Difference between revisions of "Infection Prevention and Control/Surface Decontamination"

Revision as of 16:30, 18 May 2020

Infection Prevention and Control Infection Prevention and Control/Air Disinfection

Decontamination

Decontamination is the process of making an area safe by removing, neutralising or destroying any harmful substances. Decontamination can be achieved by applying physical agents, chemical agents or mechanical removal through any combination of cleaning, sterilisation or disinfection. Physical agents could include heat, radiation and chemical agents include a myriad gasses and liquids.

Cleaning

Cleaning is the process of achieving a state where an area is visually free of contaminating debris. Cleaning is generally achieved by the application of mechanical removal and liquid chemical agents. Cleaning is often an initial decontamination process which removes organic matter from an area. Such organic matter can promote microbial growth and protect microorganisms during further decontamination stages such as sterilisation or disinfection. Cleaning is also frequently applied as the final decontamination stage during which inactivated microorganisms or residual toxins are removed from an area.

Disinfection

Disinfection is the decontamination process of reducing the number of infectious agents to the level where they no longer cause disease. Disinfection typically does not remove bacterial spores.

Sterilisation

Sterilisation is the decontamination process of removing or killing all forms of life in an area. This includes viruses, bacteria, funguses and spores forming organisms.

Surface Decontamination by Cleaning

Before cleaning, a strategy must be available which identifies target organisms, areas, processes, tools and chemical agents appropriate to the area. A review of the high touch areas in the space will inform the strategy. The selection of chemical agents should be based on their intended function (rates of cleaning or disinfection) and the resistance of the target surfaces to potentially corrosive agents. A final cleaning should be done with chemical agents and tools that remove residues from other processes leave no additional unwanted residues.

Surface Decontamination by Heat

Decontamination by heat is typically a sterilisation process with some measure of cleaning beforehand. Surface decontamination by heat is not a common practice and the temperature/time dose function typically requires long exposure times due to the low heat tolerance of surfaces.
Two heat sterilisation processes are available, wet and dry heat.
Wet heat is considered the most dependable method of sterilisation. Steam sterilisers or autoclaves apply heat and humidity under pressure (using saturated steam at 121 °C and 104 kPa) to sterilise laboratory and medical equipment. The application of steam allows for better penetration of heat through permeable insulating layers on any surface than dry heat alone. Autoclaves are occasionally used to sterilise infectious waste.
Dry heat sterilisation is less dependable than wet heat as layers of debris on a surface can insulate organic materials from the process. Dry heat sterilisation is appropriate for impermeable surfaces like glass, but higher temperatures and exposure times are required (160 – 170 °C for periods of 120 to 240 minutes).

Surface Decontamination by Chemicals

This is a section stub. See the discussion page for development

Surface Decontamination by Irradiation

Ionising and non-ionising irradiation are both able to decontaminate surfaces. Ionising radiation is not considered generally practical for surface decontamination in a clinical or laboratory setting. Non-ionising radiation such as ultraviolet light in the UV-C band effectively inactivates most microorganisms on surfaces and in the air.

Surface disinfection by Ultraviolet Germicidal Irradiation

For UVGI surface disinfection for SARC-CoV-2, refer to COVID-19 infection control guidance

The effective band of germicidal ultraviolet (GUV) radiation is between wavelengths of 250-270 nm with 265 nm the optimum efficiency. Ultraviolet Germicidal Irradiation effectively destroys most microorganisms on surfaces. Dirt, dust, and shadows can shield organisms which must be directly exposed to the GUV light. This and safety concerns are limiting factors for its general application.

