A 3 Prong Infection Control Strategy for Public

A 3 Prong Infection Control Strategy for Public Buildings Based on the School Disinfection Workgroup National Conference Call Research and Document Collaboration 2009 Project Coordinated by: Lynn Rose Training and Documents Written by: Lynn Rose and Carol Westinghouse, Informed Green Solutions, Inc. Funded by: the Massachusetts Toxics Use Reduction 1 Institute, University of Massachusetts, Lowell

Workgroup Members National: Centers for Disease Control and Prevention and Environmental Protection Agency Massachusetts: Division of Occupational Safety, Dept Public Health, MA Nurses Association, Mass. COSH, TURI Surface Solutions Lab California: Dept of Public Health, California Childcare Health Program, UCSF Connecticut: University of Connecticut Health Center New England: Informed Green Solutions, Inc. 2

Objectives http: //www. vancouverdad. com/photos/germs 1. jpg n Facilitate adequate infection control while minimizing the use of toxic cleaning products and antimicrobial pesticides. n Protect workers and building occupants from exposure to hazardous disinfectants. n Clarify the differences between cleaning and disinfecting products and processes, and when each is appropriate. 3

Presentation Overview n Why be concerned? n How is disease transmitted? n How can Facility Managers safely reduce disease transmission in their buildings? n Strategies and planning n Policies and procedures n Products and equipment n Training and resources 4

Why reduce use of disinfectants? Chemical Hazards n Disinfectants are actually antimicrobial pesticides, designed to kill microbes. cide = kill n Disinfectants do not clean, and cleaners to do not disinfect. n The active ingredients of common disinfectants are among the most toxic chemicals used in custodial work. 5

Why reduce use of disinfectants? Chemical Exposure Risks n A single janitorial worker uses, on average, 194 lbs. of chemicals annually, approximately 25% of which are hazardous substances n Environmental Working Group tested 21 common cleaning products used in California schools. They found 457 chemicals were emitted into the air: 6 known asthmagens n 11 known, probable or possible cancer-causing agents n Others - health effects are unknown n 6

Why reduce use of disinfectants? Chemical Exposure Risks n Children are at greater risk than adults when exposed to toxins because: n They are exposed at higher levels as they eat more food, breathe more air, drink more water n They metabolize and eliminate toxins more slowly n Their rapidly developing systems are more sensitive n Play closer to the ground n Have significant hand-to-mouth activity

Why reduce use of disinfectants? Occupational Hazards n If not handled properly, some disinfectants can cause serious injuries: n Eye damage n Chemical burns n Severe skin irritation n Out of 100 janitors injured each year: n n 20% are serious burns to the eyes or skin 12% are a result of chemical vapors 8

Why reduce use of disinfectants? Occupational Asthma Products # Cases Unspecified 104 Bleach 43 Acids, bases, oxidizers 23 Disinfectants 20 Carpet cleaner 17 Floor stripper/ wax 16 Ammonia 14 Note: 12% of all Work Related Asthma cases in 4 states were associated with cleaning and disinfectant products. CA, MI, NJ 1993 -1997 Rosenman et al 2003 JOEM 45(5): 556 -63 9

Why reduce use of disinfectants? Children’s Asthma Massachusetts Department of Public Health Data on Student Asthma Rates 10

Myth Buster: Question Do you always need to use disinfect to control infection? 11

Myth Buster: Answer n. No, some alternatives include: n An all purpose cleaner and microfiber n Equipment without chemicals such as a steam cleaning machine 12

3 Levels of Microbe Control: Cleaning Removing Microbes 99% Sanitizing Killing Bacteria 99. 9 to 99. 999% Disinfecting Killing Microbes 99. 99% 13

Breaking the Chain of Infection: “ 3 Prong Approach ” 1. Personal Strategies Example: Influenza a. Hand Hygiene 2. Cleaning for Health 3. Targeted Sanitization and Disinfection b. Respiratory Hygiene c. Cough Etiquette d. Social Distancing and Isolation 14

Understanding the Chain of Infection A series of events that need to occur before a person develops an infectious disease. 15

What are Microbes? Dispelling the “Fear Factor” n Microbes are everywhere in the environment – in the air, water, soil, plants and animals. n We can’t live without them. n Some are good for you, and other pathogenic” microbes cause infections and disease, commonly referred to as “germs”. 16

What are Microbes? n Bacteria* – have their own cell walls, and can live independently. n Fungi* – grow on dead and decaying matter. Common forms are yeast and molds. n Viruses – live and multiply inside of cells of a living host, and cannot live independently. * Spores produced by some types of bacteria and fungi can live in the environment for months or years. 17

How Are Microbes Transmitted? Susceptible Host Microbes make host sick Infectious Microbes Bacteria, Virus, Fungi Reservoir Microbes adapt and multiply (on animate & inanimate objects) Chain of Transmission Portal of Entry: Microbes enter new location (e. g. mucous membranes) Modes of Transmission: Microbes are transported to new location (by animate or inanimate objects) Where people come in contact with them Contact Respiratory 18 Contact Portal of Exit Microbes leave (e. g. sneeze or cough)

Reservoir n Microbes live and multiply in a reservoir. n Microbes prefer: n Warm, dark environment n Moisture n Source of food 19

Droplet Transmission n Large n n droplets containing microbes are: propelled short distances (3 -6 feet) through the air from sneezing, talking, and coughing. deposited on a host’s mucous membranes - eyes, nose or mouth n Examples: n flu, cold, strep 20 Photo: 2009 Camfil Farr , http: //www. camfilfarr. com/cou_us/industries/care/infection_transfer. cfm

Airborne Transmission Photo: 2009 Camfil Farr , http: //www. ca mfilfarr. com/c ou_us/industri es/care/infecti on_transfer. cf m n n Microbes in airborne droplets: n Survive from evaporated droplets, and n Remain in the air for long periods (hours to days). Examples: n measles, TB, chickenpox 21

Contact Transmission: Indirect Contact n Transfer of microbes from object to person n Examples such as MRSA or Norovirus - transmitted by: n Touching environmental surfaces contaminated with infectious blood or body fluids, and n Then touching mucous membranes (eyes, nose, mouth) or touching an area with broken skin. 22

Contact Transmission: Direct Contact n Transfer of microbes from person to person. n Examples such as MRSA or Norovirus - transmitted by: n Touching infected area or infectious body fluid on a person, and n Then touching mucous membranes or touching an area with broken skin. 23

Means of Entry n Breaks in the skin n Respiratory tract n Digestive tract n Circulatory system 24

Susceptible Host n Weakened Immune System - body not able to fight off infection! 25

What Influences the Survival of Microbes Outside of the Body? Conditions of Surrounding Environment Humidity, p. H, temperature, microbes present, ultraviolet light exposure Properties of the Object Microbe Properties Type of microbe and type of medium it is suspended in Adds up to microbe survival on object Porous or nonporous, How clean, How much moisture Adapted from Stephanie A. Boone* and Charles P. Gerba, Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease. Applied and Environmental Microbiology, March 2007, p. 1687 -1696, Vol. 73, No. 6

Breaking the Chain of Infection Breaking any of the links of the chain can interrupt the transmission of disease. 27

The Three Prong Approach 1. Personal Strategies and Responsibilities § Prevent transmission 2. Cleaning for Health § Remove reservoir § Prevent transmission 3. Targeted Sanitizing/Disinfection § Remove reservoir § Prevent transmission 28

Personal Strategies: Will Respiratory Hygiene and Cough Etiquette Reduce Flu Transmission? Yes. The CDC recommends: n Covering the nose/mouth when coughing or sneezing, and washing hands after. n Coughing into the elbow when tissues are not available. n Using & disposing of tissues. n Leaving a 3 -6 foot buffer between yourself and others when coughing or sneezing. 29 CDC Influenza Fact Sheet, http: //www. cdc. gov/flu/professionals/pdf/resphygiene. pdf.

Personal Strategies: Will Self-Isolation and Social Distancing Help Reduce Flu Transmission? Yes, and guidelines for sick people from the CDC include: n Staying home and away from people until at least 24 hours after they are free of fever (100° F), or signs of a fever without the use of fever-reducing medications. n Limiting contact with others and maintaining a distance of at least 6 feet from people. n Wearing a surgical or N 95 mask around other people. 30

Personal Strategies: Will Hand Hygiene Help Reduce Flu Transmission? n Yes, depending on the product and process used. n Hand washing with soap and water can reduce infections by more than 50 % in some cases! 31

Hand Hygiene: Product Types n Soap will remove, not kill microbes. n Anti-bacterial products kill bacteria and some, but not all viruses. n Anti-microbial products can kill or suppress growth of bacteria, viruses or fungi. 32

Hand Hygiene Products: Hand Soap n Soap is available in liquid, bar (not recommended) and hand wipe forms. n Soap and warm water remove microbes by breaking down the oil and dirt that harbors them, and washing them away. n The CDC guidelines call for washing hands with warm water and soap for 15 to 20 seconds to effectively prevent infection. 33

Hand Hygiene Products: Anti-bacterial Hand Soap n Kills bacteria and some, but not all viruses such as the common cold, flu, stomach flu and blood borne pathogens such as HIV and Hepatitis B and C. n A Federal Drug Advisory Panel concluded in 2005 that, for general use, antibacterial soaps are no more effective than regular plain soap at removing germs. Reference: http: //www. cdc. gov/Features/Hand. Washing , August 28, 2008

Hand Hygiene Products: Anti-bacterial Hand Soap n The most common ingredients are triclosan and triclocarban. Triclosan health issues include: n Can be absorbed through skin, linked to liver damage. n Detected in breast milk, urine and blood. n Linked to hormone disruption. 35

Hand Hygiene Products: Anti-Microbial Hand Sanitizer n Product that can kill or suppress growth of viruses, bacteria or fungi. n Available in foam, gel or hand wipes. n Most common ingredient is alcohol, which comes in 2 forms and different strengths. Note: Always replace product in dispenser, never top off to prevent microbial growth in dispenser. 36

Hand Hygiene Products: Alcohol Based Sanitizers - Concentrations Concentration Required to Kill Specific Viruses Virus Ethyl Isopropyl Alcohol Influenza A 30% Norovirus (stomach flu) 62% 95% Rhinovirus (common cold) 62% 95% Hepatitis A 62% 95% Note: 70% Ethyl Alcohol would be better than 62%, but its hard to find.

Hand Hygiene Products: Alcohol Based Sanitizers - Dangers n Routes of Exposure for Children n absorb it through skin n lick it off their hands n squirt it into their mouths 38

Hand Hygiene Products: Alcohol Based Sanitizers - Dangers n Risks n 3 squirts* can raise blood alcohol level in a toddler to be legally intoxicated. 10, which is comparable to someone that size to drinking 120 proof alcohol. n “Ingesting as little as an ounce or two of this product could be fatal to a toddler, ” says Heidi Kuhl, health educator, Central NY Poison Control Center. * Purell and Germ-X contain 62% Ethyl Alcohol Reference: http: //www. snopes. com/medical/toxins/sanitizer. asp 39

Hand Hygiene: Alcohol Based Sanitizers - Dangers n Class 1 - Flammable Liquid n Follow 527 CMR storage guidelines n State Fire Marshal reissued an Advisory for Alcohol Based Hand Sanitizers containing 60% - 95% ethanol or isopropanol. n Posted: SFO website Fire Prevention SFO Advisory 40

Hand Hygiene: Product Limits n Dirt: antimicrobial and alcohol based products don’t necessarily remove dirt on hands, which compromises their ability to kill microbes. n Proteins: soap is more effective at removing proteins from hands than alcohol sanitizers. 41

Do Hand Sanitizers Replace Hand Washing? No, hand-washing is the first and most important step, especially if hands are visibly soiled. CDC Recommendations: When hand washing is not an option (e. g. school bus or field trip), “alcohol-based hand cleaners are also effective. ” Sources: 1) City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and 2) Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging Infectious Diseases, by Dr. 42 Elaine Larson, prof pharmaceutical & therapeutic research, & prof of epidemiology, Columbia Univ School of Nursing

Infection Control Strategy as part of A Cleaning for Health Program 43

Cleaning for Health Program Cleaning that protects public health, without adversely affecting the staff, building occupants and the environment. n A comprehensive program to: n prevent proliferation of dirt and microbes n use safe cleaning products and work practices n Sample strategies include: n More frequent cleaning of high-touch surfaces n Cleaning with color coded microfiber mops/cloths n Using floor/vacuuming equipment with HEPA filters 44

Three Levels of Microbe Control 1. Cleaning Microbes 99% 2. Sanitizing Bacteria 99. 9 – 99. 999% 3. Disinfecting Microbes 99. 99% Level 1: General Surface Cleaning n Physically remove viruses, fungi and bacteria and the conditions they need to survive (e. g. organic matter). n Accomplished with water, detergent, and abrasion of the surface. n Microfiber can enhance this process by removing up to 99% of microbes. 45

Three Levels of Microbe Control 1. Cleaning Microbes 99% 2. Sanitizing Bacteria 99. 9 – 99. 999% 3. Disinfecting Microbes 99. 99% Level 2. Sanitizing n Reduces (kills) 99. 9% to 99. 999% of tested bacteria to levels considered safe for public health. n May not have claims for killing viruses or fungi. n Some products can be both a sanitizer and a disinfectant, depending on specified concentration. 46 References: Infection Control for Dummies, J. Darrel Hicks, REH, http: //www. epa. gov/iaq/glossary. html#S, http: //www. epa. gov/iaq/glossary. html#D, and Source: Cleaning for Health, Inform, Inc, and presentation by Marcie Tidd on Disinfectants, Sanitizers, and Product Labeling, Overview of EPA’s Antimicrobial Registration Process, Women's Voices for the Earth Conference Call, February 4 th, 2009

Three Levels of Microbe Control Level 2. Sanitizing n Registered by EPA for use on porous and nonporous surfaces: n Food contact surfaces: sanitizing rinses for surfaces such as dishes and cooking utensils. n Non-food contact surfaces: carpet, laundry, toilet bowl, etc. 47 References: Infection Control for Dummies, J. Darrel Hicks, REH, http: //www. epa. gov/iaq/glossary. html#S, http: //www. epa. gov/iaq/glossary. html#D, and Source: Cleaning for Health, Inform, Inc

Three Levels of Microbe Control 1. Cleaning Microbes 99% 2. Sanitizing Bacteria 99. 9 – 99. 999% 3. Disinfecting Microbes 99. 99% Level 3. Disinfecting n Destroys 99. 99% of all forms of microbial life, but not necessarily their spores. n Use on hard nonporous surfaces, which have higher transmission rates. 48

Disinfectants: Claims n All disinfectants do not kill all types of microbes. n EPA categorizes & registers products by their Disinfectant Claims based on what they kill: Limited Broad Spectrum, General Hospital, Medical Use 49

Disinfectants: Claims n Hospital / Medical Use Disinfectant: n meets the requirements for a general disinfectant n also effective against the Pseudomonas aeruginosa n does not necessarily kill TB or HIV 50

Disinfectants: Claims n To comply with OSHA BBP Standard, use: n n n a tuberculocide, or A product that lists the specific BBP viruses - HIV and hepatitis B For MRSA and other specific diseases, check the label. 51

Disinfecting: Consult the Label & EPA’s Website Listings of EPA’s registered antimicrobial products for specific diseases: http: //www. epa. go v/oppad 001/chemr egindex. htm 52

Disinfectants: Claims for H 1 N 1 and Influenza A EPA’s position October 22, 2009 An influenza A virus label claim is sufficient to support label claims against 2009 H 1 N 1 influenza A virus. 53

Disinfectants: Selection Are they ranked for safety? n EPA Design for the Environment program is implementing a 2 year pilot project Safer Product Labeling Program. n Products restricted to EPA registered disinfectants. n Evaluates critical health and environmental standards, and is available at: http: //www. epa. gov/dfeprojects/gfcp/. 54

Disinfectants: Selection EPA’s Pilot Program n Identified the following active ingredients as being least-toxic: Accelerated Hydrogen Peroxide n Lactic Acid n Citric Acid n n Products with these ingredients will not be approved: n Quaternary ammonium compounds n Sodium hypochlorite (bleach) n Ortho-phenylphenol (2 phenylphenol) n Thymol 55

Disinfectants: Selection Are they ranked for safety? n Eco. Logo - in Canada does certify disinfectants. Not all products are available in the US, or are EPA registered. n MA Operational Service Division - Environmental Preferable Products Contract FAC 59 provides a fact sheet on several uncertified antimicrobial products available through contract vendors. 56

Disinfectants: Selection Are they ranked for safety? Toxicity Health: EPA Toxicity Rating (1 -4) Acute Toxicity Category Signal Word Required Category I Danger/Poison Category II Warning Category III Caution Category IV Caution (or none required if all routes are Cat IV) 57

Disinfectant: Selection Hazardous Options - Bleach n Hazard Level n CDC Disinfection Level - Intermediate Level n EPA Toxicity Category - Category I n Claims n most bacteria and some viruses n registered as effective against HIV, HBV, H 1 N 1 (Influenza A), MRSA, TB Note: Can’t be stored longer than 3 months for disinfecting. When diluted, is only effective as a disinfectant for 24 hours. 58

Disinfectant: Selection Hazardous Options - Bleach (5. 25% and 6% Sodium Hypochlorite) n Health Effects n Corrosive to eyes and skin n Respiratory irritant n Suspected cardiovascular, gastrointestinal or liver, kidney, central nervous system, respiratory, and skin or sense organ toxicant 59

Using Bleach Safely Note: Although the project does not advocate the use of bleach as there are much safer alternatives, we provide these guidelines for those who continue to use bleach. n The dilution rate will vary depending on the strength of the original product 5. 25% or 6% and intended uses. Check the label. 60

Using Bleach Safely n Use different dilutions for specific uses, such as: n Sanitizing food surfaces n Disinfecting non-blood or body fluids, disinfecting shared sports equipment (mats, etc. ), sinks, etc. n Disinfecting blood, vomit spills (after cleaning) 61

Disinfectant: Selection Hazardous Options - Phenols n Hazard Level n CDC Disinfection Level - Some are intermediate and some are low level. Check the label. n EPA Toxicity Category - Category I or II n Claims n Read product label for specific microbes 62

Disinfectant: Selection Hazardous Options - Phenol n Health Effects n Recognized carcinogens (CA Prop. 65) n Suspected toxicant - cardiovascular, developmental, neurological, reproductive, respiratory, skin, sense organ n Corrosive to eyes and skin Absorbed through the skin and by inhalation. 63

Disinfectant: Selection Hazardous Options - Quaternary Ammonium Compounds n Hazard Level n CDC Disinfection Level - Low Level n EPA Toxicity Category - Category III n Claims n Generally effective against a broad spectrum of microbes including MRSA and H 1 N 1 (Influenza A), but not spores n Read product label for effectiveness against TB 64

Disinfectant: Selection Hazardous Options - Quaternary Ammonium Compound n Health Effects n Can cause contact dermatitis and nasal irritation. n Ammonium quaternary compounds* are respiratory sensitizers and are associated with asthma. *Includes: benzalkonium chloride, dodecyl-dimenthyl-benzyl ammonium chloride and lauryl dimethyl benzyl ammonium chloride. 65

Disinfectant: Selection Less Hazardous Options - Accelerated Hydrogen Peroxide n Claims - as a disinfectant & sanitizer (non-food contact) n n n Viruses – e. g. , Hep B & C, HIV Bacteria – e. g. , TB & MRSA Fungi – e. g. , athletes feet n Ease of Use n Rinsing not required, except for allowable food surfaces n Hazard Level n n Non flammable, not hazardous Acidic - p. H 2. 5– 3. 5 Ingredient in several products. This product is registered by EPA 66 as a Disinfectant

Sanitizer: Selection Less Hazardous Options - Ionized Water Process involves: 1. Charging - a battery applies an electrical charge to water. 2. Transforming - charged water passes through an ion exchange membrane, creating positive and negative nano-bubbles. 3. Cleaning - activated water now attracts dirt like a magnet and lifts it from the surface, enabling it to be wiped away. 67 Equipment used: Ionator

Disinfectant: Selection Criteria n EPA registered n Broad spectrum n Health - EPA toxicity rating (1 -4), select the relatively non-toxic (4 preferable) n Storage - stable shelf life, nonflammable n Ease of Use – whether rinsing is required, short dwell time, no PPE n Environmentally preferable 68

Disinfection Application Process: Selection Criteria n Using the most appropriate application for the job. n Preventing cross contamination. n Preventing exposure to workers and occupants. n Conserving resources. n Protecting the environment. 69

Disinfection Application Process: Comparison Criteria Conventional Microfiber Mop and Mop Pads Bucket and Bucket Reusable Microfiber Cloths Reusable Disposable Pre-Saturated Cotton Cloths Cotton or Wipes for Paper Towels Surfaces Effectiveness at Capturing, or Killing Microbes Captured 30% microbes in a hospital setting study. Superior – captured 99% microbes in a hospital study. Penetrate into cracks that other materials cannot reach. Significantly less than microfiber. Solution must be changed regularly to maintain efficacy. The type of microfiber affects efficacy, with 0. 13 denier the highest. Increased fiber surface area & static electric charge enable it to attract, capture & hold particulates better. Depends on saturation of wipe and ability to stay wet on the surface. Solution remains stable in presence of the wipe material. 70

Disinfection Application Process: Comparison Criteria Conventional Microfiber Reusable Mop and Mop Pads and Microfiber Bucket Cloths Ability to Good Maintain Adequate Contact/ Dwell Time to Kill Microbes Superior - microfiber cloths have such a high density and surface area, they can absorb up to 7 times their weight in water and retain that moisture. Reusable Disposable Cotton Cloths Cotton or Paper Towels Superior - Good microfiber cloths have such a high density and surface area, they can absorb up to 7 times their weight in water and retain that moisture. Cotton is better than paper, but retains less moisture than microfiber. Pre-Saturated Wipes for Surfaces Can dry out on surface. Although wipes are designed to provide a premeasured amount of solution, the possible uneven saturation level in container may compromise this. 71 Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002 [ii] Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002 [i]

Disinfection Application Process: Comparison Criteria Conventional Mop and Bucket Cross Contamination (CC) Advantages and Disadvantages Solutions must Prevents CC if be changed a color coding regularly. system is used Mop must be and if a new mop head is cleaned and used for new dried or microbes will uses or rooms. colonize on the Since the mop fibers. head is not dipped back A bucket into the divided for clean and dirty solution, there water prevents is no CC of CC when mops solution in bucket. are dipped back into Increased solution. fiber surface area & static Disinfecting mop is difficult. electric charge enable it to better hold microbes. Microfiber Reusable Mop Pads and Microfiber Bucket Cloths Reusable Disposable Pre-Saturated Cotton Cloths Cotton or Wipes for Paper Towels Surfaces Prevents CC Can serve as a CC may if changed breeding occur regularly and ground for between when uses or microbes and towel rooms change. cause CC if dispenser not laundered handle and Increased dispensers, fiber surface and dried area & static before reuse. especially if located in electric splash zone. charge enable it to better hold microbes. It dries faster than cotton so there is less chance for microbes to proliferate. Microbes can survive on the cloth and can cause CC. Avoids CC that might occur from dipping cloths back into solution. 72

Developing Protocols Criteria to Consider 73

Disinfecting: Developing a Protocol A written procedure should provide guidelines that answer the following questions: n When and how often it should be done. n What products and tools should be used. n How to use and manage products/equipment. n How to protect oneself and building occupants. 74

Protocol: Determine when to Clean, Sanitize or Disinfect n What is the surface to be managed – porous or non-porous? n What is the level of occupant contact with the surface: n Minimal – floors, walls, etc. n Frequent – high touch or high risk n Are there any regulations requiring disinfection or sanitization? 75

Protocol: Determine Management of Surfaces High Touch Surfaces - Touched by a Variety of Hands CDC Position: “does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required. ” Project Recommendation: clean more frequently during the day with a microfiber cloth and third-party certified* all-purpose cleaner. * Certification: a third party (e. g. Green Seal and Eco. Logo) gives written assurance that a product or service conforms to specified requirements. 76

Protocol: Determine Management of Surfaces High Touch Surfaces - Touched by a Variety of Hands n Restroom examples: n Faucet handles, toilet handles, towel dispensers, hand driers. n Break Room and Cafeteria examples: n Coffee pots, microwave doors, refrigerator doors n Vending machines n Water fountains 77

Protocol: Determine Management of Surfaces High Touch Surfaces - Touched by a Variety of Hands n Office examples: n Shared desks or work areas n Shared computer mice and keyboards n Fax machines, copiers, printers 78

Protocol: Determine Management of Surfaces High Touch Surfaces - Touched by a Variety of Hands n Custodial examples: Shared cleaning equipment. n Product containers and dispensers in custodial closets. n n Public Ways examples: n Doorknobs, elevator buttons, light switches, door push bars, handrails. 79

Protocols: Determine Management of Surfaces High Risk Areas n Some surfaces in the following locations may require disinfecting: n Shower and locker rooms n Rest rooms n Nurse’s office n SPED n Preschool 80

Protocol: Determine Management of Non-Contact Surfaces - Floors n Routine disinfection of floors is not supported by epidemiology, unless there is a Bloodborne Pathogens (BBP) spill or as required in certain areas of athletic facilities. n Clean floors with a microfiber mopping system and a 3 rd party certified floor care product. 81

Protocols: Ensuring Product Effectiveness n Water Hardness: n Some disinfectants can be neutralized in hard water. The label on quats may specify its effectiveness in hard water. n Temperature: n Can degrade product during storage. n Can enhance or reduce product effectiveness during use. n Product Concentration: n Less concentrated than directed will not be effective. 82

Protocols: Ensuring Product Effectiveness n Type and amount of microbes: n Product must have ingredients registered by EPA to kill target microbes. n Shelf-life of disinfectant: n Diluted products have shorter shelf life. n Length of time solution sits in bucket and number of times used: n Efficacy can be reduced, and microbes can reproduce. 83

Protocols: Ensuring Product Effectiveness n Contact time (AKA – kill or dwell time): Product must stay wet. Times varies for each product. n Material on the surface: Cleaning product residues, protein and dirt can interfere with disinfectant activity. n Compatibility of product and surfaces: Incompatible materials can damage surface. n Physical configuration of the object (e. g. crevices): Difficult to remove debris or ensure disinfectant comes in contact with all areas of a surface. 84

Protocol: Dispensing Disinfectants Diluting Product: n Measure concentrates before adding them to the dilution tank. n Follow dilution rate instructions exactly for specific uses as products are tested and only guaranteed at specific concentrations. More is not necessarily better, it can be more hazardous. 85

Protocol: Dispensing Disinfectants Required information on labels of secondary containers: n Brand name of the product or the name as listed on the MSDS. n Hazard warnings: n Health Hazard – including affects on target organs (heart, liver, kidneys, nervous system, etc). n Physical Hazard – flammable, corrosive, reactive Health Flammability Reactivity PPE HMIS Labels - an “at a glance” warning to alert workers of the degree of hazard, particularly for those who do not speak English. 86

Protocol: Dispensing Disinfectants Sample Label on Secondary Bottle CLOROX LIQUID BLEACH WARNING: STRONG OXIDIZER! STORE IN A COOL, DRY PLACE. DO NOT GET IN EYES OR ON SKIN. DO NOT MIX W/OTHER HOUSEHOLD CHEMICALS. ACUTE: CAUSES SEVERE BUT TEMPORARY EYE INJURY. MAY IRRITATE SKIN. MAY CAUSE NAUSEA & VOMITING IF INGESTED. EXPOSURE TO VAPOR OR MIST MAY IRRITATE NOSE, THROAT & LUNGS. Recommend adding date prepared, and dilution rate. 87

Protocol: Preventing Cross Contamination: n Is the transfer of infectious microbes from one surface, object or person to another. n Involves understanding Chain of Infection: n where microbes live and multiply, and n how they are transferred to a new location. 88

Protocol: Preventing Cross Contamination Sources of Cross-Contamination: n Used cloth or mop head, especially if left soaking in dirty solutions. n Solutions of disinfectants, prepared in a dirty container, stored for long periods of time, or prepared incorrectly. n Contaminated hands or gloves. 89

Protocol: Preventing Cross Contamination n Allow laundered mop heads and cloths to dry before re-use. n Replace cloths and mop heads each time a bucket of disinfectant is emptied and replaced. 90

Protocol: Preventing Cross Contamination Tools, Equipment and Supplies to Prevent Cross Contamination from: n Surface to surface – change cloths or mop heads when moving to a new surface (e. g. toilet to sink). Color coded microfiber systems help with this. 91

Protocol: Preventing Cross Contamination n Personal Protection: wear and change gloves and wash hands between tasks. n Custodial Closets: clean equipment after use. 92

Protocol: Pre-Cleaning Why? n Soil and organic matter can reduce effectiveness of disinfectant by: n Providing shelter for the microbes to hide. n Absorbing ingredients. Disinfectants need to be in contact with microbes to kill them! n Changing the chemical nature of the disinfectant. http: //www. goductpro. co m/images/microbes. gif 93

Protocol: Pre-Cleaning Why? n Biofilm can form when microbes develop a protective matrix on wet surfaces over time. n Disinfectants cannot penetrate them to kill microbes. n Biofilm needs to be physically abraded or penetrated by the use of steam vapor device to reach microbes. Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel 94

Protocol: Pre-Cleaning Key locations for a biofilm to form are in areas that are wet on a regular basis: n Plumbing facilities such as under rims of toilets and urinals, in sinks, in distribution pipes, etc. n Wet areas that surround them such as backsplashes, drain areas, etc. 95

Protocol: Separating Pre-cleaning & Disinfecting Tasks n Disinfectant/Cleaner Products: n There are 2 types of products registered by EPA to clean and disinfect. n They contain a disinfectant and a detergent. 96

Protocol: Separating Pre-cleaning & Disinfecting Tasks 1. One Step Cleaner/Disinfectants n Work only on surfaces with a moderate amount of organic soil. n Labeled as a one-step cleaner/disinfectant: “effective in the presence of 5% body fluids” 97

Protocol: Separating Pre-cleaning & Disinfecting Tasks 2. Two Step Cleaner/Disinfectant n Products that are not “effective in the presence of 5% body fluids”. n Labeled and used as a two step process. 98 References: Infection Control for Dummies, J. Darrel Hicks, REH, and What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel

Protocol: Separating Pre-cleaning & Disinfecting Tasks n All other disinfectants require surfaces to be pre-cleaned using a detergent. n We recommend using two different types of products to reduce the use of hazardous ingredients: n One nontoxic one to clean n A disinfectant to disinfect References: Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel 99

Protocol: Disinfecting n Allow time for disinfectants to react with the microbes to kill them (AKA - dwell, contact or kill time): follow directions for time required for the disinfectant to be wet on the surface. n Reduce quantity: use the smallest possible amount of disinfectant as recommended. n Rinse: rinse high-touch areas, if required on the label. Any residue may be hazardous when it comes in contact with skin. 100

Protocol: Disinfecting Protect Workers & Building Occupants: n Direct workers to spray product on cloth when possible, not into the air. n Require adequate ventilation. The HVAC system should be operating while disinfecting is conducted. n Schedule use of disinfectants when there are the fewest occupants, e. g. tasks conducted once daily. 101

Protocol: Worker Safety Require use of Personal Protective Equipment: n Non Latex Gloves n Resistant to chemicals (check label for type) n Prevent allergic reactions n Facial Protection (if needed) n Chemically Resistant Masks/Goggles (safety glasses with side piece) n Disposable face shield 102

Protocol: Worker Safety Always wear chemically resistant gloves! If…. Then…. You could be splashed Goggles or safety glasses, in the face? and a mask or a disposable face shield is required You could be splashed An apron is required on your body? If you could step in it and track it around? Booties are required 103

Protocol: Designating Roles & Responsibilities n Restrict the use of disinfectants to trained and approved staff for: n Targeted disinfecting and sanitizing. n Regulated disinfecting and sanitizing. n Events – BBP, body fluids and infectious disease outbreaks (when required). 104

Policy and Procedures: Providing Guidance and Resources All staff using disinfectants & sanitizers need: n Training. n Clear guidance on when, where and how to use and handle. n Labeled containers of approved products. n Chemical storage equipment. n Personal Protective Equipment. 105

Equipment: Microfiber Infection Control Attributes n Requires Less Chemicals: reduces need for disinfectants for most cleaning tasks since the fiber removes a high % of organic matter. n Controls Cross-Contamination: by color coding & changing mop pads after each room. n Prevents Aersolization of Dust: The fibers have a static electric charge that attracts dust and holds it when dry dusting. (Dust can transmit microbes. ) 106

Equipment: Microfiber Infection Control Attributes n Minimizes Microbial Growth: dries more quickly, which helps to prevent microbe growth inside fiber. n Captures Microbes: more effective than cotton. Use of microfiber mops in UC Davis Medical Center 2002 hospital study found 99% reduction in bacteria versus only 30% reduction using a conventional wet mop system. 107 Source: EPA Fact Sheet, November 2002 - Using Microfiber Mops in Hospitals

Equipment: Microfiber Infection Control Attributes n Absorption Ability: The increased surface area of the fibers and their shape enable them to absorb up to 7 -8 times their weight in liquid, reducing conditions for microbe survival. 108 Photo: http: //media. primetimesolutions. net/themes/shopmicrofiber. com/images/microfiber. Cleans. Better. gif

Equipment: Facility Minimize Occupant Exposure n Bathroom n Hands free towel dispenser or hand dryer n Hands free soap dispenser n Hands free faucet and toilet controls n Hands free trash can n Office and Public Areas n No-touch trash cans n Sneeze guards Note shields between public and employee behind counter 109

Equipment: Custodial Minimize Occupant Exposure Examples: n Steam Cleaners and Steam Vapor Cleaners n No Touch Cleaning Equipment http: //www. anaguard. com/images/kai_equipment. png 110

Equipment: Ventilation to Reduce Exposure During outbreaks transmitted through airborne transmission, increasing ACH can reduce airborne microbes. An example, note that increasing ACH from 6 to 15 will 'clean' the air to a 99% removal rate in 18 minutes as opposed to 46. 111 Reference: SARS & Air Filter Recommendations http: //www. filterair. info/articles/article. cfm/Article. ID/D 4 EB 5 EEC-ACCD-4 AF 7 BB 92 BD 9 B 3 DFE 9581

Facility Manager Roles and Responsibilities Flu Example 112

What role do Facility Managers play? n Reducing Transmission: n Risks to staff from their work. n Risks between staff, building occupants and the public. 113

How could a flu outbreak affect my workplace and workforce? n Absenteeism – could affect up to 40 % of workforce during pandemic peak periods. n Change in demand for custodial services – may increase with additional infection control tasks. n Change in patterns of building use - the public may come in at off-peak hours. n Interrupted supply/delivery - shipments of items maybe delayed or cancelled. 114

What is involved in fulfilling these responsibilities? n Developing Policies: n n Cleaning and Disinfecting for Infection Control Absenteeism n Stockpiling and providing items to occupants: n n n Soap, tissue, hand sanitizer Cleaning supplies, microfiber cloths PPE 115

What is involved in fulfilling these responsibilities? Providing training on: n Job related transmission routes & exposure risks. n Exposure Prevention n Protective behaviors (e. g. cough etiquette, hand hygiene) n Protective supplies (PPE) n Work practices n Cleaning and disinfection plans to be followed during outbreaks. 116

Summary: Breaking the Chain of Infection 117

Additional Resources n MA Operational Services Division Environmentally Preferable Products Program http: //www. mass. gov/ - type in EPP FAC 59 Contract n FAC 59 Criteria for Disinfectants, Sanitizers and Mold/Mildew Remediation 118

Additional Resources n Cleaning Product Certification Organizations n Green Seal - http: //www. greenseal. org/ n Eco. Logo - http: //www. terrachoice- certified. com/en/index. asp n Green Cleaning - www. greencleaningnetwork. org n Center for a New American Dream, Responsible Purchasing Network http: //www. newdream. org/work/rpn. php 119

