A truly effective infection control program must address potential attacks from a number of directions to include hands, water, hard surfaces and air, to name a few. Paying attention to just some won’t protect against all. While some needs might be more relevant to hands, for instance, looking at the big picture can position specialists to fight infection best. In this blog entry, we offer up a series of links that look at a variety of infection sources and methods to address them.
- Clean hands make a difference: Evidence of hand hygiene to reduce transmission and infections by multidrug resistant organisms in health-care settings notes that infections by multidrug-resistant organisms (MDROs) are increasing worldwide. Prevention of spread and control of MDROs in health-care settings are critical and urgent as the number of antibiotics available to treat these infections is extremely limited and development of new antibiotics is not forthcoming in the foreseeable future. Studies where hand hygiene was used as the main intervention and a significant improvement in hand hygiene compliance and/or increased alcohol-based hand rub (ABHR) consumption were achieved, demonstrated substantial decrease of MDROs’ infections and/or colonization rates, mainly for MRSA. To be successful, these interventions need to be multimodal and sustained over time in the context of an improved patient safety climate; in addition, particular attention should be paid to embed hand hygiene in the care flow and within best practices for specific procedures. Finally, combating antimicrobial resistance spread and infections involves the implementation of other specific prevention and control measures too.
- Clean water is important: Bacteria that cause Legionnaires’ Disease are not uncommon points out that Legionellosis is on the rise in the United States. A recent study published in Environmental Science & Technology described the presence of Legionella pneumophilain nearly half of the 272 water samples collected across the United States. Widespread Molecular Detection of Legionella pneumophila Serogroup 1 in Cold Water Taps across the United States and Bronx Legionnaires’ Outbreak Is Over, Health Officials Say are related reads.
- Clean laundry can impact the spread of disease: Hospital Textiles, Are They a Possible Vehicle for Healthcare-Associated Infections? discusses contaminated textiles and the need to clean them appropriately to guard against infection. The limitations of patient-centered infection control recommends epidemiological studies that track bacteria spreading in hospitals and attempt to determine if those same strains are contaminating clinician attire using whole genome sequencing.
- Clean surfaces are critical, too: Preventing the transmission of multidrug-resistant organisms (MDROs): Modeling the relative importance of hand hygiene and environmental cleaning interventions suggests that hand hygiene should remain a priority for infection control programs, but environmental cleaning can have significant benefit for hospitals or individual hospital units that have either high hand hygiene compliance levels or low terminal cleaning thoroughness. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review concludes that most common nosocomial pathogens may well survive or persist on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed. Surface contamination and respiratory viruses with pandemic potential (SARS, MERS and influenza): an underestimated reservoir? looks at respiratory viruses and their potential transmission through contact with hard surfaces.
- Clean air often overlooked but important: The American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) asks hospitals to use air filters that work at the submicron level but most don’t follow the guideline. Disease moves through the air, making the HVAC system an important part of any decent infection control program. Re-suspension of allergen-containing particles under mechanical and aerodynamic forces from human walking – Introduction to an experimental controlled methodology uses experiments to learn, among other things, that 1. for a continuous disturbance, resuspension was only observed during the first two minutes with an initial burst of particle re-entrainment followed by an exponential decrease to undetectable value; 2. particles were more easily re-suspended from linoleum flooring than from carpet flooring. Aerobiology and Its Role in the Transmission of Infectious Diseases discusses how particles move through the air. Predicting Spatial Distribution of Infection Risk of Airborne Transmission Diseases in a Hospital Ward is a related interesting read.
Virtually everyone has portable electronic devices (PEDs) they carry and use regularly to conduct business or simply stay in contact with friends. They can become a platform for disease.
PEDs are increasingly being used in the hospital setting. As with other fomites, these devices represent a potential reservoir for the transmission of pathogens. Use of portable electronic devices in a hospital setting and their potential for bacterial colonization used a convenience sampling of devices in 2 large medical centers to identify bacterial colonization rates and potential risk factors. It shows that PEDs can be colonized with a variety of pathogenic organisms. The significance of colonization and implications for patient care remains unclear. Larger, prospective, and continuous sampling studies are needed to resolve these limitations. Additional studies are necessary to determine the safety risks to patients and identify best practices and infection control policies as this technology expands in the health care arena.