The application of UVGI for surface disinfection usually involves the use of bare UVGI lamps. Two main approaches to surface disinfection systems are via permanently installed disinfection systems and portable disinfection systems. Permanently installed systems generally consist of bare UVGI lamp fixtures mounted on ceilings or walls. Portable UVGI systems are moved into a place temporarily to decontaminate surfaces ^[1]. Efficacy is dependent on the intensity of irradiation emitted from the device, proximity of the device to the surface being disinfected and exposure time. The reflectivity of the materials in the vicinity of exposure can increase or decrease efficacy. Shaded items not directly exposed to UV-C irradiation may not effectively be disinfected

UVGI Efficacy

UVGI dose

The UV-C dose required to achieve a particular pathogen reduction rate is calculated from the single-stage decay equation:

S=e^-kD

where:

S is the Survival fractional [%] k is the UVGI rate constant [m2/J] D is the UVGI exposure dose [J/m2]

The required UVGI dose for a 4 log reduction (99.99% pathogen reduction rate) is calculated by expressing the single-stage decay equation as follows:

ln(⁡S)=-k·D·ln(⁡e)	
∴D = (ln (⁡0.0001))/(-k)   mJ/cm² 	  (J/cm²)

UVGI Validation

Validation testing for UVGI surface disinfecting systems is required to ensure that the UV dose for ≥99.99% level of pathogen inactivation is achieved. As the dose rate is a function of the UV sources output and its distance to the target, the manufacturer for non-static UVGI surface disinfecting systems should specify the design minimum distance away from a surface, the UVGI intensity on the surface and the time required to achieve ≥99.99% pathogen reduction.
For disinfection that has either dynamic source or target components, repeatability and confidence studies are required to ensure that the range of variability expected does not exceed acceptable limits for efficacy and safety

UVGI Safety

Studies of personnel practising proper UVGI exposure control measures have shown no harmful effects^[2], ^[3] . Noncompliance with safety precautions can lead to injuries ^[3]. The following safety issues are associated with the handling of UV equipment.
UV radiation exposure present hazards to the skin and the eyes ^[1] ^[4].

UVGI Exposure Guidelines

The ability of UV radiation to penetrate the eyes and skin depends on the wavelength, therefore the UV radiation exposure Threshold Limit Values (TLV) for the eyes and skin published by the American Conference of Governmental Industrial Hygienists (ACGIH) ^[5] also varies according to the UV wavelength. For UVGI at 254 nm, a cumulative exposure dose greater than 6mJ/cm2 ^[5] is considered harmful to eyes and skin. Since UVGI surface disinfection systems use bare lamps with dose requirements exceeding 6 mJ/cm², adherence to PPE is highly recommended to avoid harm.

Eye Safety

The UV wavelength is the determining factor as to which part(s) of the eye may absorb the radiation and suffer biological effects.
The table below shows the absorption of different UV wavelengths by the human eye.

Absorption of UV wavelengths in the Human Eye ^[4]
Wavelength {nm}	Cornea	Aqueous	Lens	Vitreous
100-280	100%	0%	0%	0%
300	92%	6%	2%	0%
320	45%	16%	36%	1%
340	37%	14%	48%	1%
360	34%	12%	52%	2%

UVGI (UV wavelengths 200 to 280nm) cumulative exposure dose greater than 6mJ/cm2 ^[5] can cause temporary corneal injuries (photokeratitis and conjunctivitis ^[1]). Symptoms of corneal injuries (extreme pain in the eyes) present after 6 -12 hours of exposure and lasts for a few days during which corneal cells will recuperate ^[1]^[3].

Skin Safety

Because of poor penetration and absorption capability ^[2], UVGI cannot penetrate or cause permanent harm to human skin ^[4]. Some skin irritation or erythema may be experienced but this will generally clear up with proper care.

UV control measures

Administrative controls

Prevent unauthorized personnel from entering the UV radiation area.

Personal protective equipment (PPE)

Personal protective equipment (PPE) protects the wearer from harm due to UV radiation exposure. The following PPE should be worn when operating UVGI surface disinfection systems:

Plastic goggles with side shields;
Head, neck and face covering opaque to UV radiation;
Soft cotton gloves and.
Long-sleeved, tightly woven fabrics with SPF 15 or greater.

Burn safety

UV lamps, depending on the lamp technology, may operate at up to 900°C. The UV lamps and sleeves should be allowed to properly cool down before maintenance to minimize the risk of burns. The electrical equipment (e.g., ballasts) may also become hot during operation and should be evaluated prior to maintenance ^[6].

