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Charles Gerba, PhD: Environmental services plays a crucial-and often unsung-role in infection prevention. “Unfortunately, we don’t honor people enough for things they prevented or that never happened.”
Before COVID-19, infection prevention in hospitals and other healthcare facilities focused on healthcare-acquired infections, which, for the most part are bacterial. That’s going to change, says Charles Gerba, a professor of environmental microbiology at the University of Arizona. Now there will be a lot more focus on viruses, as well. Gerba also thinks that environmental services (EVS) have proven just how crucial a role they play in infection prevention and control during the COVID pandemic. He believes that continuously acting disinfectants will help EVS do a better job of keeping healthcare facilities-and even schools and office buildings-better protected from these invisible invaders. Gerba recently talked about the future of environmental cleaning with Infection Control Today®.
Infection Control Today®: Is it fair to say that the role environmental service teams play is overlooked?
Charles Gerba, PhD: Yes, it is. I mean, they really would likely have the greatest exposure. And I think it’s more important, because you’re usually dealing with an environment where people are coming in because they are ill. So, they’re usually secreting or excreting the viruses that they’re ill with or other pathogens.
ICT®: Have the heads of those environmental services reached out to you and asked for advice on how to handle COVID-19?
Gerba: Yeah, we’re working with the universities. There’s a lot of concern, of course, with educational institutions, when all the students will be coming back in the fall. How do we guarantee we’ve taken every precaution to reduce the spread of the SARS-CoV-2 virus in the institution.
ICT®: And what do you tell them?
Gerba: Well, I think basically what you need to do is really enhance the availability of, certainly, hand sanitizers. Come up with a disinfection plan to work on surfaces. And hopefully, we can come up and use more innovative infection prevention things like using continuously acting disinfectants on surfaces. I think are a new barrier against the spread of viruses and bacteria by fomites, inanimate surfaces.
ICT®: You’re talking about something other than what’s generally used at this point, which is, what? Bleach?
Gerba: I think some people have referred to these as continuously acting disinfectant surfaces. In other words, when an organism comes in contact and it starts becoming inactivated right away. I think copper surfaces have been used somewhere in the healthcare industry. And they’re really like, continuously acting disinfectants if you would have it. But we’re looking at it in a broader sense. We’ve looked at it as really one of the new barriers in infection control. You know, I look at it in the last 20 years, the innovations have been hand sanitizers, disinfecting wipes, which give the right amount of disinfectant to a surface. And I think the next innovation is going to be the continuously acting disinfecting surfaces. What the problem is with many disinfectants, they will inactivate or kill what’s on there, but these surfaces can become contaminated right away again. And that’s the role of the continuously acting disinfecting surfaces, because we know the surfaces are going to be continually contaminated all the time. I think they might play another important role too, in that we emphasize largely the high touch-areas as playing the major role in disease of infectious organisms in the spread in indoor environments, but the low-touch areas are also important. I think we ignore them a lot. And I think we need to give more credence to them and the advantage of these continuously acting disinfectants. They can cover all surfaces. You’d be able to cover what I consider probably a neglected area in infection control, which is really the low-touch areas. Two studies that have been done show they can be important to in the spread of infectious microorganisms and healthcare environments.
ICT®: When you say environmental services staff, what do you mean by that?
Gerba: We’re talking about people that are involved really in environmental health service staffs. The people who are involved in the daily cleaning of rooms, not only patient rooms, but facility rooms. Really your maintenance crew. I mean, they play a much more important role than most people realize. I think in studies we’ve done certainly in healthcare environments and office buildings in that we know viruses can spread very rapidly on surfaces. And the custodial crews basically are people who are involved in maintaining hygiene situations in patient rooms. They play a very important role of controlling exposure to infectious microorganisms. Oftentimes, really, it’s neglected. We always think of it as cleaning, which is really removal of dirt, but they play a big role in hygiene. I think they should really be renamed to include both the cleaning and hygiene they provide, too. Because they play a major role in reducing our exposure to infectious microorganisms via fomites; inanimate objects we touch all the time.
ICT®: They’re on the frontlines.
Gerba: These crews themselves are coming in contact with infectious microorganisms all the time. That’s why, you know, using proper gloves and proper attire I think is really important, too. You have to recognize that they do expose themselves. And that’s why it’s important that they be specifically trained to realize that they actually are coming in contact with these organisms. You know, in the healthcare environment, the emphasis has largely been on hospital acquired infections. Which is really concerned about exposure and transmission among patients. But I think we also have to be concerned with the exposure of the people who do the cleaning and that if they’re properly trained and have the proper tools to clean and disinfect areas that could be involved in transmission of infectious microorganisms.
