARS- CoV-2, just to name a few.Articles about “lessons learned” and what healthcare providers and hospital systems can expect in the coming months are plentiful, but no one really knows what lies ahead. Healthcare and the world have been turned on its head. Outside of healthcare, everyday items like toilet paper and paper towels became scarce. In healthcare, things that we took for granted, such as performing our daily tasks of providing patient care and keeping an eye on PPE, disinfectants and cleaners, hospital bed availability, critical medications and equipment, and especially staff, became problematic as supplies proved to be in short supply and infection preventionists (IPs) had to hit the ground running. COVID-19 demonstrated huge gaps in preparedness worldwide. So, the key “takeaway” is the need for preparation for the upcoming months and into the future. The COVID-19 pandemic is here to stay so we had better learn from it to prepare for the next one because there will be another.

During the beginning of the pandemic, the importance of ongoing communication was highlighted. IPC staff learned they needed to find ways to stay on top of all of the information that was being disseminated by the various media sources. Although social media platforms like 

Facebook and Twitter seem to be the “go- to” source for information these days, IPs had to keep up-to-date on information provided by reliable sources such as the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the Association for Professionals in Infection Control and Epidemiology (APIC), and redirect healthcare personnel to these “sources of truth.” Communication via in-person in-services and huddles, real-time education, and handouts became absolutely vital for providing accurate information and guiding practice. The ability to answer questions and explain why just yesterday we were doing something differently than today occurred fairly frequently because of the evolving nature of the pandemic. Communication had to be winnowed down to succinct bullet points with the disclaimer that we still don’t know very much, and things could change. And change they did!Another key lesson IPC staff learned was how important it was to keep a rolling supply of PPE on hand.

 Most hospitals maintain adequate supplies of PPE on patient care units and in supply rooms, but none anticipated the amount of PPE that would be needed for the volume of patients ill from the virus. PPE shortages caused serious problems for some hospitals necessitating the need to reuse, or reprocess for reuse, PPE, especially N95 masks. This was uncharted territory for IPC professionals and healthcare workers. Healthcare workers faced possible risks from reusing PPE previously designated as one time or single-patient use. Donning and doffing used PPE posed risks of self-contamination and possible PPE failure. IPC staff had to step in and train staff on how to safely reuse PPE.

Looking back, IPCs learned they needed to audit not only when PPE should be used but also how staff don and doff. They also learned that retraining staff to reuse PPE, no matter how well they messaged it, was a difficult task at best because of staff safety concerns. To counteract the justifiable staff safety issues, some hospital systems are stockpiling PPE. In order to not waste the stockpiled supplies by letting them expire, more frequent drills are planned to keep the supplies fresh. To help prevent shortages of PPE from happening in the future, hospitals in some states, California for example, have recently passed a law that requires hospitals, nursing homes, large medical groups and dialysis clinics to have a 45-day supply of pandemic-level PPE on hand. IPCs learned you can never have enough PPE on hand and staff work better when they know they are being kept safe.IPCs learned how to think outside the box to help create safe, flexible spaces to accommodate large volumes of patients, both COVID-19 positive and non-COVID-19 patients. They learned about the importance of ventilation and barriers. Fatigue and the emotional toll on the frontline staff was something no one saw coming. IPCs and healthcare staff learned to lean on each other for emotional support. They learned the importance of flexibility in planning and thinking, re-evaluating how processes and practices can be safely continued with many different variables. As states begin to re-open their economies and healthcare facilities continue to be financially and physically exhausted, fears of a second wave of the coronavirus are a growing concern. According to the director of the CDC, Robert Redfield, MD, “a second wave of the novel coronavirus will be far more dire because it is likely to coincide with the start of flu season. Hav- ing 2 simultaneous respiratory outbreaks will put significant strains on healthcare systems.”

 These factors heighten the importance of remaining prepared for what lies ahead. The pandemic mitigation tactics for the public of frequently washing hands, wearing face masks, and physically distancing and avoiding gatherings, especially indoors, remain important measures to enforce. Increasing and sustained public buy-in on these measures, as well as ramping up flu vaccination, would help prevent further strain on health systems and staff in the months ahead.

