By Robert Shor, DPM
Studies have shown that microorganisms can survive on inanimate objects or surfaces for hours, days, weeks or even months.1 Cross-contamination is defined as the spread of germs from one surface or object to another and frequently occurs when performing janitorial tasks. Effective cleaning and disinfection protocols can reduce the prevalence of cross contamination in the facilities we clean.
Infection prevention and control in hospitals has become a priority due to the emergence of life-threatening, multidrug-resistant organisms. While most research on cross contamination has been hospital based, the same principles can be applied to the cleaning of day care centers, schools, restaurants and most types of businesses.
Causes of Janitor-Induced Cross Contamination
There are many ways that cross contamination can occur while performing janitorial tasks. Contaminated mop heads and towels are common culprits. However, a recent study2 has identified a less recognized cause of cross contamination: janitorial worker’s gloves.
Researchers have found that germs can survive on gloves (like other surfaces) and can be transferred from one surface to another while cleaning. This raises the following questions: Do we have protocols for the use of gloves when performing janitorial tasks to prevent cross contamination? Can we learn anything from the Standard Precautions that were developed for patient care?
Occupational Health and Safety Administration (OSHA) requires personal protective equipment (PPE) for worker safety
OSHA’s standard 1910.138 requires the use of gloves to protect the hands of janitorial workers. To comply with this standard, the use of gloves has become an accepted practice in the cleaning industry. While OSHA regulations are concerned with worker safety, they don’t address issues relating to cross contamination or infection control; that has been the province of the Centers for Disease Control and Prevention (CDC).
CDC guidelines for infection control: standard precautions in medicine
In the 1980s, the incidence of HIV and other communicable diseases were on the rise. In 1996, the CDC developed standard precautions3 for patient care with two goals in mind:
- prevent the transfer of dangerous germs from patients to medical personnel
- prevent the spread of germs from one patient to another through cross contamination
Standard precautions that are used during patient care include the following:
- Proper hand hygiene in accordance with WHO guidelines4
- The use of various types of personal protective equipment (PPE) including gloves, masks and gowns
- CDC protocols for environmental cleaning and disinfection5
CDC guidelines concerning the use of gloves for patient care
The following CDC guidelines refer to the use of gloves when treating patients:
1. Examination gloves should be changed as soon as possible when visibly soiled, torn or punctured.
2. A separate pair of gloves must be used for each patient to avoid cross- contamination.
3. Hands should be washed after gloves are removed.
While standard precautions for the use of gloves makes sense for patient care, how can these principles be applied to prevent janitor-induced cross contamination?
Janitorial Precautions: Suggested Protocols for Using Gloves
While OSHA requires the use of PPE by janitorial workers it offers no specific guidelines as to how and when gloves should be used. The following protocols are suggestions based on CDC guidelines and can be modified for different types of facilities:
- Don gloves before performing cleaning tasks (use gloves that are appropriate for the task being performed);
- Change gloves in the following situations:
1. When they become visibly soiled, torn or punctured
2. After cleaning areas with high concentrations of germs, such as restrooms, kitchens
3. When changing the color of the towel you’re using (applicable to color coded microfiber towel systems)
4. When going from building to building or floor to floor
- Avoid contaminating your hands when removing gloves by following CDC guidelines6
- Wash hands and or use hand sanitizers after janitorial tasks are completed
Facilities that require more stringent “janitorial precautions” include day-care centers, hospitals, medical offices, restaurants and assisted living facilities. In these situations, changing gloves after cleaning each room may be indicated.
Cleaning Protocols that can Prevent Cross Contamination
The total removal of germs from surfaces beyond disinfection, i.e., sterilization, is not practical or necessary to prevent janitor-induced cross contamination. However, sterilization principles can be applied on a relative basis to the performance of janitorial tasks to reduce the likelihood of cross-contamination.