ICT®: What do environmental services teams need to do their jobs?
Gerba: I think it’s really important to recognize that they usually have the proper protective gear. And these times oftentimes, we recommend if we’re dealing with the areas where they may have COVID 19 patients and that they might wear protective gear if they’re involved in any type of spraying of anything or coming in contact with surfaces. I think the possibility exists particularly in a healthcare environment where you may have exposure in the restroom areas or other areas. If you’re spraying or wiping, you should have maybe considered face protective gear I think at these times. Particularly in situations where you may have a lot of people involved who potentially or are infected with it. I think maybe a little more enhancement and protective gear, even to the standpoint of N95. Some of the cleaning and spraying of these facilities do some deep cleaning and restrooms requires protective gear and training on how to do it properly. You know, we’ve been involved in assessing how well-trained crews do in that. And really, it makes a big difference if they’re properly trained on how to clean and disinfect. We’ve done studies of outbreaks before of norovirus and actually, if they’re not cleaned properly, they end up spreading the virus more around with their cleaning tools. So proper use of how to disinfect and clean properly is really important. Otherwise, these people who are in charge of the cleaning could actually be involved in spreading the organisms as we found, at least in some outbreaks. We’ve seen proper training can be challenging, but you know, some institutions particularly some universities, have facilities where they actually provide in-depth training. The University of Washington in Seattle is one which really has a center for training the people who are involved in everyday cleaning and in hygiene maintenance within their facility. I think that’s really needed. I think it’s proper training. People who are involved in this. Not only training, but I think the institution needs to be aware of innovations that are going on in cleaning and in hygiene. I think everybody should really get updated information. I know at my own university on a regular basis, I give seminars, to the supervisors for the cleaning crews and people involved in facilities management on things to look for and what are new innovations. I think we should do that on a regular basis with all people who are involved in environmental facilities management all the time. Because they really play a much more critical role than I think has been appreciated. And I think their role will become more recognized because of this coronavirus outbreak.
ICT®: Have you seen institutions in the country where environmental services is being done right?
Gerba: We’ve done a lot of studies and in different types of institutions. One of the things that always comes true with us with cleaning and hygiene crews is their training. It’s really their training, it comes down to it. And if they have a procedure, and methodology, please stick to it. We can find big differences in different institutions. For example, we’ve done studies where we’ve come in, we do a background on where the microbiological contamination is, where is it. Where does it occur? And then after training of these people or using professional crews in some cases that have been trained by outside cleaning companies and that, we can see a big difference. One of the things we noticed too, if it’s done right and you do a deep cleaning, and you do a maintenance of that, it makes a big difference. Even if you’re dealing with a facility that’s outside of healthcare, we’ve noticed if you do a deep cleaning on a regular basis every few months, and then you actually come in and do a regular maintenance cleaning, you can make a big difference. You can reduce the number of bacteria, for example, in classrooms, in universities, after deep cleaning. It’ll keep the number of bacteria down about 90% after you do regular maintenance. I think there’s innovation for that. When we see it in our studies, outside of healthcare. It makes a big difference in regards to what people are going to be exposed to.
ICT®: You have to weigh the time it takes to clean a room and operate an emergency department to standards that you'd like to see against the need to hurry up and help patients. Is the new technology possibly an answer to that?
Gerba: Yeah, I think the continuously acting disinfectants are a new barrier that can be applied. I like the concept because when you get areas that are often missed, it gives you additional assurance you have some protection. It’s not a substitute for regular cleaning and disinfecting, but it adds another barrier to it and I think we really need that. I don’t think it’s so much as might be reducing time, as enhancing an additional barrier to infection control and in the areas that are overlooked or not done properly. It does add another barrier to that. Wouldn’t want to say we need to change any of our routine disinfecting and cleaning all the time. Because these continuously acting disinfectants are available now that they will also give us additional assurance that these areas can inadvertently re-contaminate or miss during a cleaning operation. We still have another barrier intact.
ICT®: What do you mean by continuous acting disinfectants?
Gerba: Continuous acting disinfectants are those type of disinfectants that are usually applied to a surface, and they continually kill microorganisms that may come in contact, like viruses or bacteria. So, in other words, when you clean normally you disinfect and you reduce the number of organisms by saying 99%. Continuously acting disinfectants keep killing the organisms below that level, oftentimes, if given sufficient time. So, you always have something that’s always killing organisms all time. The trouble is you never know when that surface is going to be re-contaminated. And so these continuously acting disinfectants give you that additional assurance and barrier.
ICT®: Is this a fairly new technology?