Health systems and healthcare workers should have evaluated what worked and what didn’t during the pandemic onset. They should be stocking up on equipment like ventilators, medications, and personal protective supplies, including gowns, eye protection, and masks. Cleaners, disinfectants, and hand sanitizers should have been purchased in sufficient quantities, if available. Alternative products should be investigated and validated. IPCs should be rounding, auditing, and training on all aspects of PPE, cleaners and disinfectants, especially if new products have been introduced. Examination of patient surge capabilities and patient throughput should be performed, refined and tested, running drills for worst-case scenarios. Processes and protocols should be in place to support staff mentally and emotionally. COVID-19 has already taken over 1 million lives worldwide, more than 200,000 of them American lives, as of October 8, 2020. COVID-19 is here to stay. Some believe the future course of the pandemic will play out as different scenarios such as low-grade continuing infectivity, gradually infecting more younger people, or local and multiple outbreaks on a small scale. Worse yet, disastrous uncontrollable second waves may occur in the United States as well as in many other countries. Best advice—plan for the worst, hope for the best. The devil is in the details.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of 

Johns Hopkins University & Medicine Coronavirus Resource Center. Accessed October 4, 2020. https://coronavirus.jhu.edu/data/cumulative-cases

LagasseJ. California passes nation's first bill requiring hospitals to keep a 45-day supply of PPE.Healthcare Finance News. September 2, 2020. Accessed October 4, 2020. https://www.healthcarefinancenews.com/news/california-passes-nations-first-bill-requiring-hospitals-keep-45-day-supply-ppe.

Washington Post. CDC Director warns second wave of Coronavirus is likely to be even more devastating. Washington Post website. Accessed October 5, 2020. https://www.washingtonpost.com/health/2020/04/21/coronavirus-secondwave-cdcdirector/

Articles

The ability to answer questions and explain why just yesterday we were doing something differently than today occurred fairly frequently because of the evolving nature of the pandemic. 

The Year Infection Preventionists Showed the World Their Worth

As the fight against coronavirus disease 2019 (COVID-19) continues, the consumer market for gadgets to keep you from touching doorknobs and elevator buttons, and gizmos to disinfect your phone, your packages, your groceries, glasses, shoes, and the air you breathe—just to name a few—is mind-boggling. Similarly, lots of new and old technologies are being marketed to the healthcare sector, promising cleaning and disinfection on all kinds of surfaces contaminated with SARS-CoV-2.

Contact with surfaces contaminated with the virus is of great concern even though the primary mode of transmission is through close, prolonged contact (defined as <6 feet for >/=15 minutes

) with respiratory droplets and aerosols. There is possible risk of transmission, albeit low, from inadvertently touching a deposit of these respiratory particles on a surface, and then touching one’s face or eyes. Recently, an article published in 

 spoke about real life SARS-CoV-2 transmission versus laboratory-simulated situations stating “the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1–2 hours).” Knowing that contaminated surfaces may place patients and healthcare workers at risk, let’s look at some of the technology being marketed for use in disinfection of COVID-19 contaminated surfaces.

Ultraviolet Germicidal Irradiation (UVGI)

 is a type of ultraviolet (UV) light that is composed of 3 types of light—UVA, UVB, and UVC.UVC is the most effective of all germicidal light. It was first used in the early 19th century

 as a method to disinfect air. It was during this time that the spread of airborne infections by droplet nuclei was discovered, and also the bactericidal effects of sunlight (UV) to prevent that spread. Despite early successes in applying UVGI, its use fell out of favor. However, in the 1980s, an increase in infections from tuberculosis (TB) led to renewed interest in UVGI. It was found to be safe and very effective in disinfecting the air, preventing transmission of a variety of airborne infections in addition to TB.

When it comes to disinfecting the air, there are 3 primary methods of applying UVC systems against infectious agents in the air: upper-air, coil irradiation, and airstream disinfection. Upper-air systems are typically installed in room spaces, such as above patient beds, in waiting rooms, corridors and break areas, etc., where they kill airborne microorganisms that inherently circulate into the path of the UVC light.

Coil irradiation and airstream disinfection systems are installed within air handling units or duct runs within HVAC systems, downstream of cooling coils, to keep coils clean and to provide supplemental kill ratios in airstreams and on filter surfaces. Reduction of potential pathogens in the air can help prevent resettling onto surfaces, helping to contribute to a reduction in microorganism transmissions.

In healthcare, we hear a lot about UVC being used to disinfect surfaces more so than air or water. It relies on a short wavelength of light to break down microorganisms by naturally damaging their DNA and RNA, rendering them unable to replicate. Since viruses are not considered microorganisms, UVC does not actually “kill” viruses. Instead, it inactivates the virus and prevents any illnesses it might spread.

UVC has been shown to be effective in reducing pathogenic microorganisms present on frequently touched surfaces and is already being used in some hospital settings for disinfecting rooms, surfaces, and equipment. Interestingly, the US 

Centers for Disease Control and Prevention

 lists UVC as one of the most promising methods of disinfecting air-filtering face masks, such as the N95, for reuse when there is a shortage of personal protective equipment (PPE).UVC devices are an effective means of reducing concentrations of airborne and surface microorganisms that can lead to healthcare-associated infections (HAIs).