Mobile Phones in Hospital Settings: A Serious Threat to Infection Control Practices – Health professionals need to help raise awareness about the health risks of using an unclean cell phone. Found at the Occupational Health and Safety website, the story points out that obvious health risks of using germ-infested mobile devices. Unlike our hands, which are easily sterilized using hand sanitizers made available readily across all hospitals and medical facilities, our mobile phones are cumbersome to clean. It concludes that “Health professionals, from microbiologists, epidemiologists, doctors, and dentists to behavioral scientists and occupational health and safety consultants, need to take note of how and where we are using our cell phones, draft new guidelines and prevention tips, and help raise awareness about the health risks of using an unclean cell phone.”
Bacterial Assessment of Electronic Hardware User Interfaces in Ile-Ife, Nigeria is a study that focuses on shared electronics to quantify and identify bacterial contaminants associated with private and open access user interfaces in various establishments in the town of Ile-Ife, Nigeria.
Mass transportation systems are highly contaminated with the bacteria and viruses we carry. Rapid transportation has shrunk our world to where pathogens can move overnight across oceans, borders and vast territories. Or just across town. These systems shrink our world to where pathogens can move overnight across oceans, borders and vast territories.
The Role of Human Transportation Networks in Mediating the Genetic Structure of Seasonal Influenza in the United States is a study that investigated how human movement along the aviation and commuter networks contributed to intra-seasonal genetic structure of influenza A epidemics in the continental United States using spatially-referenced hemagglutinin nucleotide sequences collected from 2003–2013 for both the H3N2 and H1N1 subtypes.
The authors summarize that “the rapid, long-distance spread of human pathogens such as seasonal influenza A across modern transportation networks presents a tremendous challenge for public health and that the results demonstrate that genetic structure does exist for influenza populations during the course of a single season at the regional scale, highlighting the need to incorporate host movement patterns when studying spatial population structure.”
Some related pieces of interest:
- We’ve Been Looking at the Spread of Global Pandemics All Wrong – Redrawn maps of the world’s air-transport network could change the way we track disease from city to city. The idea that disease travels through airport networks is not a novel one to epidemiologists. But the discovery that pandemic patterns have not changed so much after all in the last 500 years is.
- Risk assessment guidelines for infectious diseases transmitted on aircraft (RAGIDA) – Influenza is a wonderful document produced by the European Centre for Disease Prevention and Control. The RAGIDA project combines evidence retrieved from the literature with expert knowledge for infectious diseases. In 2009 the production of the series of guidance documents for assisting in the evaluation of risk for transmission was initiated for several infectious diseases. The resulting disease-specific operational documents provide a host of viable options for decision-makers, particularly when faced with the choice of whether to contact trace air travelers and crew that were potentially exposed to infectious diseases during a flight.
- While most of the germs found on New York City subways seem to be harmless, some are. Photographer Craig Ward created this stunning visualization, called “Subvisual Subway.”
- From crossing oceans to simply traveling across town, mass transit can assist with the spread of disease. Bay Area Rapid Transit (BART) riders in the San Francisco area might have been exposed to measles.
Review of human hand microbiome research at the Journal of Dermatological Science is an abstract that discusses a comprehensive and systematic database search that was conducted for skin microbiome-related articles published from January 1, 2008 to April 1, 2015. Only primary research articles that used culture-independent, whole community analysis methods to study the healthy hand skin microbiome were included. The microbiome of the hands is in constant flux as the hands are a critical vector for transmitting microorganisms between people, pets, inanimate objects and our environments. Future studies need to resolve methodological influences on results, and further investigate factors which alter the hand microbiome including the impact of products applied to hands. Increased understanding of the hand microbiome and the skin microbiome in general, will open the door to product development for disease prevention and treatment, and may lead to other applications, including novel diagnostic and forensic approaches.
Life on Human Surfaces: Skin Metagenomics is a fascinating study that tells us deciphering functional diversity and dynamics with human skin microbial communities is critical for understanding their involvement and for developing the appropriate substances for improving or correcting their action. The approach provided access to the functions carried out by dominant skin colonizing taxa, including Corynebacterium, Staphylococcus and Propionibacterium, revealing their specific capabilities to interact with and exploit compounds from the human skin.
As the current arsenal of effective antimicrobial weapons against potential pathogens is gradually diminished by antibiotic resistance, Skin Microbiome: Looking Back to Move Forward says it is vital to explore not only antimicrobial chemicals derived from microorganisms but also the possibility that prebiotic and probiotic microbial organisms themselves may offer promise as viable alternatives.
