IFH Newsheet July 2015
Latest from IFH
Hygiene and the 2015 Sustainable Development Goals
Spotlight on norovirus and hygiene
Reviewing laundry hygiene
Other news and new research
Antibiotic resistance and hygiene
Get the latest news & research as it happens – Follow IFH on Twitter @IFH_homehygiene
1. Latest from IFH
IFH fact advice sheets have been updated
The IFH website features a range of fact sheets on specific aspects of hygiene and hygiene issues in home and community settings. Topics include specific diseases and organisms, situations (kitchen, bathroom, laundry, hands etc.), hygiene procedures, emergency situations, at-risk groups, the hygiene hypothesis and antimicrobial resistance. These are intended for use by healthcare professionals, community workers, the professional and consumer media, and anyone who is looking for information on a specific topic. Many of these fact sheets also offer hygiene practice advice tailored to address a particular aspect of hygiene. These fact sheets have updated in the last few months. We invite you to download and adapt them for your own use (with appropriate acknowledgement to IFH).
The fact sheets can be found at: http://www.ifh-homehygiene.org/factsheets-hygiene-advice
Effectiveness of different hygiene procedures in domestic kitchens
Surprisingly few studies have compared the effectiveness of hygienic cleaning under simulated-use conditions. This new study by Solveig Langsrud and co-workers from NOFIMA, Norway, together with IFH Board member Sally Bloomfield, compares various commonly used cleaning methods (with or without disinfection) for food contact and hand contact surfaces in domestic kitchens in Norway. Laboratory models involving cutting boards, tap handles and mobile phones, contaminated with E. coli and Staph. aureus, were used to compare the efficacy of commonly used dry cloth and water or detergent-based cleaning methods together with new technologies (sprays, single-use wipes, and chlorine-based disinfectants). Commonly used cleaning methods produced a mean log reduction (LR) in contamination of 1.5–2.5. Efficacy could be improved by drying or including a disinfection step (mean LR 3.1–4.6). The authors conclude that, in many situations, methods commonly used by consumers may be sufficient to hygienically clean surfaces. However, in some situations, such as where there are infected or immune-compromised individuals, or where high risk foods are being handled, hygiene practices producing higher LRs should be recommended. The study shows the importance of using models simulating use conditions to evaluate detergent-based removal practices and determine how and when these procedures need to be enhanced by inactivation processes such as drying and disinfection to ensure that contamination from food-borne pathogens is reduced to acceptable levels to prevent infection transmission. The study can be found at:
J Appl Microbiol 2015;119:582−93.
Contamination of student nursing scrub tops pre- and post-laundering
IFH board member Professor Liz Scott and colleagues from Simmons College Boston USA have carried out a study of 89 student nurses during 2013−14. Student nurses swabbed their scrub tops after clinics and after laundering, and completed a laundry survey; 13.5% of students wore the same scrub more than once, and few followed recommended laundering guidelines by using hot water (20%) or bleach (5.6%). MRSA was not detected, but 15 (17.3%) of pre-laundry swabs tested positive for MSSA. Of those positive pre-laundry, 9 (64.3%) were negative after laundering, but 34.7% (6) were positive i.e. survived the laundry process. There was no significant reduction in MSSA after laundering and no statistically significant differences between effectiveness of hot water use, dryer time, bleach use,
The authors comment that lack of association between laundry effectiveness and laundering conditions in this study may have been caused by being underpowered. However, with a US student nurse population of >300,000, it is possible that >50,000 MSSA-contaminated student nurse scrubs could be leaving clinical settings with 17,000 still being contaminated after laundering. They concluded that, “nurse educators should include safe laundry practices in nursing courses. Students should be taught to change out of scrubs immediately after their shift to prevent potential cross-contamination”. The study is published in Am J Infect Control 2015 Jul 1. pii: S0196-6553(15)00530-1. doi: 10.1016/j.ajic.2015.05.007.
2. Hygiene and the 2015 Sustainable Development Goals
Raise your hand for hygiene: Hygiene now included in the SDGs
Hygiene − specifically handwashing with soap − is one of the most important interventions for human health and development. But, despite its importance, hygiene was initially neglected in the SDGs at the indicator level. This means that hygiene would not be measured globally, the target to improve hygiene would not be monitored, and the SDGs might not improve hygiene as much as they could.
After intensive lobbying, it is now reported that hygiene is included in the SDG agenda—both in the vision statement and included in target 6.2. While this is a major step forward the work advocating for hygiene is not yet complete. We still need a mandatory, global indicator to ensure that hygiene is prioritized, progress made, and commitments fulfilled.
Goal 6 states. Ensure availability and sustainable management of water and sanitation for all
Goal 6.2 states: By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations
3. Spotlight on norovirus and hygiene
New study indicates airborne transmission of norovirus during outbreaks
A new study shows that norovirus genomes are frequently detected in the air of healthcare facilities during outbreaks, even outside patients' rooms. In vitro models also suggest this virus may withstand aerosolisation. Noroviruses are responsible for at least 50% of all gastroenteritis outbreaks worldwide. Noroviruses GII can infect humans via multiple routes including direct contact with an infected person, contact with faecal matter or vomitus, and with contaminated surfaces.
Though norovirus is an intestinal pathogen, aerosols could, if inhaled, settle in the pharynx and later be swallowed. In this study a total of 48 air samples were collected during norovirus outbreaks in 8 healthcare facilities. Samples were taken 1 m away from each patient, in front of the patient's room and at the nurses' station. The resistance to aerosolisation stress of murine norovirus MNV-1 bio-aerosols was also tested in vitro using an aerosol chamber. Norovirus genomes were detected in 6/8 healthcare centers. The concentrations ranged from 1.35x101 to 2.35x103 genomes per m3 in 47% of air samples. Norovirus MNV-1 preserved its infectivity and integrity during in vitro aerosol studies. The study can be found at: Clin Infect Dis 2015 doi: 10.1093/cid/civ321
Can humans get norovirus from their dogs?
A new study in the US shows that human norovirus (nv) may infect our canine companions, raising the possibility of dog-to-human transmission. The research showed that some dogs can mount an immune response to human nv, which suggests that these dogs are infected with the virus. Human nv can bind to the cells of the canine gut, which is the first step towards infection of cells. It is not clear just how much of a problem canine infection transmission may represent for humans. Despite dogs’ apparent susceptibility, the investigators failed to find nv in canine stools. They found it in serum samples of only about one-seventh of 325 dogs tested. Additionally, it is not known whether human nv can cause clinical disease in dogs. Even assuming that dogs become infected with human nv, it remains unknown whether they could shed the virus in quantities sufficient to infect
humans − although clinical investigators have estimated that as few as 18 virus particles can cause human infection. The authors conclude, “Until more definitive data is available, sensible hygiene precautions should be taken around pets, especially when gastroenteritis in either humans or dogs is present in a household.” The full study can be found at: http://jcm.asm.org/cgi/reprint/JCM.02778-14v1?ijkey=UzdFXaII51jUw&keytype=ref&siteid=asmjournals.
Could amoebae in the environment be a source of human norovirus infection?
Human noroviruses (HuNoVs) are the most common cause of food-borne disease outbreaks, as well as virus-related waterborne disease. A study by Hsueh et al examined whether common, free-living amoebae (FLA) − ubiquitous in the environment, known to interact with pathogens, and frequently isolated from water and fresh produce − could potentially act as reservoirs of HuNoV and facilitate the environmental transmission of infection. The study showed that after 1 h of amoeba-virus incubation with HuNoV surrogates, murine norovirus (MNV-1) and feline calicivirus (FCV) at 25°C, 490 and 337 PFU of MNV-1/ml were recovered from A. castellanii and A. polyphaga, respectively, but only few or no FCVs were detected. Prolonged interaction (8 days) of MNV-1 with amoebae showed that MNV remained stable at around 200 PFU/ml from day 2 to day 8 in A. castellanii. After a complete amoeba life cycle including cvst formation, infectious viruses could still be detected. Immunofluorescence showed MNV-1 transitioning from the amoeba surface into the cell over 24 h. Results suggest that HuNoVs may interact with microorganisms in the environment to aid survival, as well as transmission in water, and to fresh produce. The article can be found at: Appl Environ Microbiol 81:4005–13. doi: 10.1128/AEM.00649-15.
New norovirus strain sweeping the world
A new strain of norovirus emerged in Asia last winter and appears to be spreading globally, threatening larger outbreaks of gastro infections that are the bane of luxury cruise liners. The new strain known as GII.17, that emerged in southern China has the potential to spread widely because people will probably lack immunity to it. The virus is highly contagious and is transmitted by infected food and people. Although outbreaks on cruise ships are especially noticeable because the contained environment allows the disease to spread quickly (more than 80% of passengers are often affected) according to WHO figures, most epidemics occur on land. Cases of GII.17 have been detected in the USA, South America, Europe and Africa. Read more at: http://www.nzherald.co.nz/world/news/article.cfm?c_id=2&objectid=11477140
4. Reviewing laundry hygiene in healthcare
Recent innovations have led to major advances in laundry equipment, laundry chemicals, fabric technology etc. which have enabled healthcare facilities and contractors to provide a quality product for bed linens, towels, gowns, uniforms, scrub, drapes etc. Healthcare professionals have questions about the infection prevention effectiveness of these modern healthcare laundry developments. In a 2015 review, Lynn Sehulster reviews recent developments to give infection preventionists an insight on these topics that may be helpful in future purchase/procurement decisions. She concludes that infectious disease outbreaks associated with laundered HCTs are extremely rare, only 12 such outbreaks being reported in the past 43 years. A root cause analysis identifies exposure of clean HCTs to environmental contamination or laundry process failure. To date, patient-to-patient transmission of infection has not been associated with HCTs laundered in accordance with industry process standards. Occupationally acquired infection involved mishandling of soiled HCTs and failure to use personal protective equipment properly.