Until very recently, UVC wavelength devices for disinfection of surfaces had not yet been proven effective against COVID-19. There were only data to support effectiveness against other coronaviruses with fairly similar RNA structures to the virus that causes COVID-19. However, on May 21, 2020, Xenex recently tested its LightStrike™ robot specifically on SARS-CoV-2 in a biomedical lab in Texas, and found that, in 2 minutes, it was able to achieve a reduction of the virus greater than 99.99% within about a 3-foot radius.

So, the effectiveness of UVC for reduction of microorganisms including bacteria, viruses, and fungi has been proven time and again. But using UVC radiation to disinfect is not simple and requires lots of protocols to use safely. The radiation must be contained, often in a device of some kind, be it a light box, robot, or tower. When UVC light is used to disinfect a room, people must be cleared from the room before the device is turned on because it can be harmful to eyes and skin. Sometimes the robots need to be repositioned to eliminate “shadowing,” which blocks the UV light from touching the surface intended for disinfection. Installing UVC lights to irradiate a room or determining the placement of mobile devices is also a complicated process and must be appropriately validated to work effectively. Some systems are very costly. Lastly, and most importantly, all surfaces need to be free of any soil or bioburden in order for the UV light to touch the surface and for disinfection to occur, therefore, it does not replace cleaning. It can be a powerful tool used as an adjunct to a thorough cleaning process.

Misters, foggers, fumigation, or electrostatic spraying

are technologies used to apply disinfectants, like hypochlorous acid and hydrogen peroxide, to entire rooms such as empty public waiting rooms, operating rooms, and patient care spaces. Misters work by using a pressure pump that operates under pressure (ex, 1000 psi) and pushes water and any other product through small orifices that atomize the substances and turn them into a mist. Foggers work almost the same way but turn the mist into fog by allowing for flash evaporation. Electrostatic sprayers work by charging liquids (ie, cleaners, sanitizers, disinfectants) as they pass through a sprayer nozzle.

This generates charged droplets that repel one another and, when applied to environmental surfaces, they stick to and even wrap around them to coat all sides. This “whole room” approach to disinfection can help eliminate some of the human error that may occur from the repetitive and tedious task of repeatedly cleaning patient care spaces as often as needed in a healthcare environment. Whole room disinfection devices also limit the use of chemicals which benefit the environment as well as the employees who are exposed to harmful cleaning products on a regular basis. Some of these devices, in addition to disinfecting surfaces, have been proven to clean the air as well.

Since disinfectants are considered pesticides, they are reviewed and regulated by the US Environmental Protection Agency (EPA). Unless the disinfectant product label specifically includes disinfection directions for fogging, fumigation, or electrostatic spraying, the EPA does not recommend using these methods to apply disinfectants because the EPA has not evaluated the product’s safety and efficacy for methods not addressed on the label. Also, a disinfectant’s safety and effectiveness may change based on how it is used. Currently, the CDC recommends cleaning contaminated surfaces with liquid disinfectant products to prevent the spread of disease. However, the EPA announced the 

 of certain Pesticide Registration Improvement Act (PRIA) submissions for products already on List N that are effective against COVID-19 and applied for use using alternate application methods such as misters, foggers, fumigation and electrostatic spraying.

 One such product, Spore Defense applied through the Clorox Total 360® electrostatic sprayer, may be an effective way to eliminate SARS-CoV-2 from complex surfaces and is eligible for use against SARS-CoV-2, based on the EPA’s emerging Viral Pathogen Policy.

No doubt more and more makers of disinfectants will consider submitting an application to use these alternate methods for “whole room“ disinfection. Keep in mind all of these technologies still require cleaning of the surfaces prior to their use. They also have some time constraints for application and re-occupancy of the area. Fogging, for example, is typically carried out for a minimum of 15 to 30 minutes to enable the fog to disperse and the chemical action to occur. After fogging, an additional 45 to 60 minutes is required for the droplets to settle from the air onto the surfaces. During this “aeration” period, no one should enter the area. Also, when fogging, the equipment in the space being addressed should be limited, and the remaining equipment should be powered off and covered so that the disinfectant does not penetrate the sensitive electronic circuitry. If powering off and covering the equipment is not an option, fogging should not be considered. A final, very important consideration should also include the health and safety of staff and patients in areas where this technology is being routinely used.

 technologies range from antimicrobial agents for medical devices and surgical implants such as silver and copper to coatings that ensure surfaces are disinfected. They prevent the growth and spread of bacteria on surfaces such as medical instruments, walls, counters, door handles, and other high-touch areas. Silver ions prevent bacteria from reproducing. Copper destroys bacteria by damaging bacterial DNA and cell proteins. Copper is also effective against viral and fungal pathogens. Now there is an EPA-approved surface coating with antiviral properties effective for use against SARS-CoV-2 and proven to provide long-term, non-toxic surface protection within 2 hours of application for up to 7-90 days.