From Beijing to Mumbai, we read news reports on the health cost of pollution and particulate. Long-term exposure to ambient fine particulate matter (≤ 2.5 μg/m3 in aerodynamic diameter; PM2.5) is associated with increased mortality from non-accidental and cause-specific diseases.
The main exposure to fine particulate matter is through inhalation and, because of their size, they are respirable. Unlike larger particulates, they are deposited in the lungs and can penetrate tissue and be absorbed into the bloodstream, which can create negative health issues.
An Integrated Risk Function for Estimating the Global Burden of Disease Attributable to Ambient Fine Particulate Matter Exposure at Environmental Health Perspectives is a study that addresses issues caused by fine particulates. The study developed a fine particulate mass-based model that covered the global range of exposure by integrating relative risk (RR) information from different combustion types (ambient air pollution [AAP], second-hand tobacco smoke, household cooking fuel and active smoking [AS]) that generate emissions of particulate matter. The model can be updated as new RR information becomes available.
The study concludes that “fine particulate mass–based RR models can be developed that cover the entire global range of ambient exposure to PM2.5 by integrating RR information from different combustion sources that generate emissions of particulate matter. The specific RR model form we identified in the present study can provide superior predictive power for leading global causes of mortality for air pollution compared with a range of alternative model forms.”
The Taliban’s propaganda campaign against vaccinations contributed greatly to polio outbreaks in recent years in Pakistan. Direct attacks have killed health workers and security personnel as the Pakistani Taliban, which in 2012 again voiced its intent to scuttle any ongoing vaccination programs, continue to hinder efforts. Attempts to engage the Taliban leadership has met with mixed results, but we hope efforts for a sustained peaceful resolution continue so that children can get the necessary vaccinations to prevent additional illness and death.
The war against vaccinations isn’t limited to Pakistan, either:
- 75 suspected polio cases reported in Helmand reports that clashes between security forces and militants have contributed to a breakdown in polio immunization efforts, leading to 75 suspected cases of the disease because an estimated 10,000 children were unable to get polio drops, according to officials in Helmand province in Afghanistan in a report at Pajhwok Afghan News. An official with the World Health Organization (WHO) said tribal elders, religious scholars, teachers and students were assisting them in a nationwide polio vaccination campaign being waged this month.
Megan Coffee, MD, an infectious diseases expert, provides a terrific look at measles, and she also takes a look at the implications of the virus in What’s so bad about measles? Measles is one of the most infectious diseases we know. People still get measles, even though simple vaccination that most can get will keep it at bay. Dr. Coffee points out that in the first five weeks of this year, 121 people in 17 U.S. states were infected; many cases were connected to exposures from visiting Disneyland. Before the vaccine was licensed in the U.S. in 1963, about 549,000 people had measles in the U.S. each year; about 495 died annually. Measles can be spread through the air by someone who unwittingly has the virus, making it especially insidious.
Borno To Give Measles Vaccination In 15 Local Government Areas outlines a measles vaccination campaign in the Borno state of Nigeria, despite political complications. Dated Nov. 23, 2015, the story at The Nigerian Voice says about a million children between 9 and 59 months were to be immunized against measles in a five-day stretch to combat one of the chief causes of death in children there. The campaign is expected to go a long way toward reducing the threat of measles. We applaud officials there who are making this effort despite the difficulties to do so.
Outbreaks in Cameroon and southeast Congo illustrate the need for initiatives like that in Nigeria:
- An epidemic outbreak in Cameroon has spread across that country and involves 858 cases recorded in mid-November, now posing a significant health risk.
- Deadly measles outbreak kills 400 in southeast Congo is a Reuters News Service report that notes mortality rates can be as high as 20 percent in poor countries, according to medical charity Medecins Sans Frontieres, even though it only costs about $1 to vaccinate a child. It also reiterates that the World Health Organization warned last November that progress toward wiping out measles has stalled worldwide due to poor vaccine coverage.