Gerba: You know continuously acting disinfectants; the concept has been around for about a decade and its emphasis has largely been in reducing hospital acquired infections. Now there’s epidemiological data that indicates that these types of products will reduce the number of infections in healthcare environments. But I think more importantly outside the direct healthcare environment they’re also important like in office buildings, schools and that. I think they’re really needed. You know, in our studies, we’ve studied tracer viruses-how they move through an office building or a healthcare center. They don’t infect people. And we noticed like in an office building, within four hours, 50% of the surfaces will be contaminated with this tracer virus. Same thing in the healthcare environment. You’ll see that rapid spread of a virus because of all the activity. And I think these continuously acting disinfectants give you an additional barrier that this will reduce that level of contamination in exposure to people in these environments.
ICT®: Is this something you can use with a mop and a bucket or rag or spray bottle? How do you how to use it?
Gerba: Well, I think cleaning with regular products is still essential for this. One of the concerns I had with a lot of cleaning tools we noticed-you mentioned, mops and buckets. Well, they’re a great way of spreading microorganisms around if you’re not using a disinfectant with that product. You have to remember that anytime you use any cleaning tool, particularly in a healthcare environment, you’ve got to use a disinfectant with it. You’ve got to make sure you have an adequate dose of disinfectants. Otherwise, you’ll end up spreading these microorganisms around your facility. And we’ve seen it with viruses during outbreaks of norovirus
ICT®: Has COVID-19 changed the way environmental services will be done from here on?
Gerba: I think the future way environmental surfaces will be done…. Let me restate that. I think because of the SARS CoV-2, there will be a major change in environmental services in both healthcare and outside of the healthcare area. Particularly, emphasis will be on viruses now, too. We have to have products that ensure us that they will be active against the virus and can reduce the spread of viruses. I know in our university, they’re rethinking how they’re going to do that to ensure that we have the minimum amount of exposure to viruses to the students when they return in the fall. We need assurances about virus speading. I really feel, particularly when it comes viruses, they’ve been really overlooked in general. We’ve kind of ignored the importance of surface fomites and their spread in buildings. We’ve certainly seen it in our studies. You know, during the cold and flu season, a third of the office environments in the fall we can find parainfluenza, which is one of the causes the common cold on office surfaces. And they’re very common, interestingly enough, in nurse and physician breakrooms and that’s because they don’t get deep cleaning all the time.
ICT®: Can’t it be overdone? How much cleaning can you do?
Gerba: Well, that’s why … how much cleaning can you do? How much disinfecting can you do? In some ways, I feel like currently it may be overdone all the time because it’s continually being applied. One of the concerns I’m starting to develop, I see all these spraying disinfectants everywhere since the SARS CoV-2 outbreak and I’m concerned we might be overdoing it. That’s why I feel continuously acting disinfectants needs to come in between these events when they’re cleaning and spraying all the time. And there’s a lot of concern, too, in some institutions like-where we have young children in schools-of spraying disinfectants all the time, making people sensitive to them. A balance has to be developed between using our traditional disinfectant methods by environmental services and using continuously acting disinfectants. I think there’s a role to minimize the risk and exposure via surfaces and fomites of viruses. So, I think it’d be more emphasis on virus than there has ever been before. Really, historically, the emphasis has been on hospital acquired bacterial infections. I think there’s going to be a new emphasis in the future on viral infections and how they spread and how we can control them, both in healthcare and outside of healthcare.
ICT®: Do you see infection preventionists and environmental services teams working more closely now?
Gerba: Yeah, I think there’ll be more emphasis on working with them closer, particularly when it comes to virus spread. I think this SARS CoV-2 is creating an awareness of the exposure, really, to the physicians and nursing staffs and other staffs in these facilities. They really are exposed. Viruses spread very readily. It’s not just about hospital acquired infections. Now it’s about virus spread among the caregivers and the people-the environmental services people, too. And I think that’s why we need a real emphasis on controlling virus spread in these environments. I think we saw the impact on healthcare providers, and we need to really give them an additional barrier protection that’s active against the viruses.
ICT®:Any final words for environmental services staff?
Gerba: I want to emphasize that you guys play more of a role than you realize. We’ve done interventions with trained environmental service staffs, and we were able to reduce the exposure to viruses in facilities by 80% to 90%. And that was just a matter of properly training environmental services people. And that’s all it takes. But you play much more of a role. Proper use we feel in our studies can reduce transmission of common respiratory diseases by 80% in a facility. So, your role is more important. You know, unfortunately, nobody’s going to give you a medal for preventing a disease, I always tell my people. You have to realize the importance of what you’re doing. Because you don’t get all the pats on the back you deserve or the emphasis for the role you play in something that never happened. Unfortunately, we don’t honor people enough for things they prevented or that never happened.
This interview has been edited for clarity and length.