Lamp breakage issues and mercury exposure

UV lamps pose two safety hazards if broken; the lamps and sleeves are constructed of quartz that, when broken, can pose a risk of serious cuts, and UV lamps contain mercury that can create an inhalation or contact hazard ^[6].

UV-C effects on materials

UV radiation that is incident upon a surface can be transmitted, reflected or absorbed ^[3]. Absorption of UV causes photodegradation that result in an alteration to the colour, texture or mechanical properties of the materials ^[3]. Materials with high UV absorption indicate greater potential for photodegradation while those with high reflectivity indicate protective effects ^[1]. All metals do not experience damage under UV exposure ^[1]. Some of the materials that experience photodegradation are wood, plastic, Polyvinyl chloride (PVC), fabrics, paint and glass ^[1].

Maintenance and monitoring

Proper maintenance and monitoring of UVGI surface disinfection systems ensure continued efficacy. Maintenance tasks and their frequencies are shown in the table below.

Maintenance tasks for UVGI surface disinfection system
Task	Frequency	Action
Check lamp run time values	Monthly	Change lamps if operating hours exceeded design life of 9–10 thousand hours ^[1]
Check intensity of UV lamps	Bimonthly	Replace lamps when UVGI dose is equal to or less than the validated UVGI dose after verifying that this condition is caused by low lamp output.
Visually inspect bulbs to ensure all bulbs are operational.	Weekly	If the bulbs show visual dust accumulation, they should be cleaned. Lamps can be wiped clean with a cloth dampened with water or a cleaning agent like dilute alcohol ^[1]

The surface UVGI system should be equipped with sensors that automatically monitor UV intensity, validated UV dose and lamps status. A decision chart for UVGI surface disinfection system monitoring is shown below.

Decision chart for UVGI surface disinfection system monitoring

UVGI lamps disposal

LPMV lamp contains mercury which is a toxic heavy metal which cycles through the soil, water and atmosphere in the environment. Send spent lamps to a mercury recycling facility or back to the manufacturer to prevent personal or environmental exposure.

Training

Operators designated to care for the UVGI systems should receive adequate training in both UV system theory, operation, maintenance and safety.

Ultraviolet Surface Disinfection for SARS-CoV-2

UV-C air disinfection was been explored extensively in the context of TB infection prevention and control by the South African scientific community in association with international experts. National Technical Standards, Protocols, guidelines and testing capacity for application of upper-room UVGI in airborne transmission have been established^[7]. This experience has provided important basic knowledge and key insights into the underpinning science and theory as well as application constraints, albeit for a different application.

The coronavirus, SARSs-CoV-2, is understood to be transmitted primarily by contact and droplet spread^[8], is highly contagious and spreads more rapidly than its predecessors Severe Acute Respiratory Syndrome (SARS-Cov-1) and Middle East Respiratory Syndrome (MERS)</ref>^[9], so any residual surface contamination can pose a public health threat^[9]. COVID-19 transmission remains controversial as researchers across the globe remain conflicted about droplet and airborne as modes of transmission^[9]. Clarifying the transmission routes and survival of viruses on frequently used surfaces is essential for containment of the outbreak. Research has successfully demonstrated that the virus has the potential to be aerosolised^[10], and therefore can theoretically opportunistically transmit through the airborne route, it is understood that, except in aerosolising procedures, risk of coronavirus transmission via the airborne route ^[11] is low. Similarly, risk via water and wastewater is low ^[12]. Persistence of the virus on a variety of surfaces has been demonstrated ^[10], underpinning concern that SARS-CoV-2 may be transmitted from infected (even asymptomatic) persons to others from touching common surfaces, even after the infector has departed for several hours ^[13]^[14]. Efforts to contain the coronavirus, to stem the pandemic, should therefore primarily focus on contact and droplet transmission. Contact and droplet transmission is of concern in public transport systems taxis which convey very large transient populations is normally congested conditions, such as in trains and mini-bus taxis. Transfer of suspected or confirmed Covid-19 patients in planned transport or emergency service vehicles poses a risk since studies show that conventional decontamination procedures may be inadequat^[11]. In a pandemic, and within already constrained healthcare infrastructure, overcrowding and close proximity of infectious and susceptible individuals will become highly. These conditions will amplify the risk of Covid-19 transmission.

In the South African context, the reduction of exposure to Covid-19 is a priority, in order to:

reduce and delay occupational exposure of frontline workers especially healthcare and transport services workers;
reduce exposure to public health risk, especially to the most vulnerable, such as PLHIV and persons with TB who are the principal users of public transport;
contribute to the strategy of “flattening the curve”; and
preserve and protect the healthcare service so as to ensure continued service.

This article proposes UV-C surface disinfection for reducing contact and droplet transmission of SARS-CoV-2 through the following applications:

Portable disinfection devices for use in the transport sector (minibus taxis, trains and emergency and planned patient transport)
Public Spaces
Commercial and industrial occupational settings
Decontamination of personal and respiratory protection equipment

UV-C: potential for disinfection for SARS-CoV-2

The disinfection effect of ultraviolet light has been described for over 100 years^[15]. It is effective against a variety of microorganisms and has been successfully deployed for the purpose of disinfection of water, air and surfaces. Effectiveness depends on a range of variables related to the microorganism of interest, environment and application. Ultraviolet radiation in the UV-C range has been used for its germicidal properties specifically for infection prevention and control - have been demonstrated to work at laboratory scale, in ducts, as upper room irradiation and as portable devices. Safety guidelines have been established (ACGIH)^[9]. There is good reason to expect that SARS-CoV-2 will be susceptible to UV-C. UV-C, when applied at the correct dose as it has been found effective against influenza viruses ^[16]including human coronavirus ^[17]^[18] (SARS-CoV-1).

According to Kowalski et. al. ^[19], Covid-19 is susceptible to existing disinfection methods such as chemicals and exposure to ultraviolet radiation in the electromagnetic range ~ 200 – 280nm (UV-C) because of the similarity of its structure to other susceptible coronaviruses such as SARS-CoV-1 and MERS.

UVGI surface disinfection has advantages over chemical disinfection because:

There is no off-gassing of chemicals or residual chemical contamination frequently associated with chemical-based disinfection methods. Therefore, vehicles or spaces can be occupied immediately after UVGI disinfection^[1];
It has high pathogen reduction rates when compared to chemical cleaning; and
Chemical disinfection methods are time-consuming ^[20].

A guideline on hospital infection control ^[2]^[3] recommends the use of both UVGI and chemical disinfection since UVGI has no penetrating power on dust, dirt and grease, which may harbour microbial contamination. Exposure to UV-C may degrade some materials.

As SARS-CoV-2 is recent and novel, UVGI efficacy has not yet been conclusively established against this particular pathogen^[9]. For the reasons stated above, UVGI – the exposure of potentially contaminated contact surfaces to UV-C is identified as a measure with good prospects to reduce and delay occupational exposure of healthcare and transport services workers, as well as their clientele, and to contribute to the strategy of “flattening the curve”.

Case Studies

Moscow trains

In Moscow, Russia, Kostyuchenko, et. al., ^[20], investigated the potential of UVGI disinfection on internal surfaces of train carriages and on escalator handrails. They found that the required UV doses for effective disinfection are higher than the theoretically calculated doses.

Ambulance decontamination ^[9]

Respiratory Protective Equipment decontamination ^[9]

Elements of a successful UVGI Disinfection Program

Messaging

It is important for messaging around a UVGI Disinfection Program to detail that UVGI can be safe and effective when applied according to a defined and validated protocol

The messaging program should include the following safety aspects:

UVGI is a form of actinic radiation which does not cause skin cancer
UVGI/UVC is not the same as UV found in outdoor sunlight
UVGI can cause reversible skin and eye irritation
Skin and eye protection should be worn when the possibility of irradiation is present
UV Lamps should not be used for skin or hand sterilisation

The messaging program should include the following efficacy aspects:

UVGI is a supplemental surface disinfection technology
UVGI can be used to kill the new coronavirus as well as a number of other common pathogens

Efficacy

UVGI dose