The white coat controversy, discussed in this Boston Globe story, could be labeled a joke if it wasn’t so decidedly unfunny. There is nothing comical about the risks inherent when proper cleaning of white coats, hospital uniforms, linens, blankets, privacy curtains, etc. is not taken seriously. Some doctors are convinced no credible evidence exists that shows viruses and infection can be transferred from contaminated white coats to patients or their surroundings. Other are just as sure they can be. So, who’s right? Maybe we don’t know with absolute certainty. Many health care professionals point to the lack of evidence connecting dirty uniforms and linens to infection risk. Do we really need countless studies that offer overwhelming, beyond-the-shadow-of-doubt data to before we establish an industry standard? We really should not. There’s enough evidence that meets a more-likely-than-not threshold, which really should be enough to warrant action. We’ve consulted with hospital personnel who steadfastly maintain infections haven’t been shown to be linked with uniforms or linen. This simply isn’t true.
One of our earlier posts describes the peril of leaving hospital staff to clean their own uniforms. It details a study that shows bacteria aren’t eliminated from improperly laundered uniforms and clothing, and it points to a need for a consistent industry standard for their cleaning. Worse yet, when previously uncontaminated clothing is mingled with contaminated pieces, viruses are readily transferred. There’s not much reason to believe this same process doesn’t lead to contaminated white coats, uniforms, scrubs and the like transferring viruses and bacteria to patients and uncontaminated bedding, for example, in a hospital setting.
Low-cost technology to make fabrics and clothing antimicrobial has existed for years. It’s time to use it. Why not error on the safe side rather than continue to wait for some definitive study that eliminates all doubt? We are putting countless lives at stake as well as creating unnecessary costs created by preventable infection.
Detailed linens, uniforms cleaning protocol is essential to infection control is a piece we posted earlier and that relates to this conversation. It points out with no uncertainty that fabrics – linens, uniforms, bedding, etc. – should be considered materials that can harbor pathogens if not properly cleaned.
The post antibiotic world was center stage recently as the World Health Organization (WHO) highlighted “World Antibiotic Awareness Week (Nov. 16-22). You can find the core subject document at our website. It is titled Antimicrobial Resistance: Global report on surveillance. It suggests that a post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century. It goes on to say that the WHO, along with partners across many sectors, is developing a global action plan to mitigate AMR. Strengthening global AMR surveillance will be a critical aspect of such planning as it is the basis for informing global strategies, monitoring the effectiveness of public health interventions and detecting new trends and threats.
To that point, Alarming new “superbug” gene found in animals and people in China by Reuters says the discovery a new gene that makes bacteria highly resistant to a last-resort class of antibiotics is “alarming” to scientists, who called for urgent restrictions on the use of polymyxins – a class of antibiotics that includes the drug colistin and is widely used in livestock farming. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study reports in detail about this emergence of the first plasmid-mediated polymyxin resistance mechanism, MCR-1, in Enterobacteriaceae.
Also, check out this related piece at PubMed Central®:
- New metallo β-lactamase NDM-1: Bacteria have countered the introduction of successive classes of antibiotics by developing a variety of resistance mechanisms. At the top of the pyramid are the carbapenemases. The metallo β-lactamases (MBL) are the more versatile enzymes that can convert the host bacteria into almost total β-lactam insusceptibily4. Infections by such organisms are practically untreatable by β-lactam antibiotics, which are the most favoured agents used in Gram negative sepsis.
During the past year, several high profile zoonotic bugs have jumped from animals to humans. Ebola, bird flu and Middle East Respiratory Syndrome (MERS) are just a few of note. Zoonotic bugs will continue to infect people, so we must continue to study them intensely to be even better prepared to fight back.
According to a study at PubMed Central (PMC): Influenza A infects large numbers of warm-blooded animals, including wild birds, domestic birds, pigs, horses, and humans. Influenza viruses can switch hosts to form new lineages in novel hosts. The most significant of these events is the emergence of antigenically novel influenza A viruses in humans, leading to pandemics. Influenza pandemics have been reported for at least 500 years, with inter-pandemic intervals averaging approximately 40 years.
The piece, which is authored by Jeffery K. Taubenberger, MD, PhD and David M. Morens, MD, concludes: How might we prevent and manage a future influenza pandemic? (First), the most obvious requirement is a rapid and expansive influenza surveillance and response network with open global communication and data sharing. Such surveillance activity also needs to include humans, domestic animals, and wild birds. Second, we must develop further, effective intervention strategies to reduce transmission and disease. The conclusive points again illustrate the pressing importance of the One Health initiative, which we’ve discussed in a previous blog post.
Here are a few other studies and articles of merit on the topic of zoonosis and zoonotic bugs: