Addressing High-Concern Pathogens and Familiar Threats

In recent years, it has become clear that facilities across the spectrum of care need to take stock of their existing infection prevention and control protocols and consider where there might be knowledge gaps, areas for improvement or need for changes—not only in the context of familiar threats, like Clostridium difficile (C. difficile) and influenza, but also as they apply to emergency preparedness and response plans for high-consequence pathogens and emerging infection risks.

Most health care facilities understand what is at stake if their chosen surface disinfectant does not effectively kill C. difficile, which can not only have serious implications for patient safety, but also carry significant financial consequences for facilities. A study of 170,000 discharges from 477 hospitals from 2009 to 2011 calculated that a single case of C. difficile-associated diarrhea can increase a hospital stay by 4.7 days and add $7,286 to hospital costs.¹ However, as health care facilities work to reduce C. difficile, which remains a leading cause of health care-associated infections (HAIs), they also need to be prepared for emerging threats.

Although the risk posed by emerging infectious diseases may seem less immediate, the reality is that in our increasingly global and interconnected society, an outbreak anywhere creates a health risk everywhere.

Emerging and re-emerging infectious diseases present serious challenges for health care facilities. This is especially true of pathogens with high potential for hospital-associated transmission, such as Severe Acute Respiratory Syndrome-associated Coronavirus (SARS-CoV) and Middle East Respiratory Syndrome-associated Coronavirus (MERS-CoV), which have caused large hospital outbreaks in Saudi Arabia in 2013 and 2014 and in South Korea in 2015.^2,3 The SARS outbreak in Toronto was significantly spread through health care exposures and hospitals acted as disease amplifiers. Both MERS-CoV and SARS-CoV are included in the World Health Organization 2018 list of priority diseases likely to cause severe outbreaks.⁴ Scientific evidence has shown that pathogenic viruses, including SARS-CoV, MERS-CoV, and certain strains of the influenza virus, can survive on surfaces for extended periods, sometimes up to months, and may play a role in transmission.⁵ Outbreaks of disease like SARS and MERS underline the importance of infection prevention within a health care setting during epidemics, and also the importance of consistently strong practices. These diseases were novel biological events, which challenged health care response. Strong infection prevention practices, which include surface disinfection and proper isolation, can significantly slow the spread of a disease, even if it’s new.

One of the challenges associated with emerging infectious diseases is that it’s not always easy to know what products to use or the right way to use them. For emerging pathogens or pathogens that are hard to isolate or handle safely in the laboratory, such as the Ebola virus, there often is no regulatory pathway to obtain a US Environmental Protection Agency (EPA)-registered sanitization or disinfection claim. The Centers for Disease Control and Prevention (CDC) and EPA developed a recommended approach⁶ to help bridge the gap between disinfectant efficacy claims for common health care-associated pathogens and emerging viral pathogens to make it easier for health care professionals to choose appropriate manual disinfectants when no disinfectants with EPA-registered claims are available. For many working in health care during the 2014/2015 Ebola outbreak, the changing personal protective equipment (PPE) guidance was not the only challenge; disinfecting practices became hot topics. Although Ebola is an enveloped virus, the limited research on disinfection practices in health care settings and national concern, the CDC guidance pushed for EPA-registered hospital disinfectants with a label claim for non-enveloped viruses, as they are harder to kill. These recommendations highlight the challenges of maintaining infection prevention practices when dealing with novel or emerging infectious diseases in US hospitals. Although we may be used to fighting MRSA, C. difficile, and other more common infections, it is important that infection prevention practices are not only followed by health care workers, but also inclusive of those diseases that require additional efforts.

Another important emerging threat is Candida auris (C. auris), a multidrug-resistant yeast causing invasive HAIs with high mortality. C. auris is resistant to multiple antifungal drugs, is difficult to identify with standard laboratory methods and has caused outbreaks in health care settings. It can persist on surfaces in health care environments and quaternary ammonia products that are commonly used for disinfection may not be effective against it. Until more is known about C. auris, the CDC recommends the use of an EPA-registered hospital-grade disinfectant effective against C. difficile spores for thorough daily and terminal cleaning and disinfection of patients’ rooms as well as any areas outside of their rooms where patients receive care (eg, radiology, physical therapy). Shared equipment such as ventilators and physical therapy equipment must also be thoroughly cleaned and disinfected before being used by another patient.⁷

Because today’s health care facilities can’t be sure what pathogens might come through their doors next, many are opting to expand the use of sporicidal disinfectants which offer broad-spectrum efficacy for a more comprehensive approach to environmental infection control. For example, Clorox Healthcare Bleach Germicidal Wipes and Germicidal Cleaners, which are EPA-registered to kill C. difficile spores, SARS-CoV, MERS-CoV and many other common causes of HAIs.

While emerging infectious diseases and high-concern pathogens represent a challenging and serious threat, proper education, ongoing training, the right products and daily implementation of strong cleaning and disinfecting protocols can help health care facilities safeguard the environment of care and protect public health.

Lori Strazdas, MPH is a Public Health Liaison with Clorox Healthcare. In her 12 years at Clorox, Lori has held various positions within Research & Development (R&D) and currently focuses on the technical attributes and public health benefits of Clorox Healthcare’s diverse manual disinfecting product portfolio. She is also responsible for identifying new evidenced-based opportunities where Clorox Healthcare can help improve health outcomes and promote infection prevention and control. Prior to joining Clorox, Lori worked for the Pima County Health Department as a Communicable Disease Investigator and Epidemiologist, and in various clinical settings. Lori is a member of the American Public Health Association and the Association for Professionals in Infection Control & Epidemiology and received both her Bachelor’s in Environmental Science and Master’s in Public Health Epidemiology from the University of Arizona. She was subsequently awarded a Fulbright Scholarship to Lithuania, where she studied the risk factors for stomach cancer, including the bacteria Helicobacter pilori.

References:

1. Magee G, et al. Impact of Clostridium difficile-associated diarrhea on acute care length of stay, hospital costs, and readmission: A multicenter retrospective study of inpatients, 2009-2011. Am J Infect Control 2015;11:1148-1153.
2. Assiri, A, et al. Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus. N Engl J Med 2013; 369:407-416. nejm.org/doi/full/10.1056/NEJMoa1306742#t=article.
3. Chowell, G, et al. Transmission Characteristics of MERS and SARS in the Healthcare Setting: a Comparative Study. BMC Medicine 2015;13:210. bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0450-0.
4. List of Blueprint Priority Diseases. World Health Organization website. who.int/blueprint/priority-diseases/en/. Accessed Jan. 23, 2018.
5. Otter, JA et al. Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination.” J. Hosp. Infect. 2016, 92 (3), 235—250.
6. Emerging Viral Pathogen Guidance for Antimicrobial Pesticides. US Environmental Protection Agency website. epa.gov/pesticide-registration/emerging-viral-pathogen-guidance-antimicrobial-pesticides. Accessed Jan. 23, 2018.
7. Recommendations for Infection Prevention and Control for Candida auris. Centers for Disease Control and Prevention website. cdc.gov/fungal/diseases/candidiasis/c-auris-infection-control.html. Accessed Jan. 23, 2018.