Resources: Project Handbook for Schools Disinfection Overview • • Definitions The Science of Disinfection and Infection Control Development of Protocols • • • Writing a Procedure for Disinfection Choosing the Right Level of Microbe Control Managing Surfaces for Infection Control Dispensing Disinfectants Labeling Secondary Containers Pre-Cleaning Surfaces and Using Disinfectant Cleaners Identifying Factors that Compromise Disinfectant Efficacy Preventing Cross Contamination Storing Disinfectants Disposing of Wastes Taking Precautions Assigning Roles and Responsibilities, and Educating School Staff Selection of Products, Dispensing Equipment and Application Systems • Selecting Products for Infection Control: Decision Making Flow Chart • Comparing Disinfectants: Comparison Chart for EPA Registered Hard Surface Disinfectants • Using the Disinfectant Label Information to Make Informed Decisions • Using Information from Hazardous Materials Rating Systems for Product Selection • Using Information from Material Safety Data Sheets for Product Selection • Selecting the Disinfectant Application System • Choosing Between Concentrated Products and Ready To Use Products • Selecting and Installing Product Dispensing Systems 120

Resources: Project Handbook for Schools Safe Use Practices • • Using Bleach (Sodium Hypochlorite) Hazard Overview of Bleach Protocol for Safe Use of Bleach Using Disinfectants Classroom, Nurse and Custodial Guidelines and Posters • Sample Classroom Policies • Cleaning Surfaces for Infection Control for School Custodians – Poster • Sample School Nurse Polices Infection Control Practices • Cleaning for Healthy Schools: Best Practices • Understanding Hand Hygiene: Products and Practices • Cleaning Up Blood and Body Fluid Spills: Protocol Poster • Blood Spill Kit: Sample Memo with List of Kit Items Equipment for Infection Control • Using Devices to Eliminate Chemical Use: Ionator, Steam Technology and Hands-Free Technology • Using Microfiber Mops and Cloths for Infection Control • Using Ventilation to Reduce Microbe Populations Resources • Organizations • Green Product Certification and Labeling: Appendices • Selecting Greener Disinfectants • Program Planning Handout: Cleaning for Healthy Schools and Infection Control • Interpreting the Disinfectant Label: • Interpreting Information From Hazardous Materials Rating Systems: NFPA /HMIS • EPA's Toxicity Categories • Selecting Disinfectants for Hard Surfaces: • Regulatory Categories • Cleaning for Health: Program Components 121 • Using Ventilation for Microbe Control

Project Contact Information n Lynn Rose, Project Coordinator lynnfaith@comcast. net 1 -413 -774 -6540 n Carol Westinghouse, President Informed Green Solutions, Inc. westies@ecoisp. com informedgreensolutions. org 1 -802 -626 -8643 n Joy Onasch, Community Program Manager Toxics Use Reduction Institute joy@turi. org http: //www. turi. org/community 1 -978 -934 -4343 122

References 1. Infection Control Best Practices for Laundry and Housekeeping Professionals, Nicole Kenny, B. Sc. , Virox Technology, Inc 2. A Guide to Selection and Use of Disinfectants, BC Centre for Disease Control, 2003 3. Taking the Mystery Out of Chemical Disinfection, Nicole Kenny, B. Sc. , Director of Professional and Technical Services, Virox Technology, Inc 4. Infection Control for Dummies, J. Darrel Hicks, REH, 5. What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel 6. Indoor Air Chemistry: Cleaning Agents, Ozone and Toxic Air Contaminants, Final Report, Prepared for the California Air Resources Board and CA EPA 123

References 1. Cleaning for Health, Inform, Inc 2. City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and 3. Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging Infectious Diseases, by Dr. Elaine Larson, prof pharmaceutical, therapeutic research & epidemiology, Columbia Univ School of Nursing 4. 1 Didier Pittet, “Clean hands reduce the burden of disease, ” The Lancet, www. thelancet. com, Vol. 366, July 16 2005, pgs 185 – 187. 5. www. flu. gov 6. CDC - http: //www. cdc. gov/h 1 n 1 flu/guidance/exclusion. htm, 7. CDC - http: //www. socialdistancing. org/determining-your-socialdistance-group-plan/ 124

Self Isolation Poster Source: CDC Preparation for Home Stay Checklist: http: //healthvermo nt. gov/panflu/famil y_checklist. aspx 125

Hand Washing Guidelines n Wet your hands with warm running water and apply liquid soap. n Rub hands together to make a lather and scrub all surfaces for 20 seconds. n Rinse hands in running water. n Dry your hands using a paper towel or air dryer. n Use paper towel to turn off faucet. n 1 Didier Pittet, “Clean hands reduce the burden of disease, ” The Lancet, www. thelancet. com, Vol. 366, July 16 2005, pgs 185 – 187. 126

Combination Poster: Respiratory Etiquette and Handwashing http: //organizedwis dom. com/Special: O W_Special_Nugget/ Handwashing. Poster _Engl_Spanish 2006_1_copy. pdf/26 9/363068 127

Cough Etiquette Posters & Flyers available from the CDC Website in many languages http: //www. cdc. gov/fl u/protect/covercough. htm 128

Alcohol Based Hand Sanitizer Available as foam rubs, gels, or wipes. To be most effective, a dime-size dollop of alcohol gel should be rubbed into the hands for 30 seconds. If hands are dry after only 10 -15 seconds, it is likely that not enough sanitizer was used. Reference: http: //edis. ifas. ufl. edu/fy 732 129