Maintaining a “sterile field” during a surgical operation is based on the following principles: Sterile objects should only touch other sterile objects. Objects should be removed from the sterile field when they become contaminated. These concepts can be applied on a relative basis when performing janitorial tasks to maintain a “clean field” whenever possible:
- The sequence of cleaning should be from clean to dirty areas
- Cleaning should be performed from high to low areas
- Use no-touch systems for cleaning and disinfection when possible
- Use mopping systems that apply fresh cleaning solution with each pass
- Use color coded microfiber towel systems
- Change towels, gloves, and supplies when they become visibly soiled or contaminated
Case Study: Outbreak of Hand, Foot and Mouth Disease in a Preschool
Hand, foot and mouth disease in pre-schools is not uncommon. When this occurs, thorough cleaning and disinfection of the facility is warranted and should help stop the spread of the disease. Recurrent outbreaks in one preschool prompted the administrators to consult with our company to evaluate the cleaning protocols in use at the time.
There were approximately 100 children attending the preschool. The virus was spreading from one classroom to another. The school and administrative offices were in separate buildings. Administrative staff that had no contact with the preschool children were also contracting the virus. There was some concern that the center wasn’t being cleaned properly, but nobody suspected that the virus was spreading because of janitor-induced cross-contamination.
While the spread of viruses from one child to another by direct contact (i.e., sneezing and coughing) was occurring, the viruses seemed to be spreading by indirect contact also (i.e., touching contaminated surfaces). Cross-contamination was a plausible explanation for the adults who were contracting the illness in the administrative building.
It was determined that the following practices could have been contributing to cross contamination:
- String mops and buckets weren’t sanitized properly (mop heads weren’t laundered and dried after each use)7
- The cleaning crew was using the same mop head to clean all areas in both buildings.
- The crew wasn’t following best practices for disinfection:
- They were using paper towels to clean and disinfect.
- They were using ineffective, store bought cleaning supplies and disinfectants;
- The crews weren’t changing gloves, towels and other supplies frequently enough (i.e., when they became contaminated).
Recommendations to reduce the likelihood of cross-contamination in this case study were:
- Replace string mops with a microfiber flat mop system for routine floor cleaning.
- Clean and disinfect floors daily, as floors in preschool classrooms are considered high-touch surfaces
- Change mop heads after each classroom
- Use a different mop head to clean the administrative building
- Use a color-coded microfiber towel system
- Change gloves after cleaning each classroom; after cleaning restrooms and kitchen areas; and before entering the administrative building
Clean the administrative offices first (if possible)
In conclusion, cleaning and disinfection protocols to prevent cross contamination are a necessary part of any cleaning program. The protocols should focus on the sequence of cleaning as well as the type of equipment and supplies that are used. Standard “janitorial precautions” should be customized for each facility and should include protocols for using gloves to reduce the incidence of cross contamination.
Robert Shor, DPM, is the director of environmental services for Ace Cleaning Systems in Coral Springs, Fla. Shor was a practicing physician and surgeon for 20 years and has been developing cleaning and disinfection programs for the janitorial industry since 2010.
1. Otter J, Yezli, S, Salkeld J, French G. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control. May 2013.
2. Otani S and Fujita K. Contaminated gloves increase risks of cross-transmission of pathogens. American Society for Microbiology. June 2016.
3. Centers for Disease Control and Prevention. Standard Precautions for Patient Care. January 2017. Accessible at: https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html.
4. World Health Organization. Hand Hygiene: Why, How & When. Accessible at: http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf.
5. Centers for Disease Control and Prevention (CDC). Guidelines for Environmental Infection Control in Health-Care Facilities. Feb. 2017. Accessible at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf
6. Centers for Disease Control and Prevention (CDC). Guidelines for the Selection and Use of Personal Protective Equipment in Healthcare Settings. October 2016. Accessible at: https://www.cdc.gov/hai/pdfs/ppe/ppeslides6-29-04.pdf
7. Westwood JC, Mitchell MA and Legacé S. Hospital sanitation: the massive bacterial contamination of the wet mop. Appl Microbiol. 1971 Apr;21(4):693-7.