 The non-toxic coating “SurfaceWise2” is applied via an electrostatic spray to provide always-on protection on treated surfaces.

These long-lasting surface coatings may help provide persistent reduction in environmental contaminants, potentially improving patient outcomes. One thing to consider might be what are the long-term effects of coating, then recoating hospital equipment and surfaces? Much more to come as the surface coating race continues.

obtained by a achieving a temperature of 100 °C, 5% relative humidity for 50 minutes was found to effectively decontaminate 3 million N95 masks, allowing for reuse by healthcare workers during shortages, based on a study by the University of Illinois. It did not alter their integrity or fit and was least likely to reduce the filtration efficiency when compared with other available decontamination methods such as moist heat, ethanol, isopropanol solution, bleach, and ultraviolet light. The study found that “...dry heat decontamination generated by an electric cooker, like rice cookers, instant pots, and ovens could be an effective and accessible decontamination method for the safe reuse of N95 respirators.”

The mask should be enveloped in a towel or dishcloth to prevent it from touching the side of the pot and melting.

If an oven is being used to decontaminate the mask, it should be placed in a paper bag and no part of the mask should come in contact with the heating element to prevent a fire. We may scoff at this now, but continuing increases in COVID-19 infections leading to increased hospitalizations may again causes PPE shortages, so keep your eye on that instant pot.

During the trial and evaluation of any technology for disinfection, infection preventionists, environmental services (EVS) crew, and other stakeholders should undertake a comprehensive evaluation of the item under consideration.

For example, any new device being considered for purchase and implementation in a healthcare organization should be evaluated for its cost-effectiveness; whether the technology demonstrates a reduction in infection rates that justifies the cost associated with the purchase and maintenance of the device; whether the claims made by the manufacturer, such as spectrum of activity or dwell for disinfectants, are pertinent to your hospital and doable by your staff. Evaluators should identify the ongoing costs involved in use, education and training, staffing, and sustainability. Finally, any new technology should be evaluated for its relevance of use once the COVID-19 pandemic has passed.

Even now the need for enhanced cleaning surrounding COVID-19 is being questioned. Is it really needed and sustainable? Ask yourself a couple of questions before jumping feet first into any of these technologies. Will this technology also help with reduction of multidrug-resistant organisms or other problem organisms seen at my facility? Is my current level of cleaning and disinfection acceptable? Are there other things that could be done to improve cleaning and disinfection at my facility without adding to current practices? No matter the answer, know these technologies are available to add to your “toolbox” of best cleaning and disinfection practices when you need them but be aware of the caveats for their use.

Sharon Ward-Fore, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

CDC Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Health Departments, Public Health Guidance for Community-Related Exposure. 

Current guidance based on community exposure, for people exposed to people with known or suspected COVID-19 or possible COVID-19. 

Updated July 31, 2020, Accessed August 30, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html

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. 2010; Jan-Feb; 125(1):15–27.doi:10.1177/003335491012500105.

CDC Centers for Disease Control and Prevention. Healthcare Workers-Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N95 Respirators. Updated August 4, 2020. Accessed August 27, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Xenon LightStrike™ pulsed xenon disinfection robot. Product information. Accessed August 28, 2020. 

https://www.go.xenex.com/SARs-CoV-2-Results

US Environmental Protection Agency Pesticide Registration. Expedited Review for Adding Electrostatic Spray Application Directions for Use to Antimicrobial Product Registrations. Accessed August 30, 2020. 

https://www.epa.gov/pesticide-registration/expedited-review-adding-electrostatic-spray-application-directions-use

Allied BioScience’s SurfaceWise2 Press release. August 24, 2020. Accessed August 28, 2020.

Oh C, Araud, E, Puthussery J, Bai H, Clark G, Wang L, Verma V, Nguyen T.Dry Heat as a Decontamination Method for N95 Respirator Reuse.

 2020; 7, 9, 677–682. doi: 10.1021/acs.estlett.0c00534.

Infection preventionists should know that these technologies are available to add to their toolboxes of best cleaning and disinfection practices when they need them, but be aware of the caveats for their use. 


By Sharon Ward-Fore, MS, MT(ASCP), CIC

Articles

The Year Infection Preventionists Showed the World Their Worth

When It Comes to COVID-19 Disinfectants: Use With Care