Sehulster also makes reference to concerns about home laundering of HCTs and their potential to expose family members to healthcare-associated pathogens. Although she rightly concludes that infections attributed to home laundering of healthcare attire have not been demonstrated conclusively, she appears to have overlooked much of the extensive data included in two IFH reviews, which suggest that clothing etc. in domestic settings probably contributes to spread of infections (although to a lesser extent than surfaces such as hands and other contact surfaces) and illustrates the lack of systematic data to show domestic laundry cycle conditions required to prevent spread of infection in this setting. The study can be found at: Infect Control Hosp Epidemiol 2015;00(0):1–16.
IFH reviews of domestic laundry risks and effectiveness of laundry cycles can be found at:
http://www.ifh-homehygiene.org/best-practice-review/infection-risks-associated-clothing-and-household-linens-home-and-everyday-life and http://www.ifh-homehygiene.org/review/effectiveness-laundering-processes-used-domestic-home-settings-2013 and http://www.ifh-homehygiene.org/factsheet/clothing-household-linens-laundry-and-home-hygiene
5. Other news and new research
Lancet says “Bacteria make us human”
A recent article in the Lancet says, “In the hierarchy of biological organisation, human beings have traditionally been classified as organisms. Infectious diseases physician and researcher Martin Blaser disagrees. He views the human body as an ecosystem, “much like a coral reef or a tropical jungle, a complex organisation composed of interacting life-forms”. These life-forms include many bacteria, archaea, viruses, and fungi—collectively termed the human microbiota − without which we would not survive”. Read more at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60879-0/fulltext
Modern lifestyle may be destroying microbiome diversity, which is important to health
A new study in Science Advances used DNA sequencing to study a South American tribe of Yanomami who had never interacted with Westerners before. They found that the Yanomami had the highest levels of microbial diversity ever reported in a human group. The villagers spend much time outdoors hunting and gathering, and have had almost no contact with the antibiotics and processed foods associated with a Western lifestyle.
Co-author Dominguez-Bello says the work suggests there may be a link between bacterial diversity, industrialised life, and diseases such as obesity, asthma, allergies, and diabetes. "We believe there is something environmental occurring in the past 30 years that is driving these diseases. We think the microbiome could be involved." William Hanage, a Harvard epidemiologist said, “The relationship between the microbiome and human health is complicated. Though we know that low bacterial diversity is associated with some modern illnesses, it’s not clear whether the low diversity causes the illness or vice versa. It is a leap to say that more diverse is necessarily healthier.”
Although Yanomami microbes were susceptible to antibiotics, they carried antibiotic resistance genes. Since they had never been exposed to Western culture, this means bacteria don’t need to be exposed to antibiotics to possess antibiotic resistance genes. Co-author Gautam Dantas said, “A critical part of trying to curb the spread of antibiotic resistance is understanding where it comes from.”
The study concludes, “Our work emphasises the value of detailed characterisation of microbiomes of people living ancestral life-styles, particularly if practices in industrialised societies might eradicate potentially beneficial microbes and their encoded functions. Causation and consequences of microbiome changes need to be understood before restoration is possible to attempt to reverse current global trends in metabolic and inflammatory diseases. The article can be found at: http://advances.sciencemag.org/content/1/3/e1500183
Reducing the risk of pet-associated zoonotic infections – new review
A review by Stull and co-workers evaluates human infections acquired from pets (i.e., dogs, cats, fish, birds, amphibians, reptiles, rabbits and other rodents) and their risk factors. It also sets out some guidelines for infection prevention with specific emphasis on high-risk groups.
Stull says "Although pet ownership can have health, emotional and social benefits, pets can be a source of infections. Surveys suggest that the general public and people at high risk for pet-associated disease are not aware of the risks associated with high-risk pet practices or recommendations to reduce them. One study showed that 77% of households that obtained a new pet following a cancer diagnosis acquired a high-risk pet. Studies suggest physicians do not regularly ask about pet contact, nor do they discuss the risks of zoonotic diseases with patients, regardless of the patient’s immune status". The review can be found in the Canadian Medical Association Journal 2015. DOI:10.1503 /cmaj.141020
Smarter washroom technology to improve hygiene
The following article describes new features of design of public toilets/washroom to improve hygiene standards and sustainability:
6. Antibiotic resistance and hygiene
Do people understand what antibiotic resistance actually is?
Did you know that many people believe it is the patient who builds up a resistance to antibiotics prescribed, rather than the bacteria they treat? A new study commissioned by
The Wellcome Trust has involved conducting focus groups and pair interviews with members of the public, and conversations with GPs, to explore their relationship with antibiotics. The results are fascinating and highlight a need to rethink the way we communicate the issue to the public.
Even the term “antibiotic resistance” left the vast majority of participants confused. The research highlighted that many people feel validated when they are prescribed antibiotics, commenting, “It confirms I’m ill” and, “I don’t feel like I’ve wasted the doctor’s time”. Others think of antibiotics as “a magic pill” to help them get better, without understanding that they are only effective against bacterial infections.
The researchers concluded that it is only by understanding people’s attitudes to antibiotics, and what has led them to these beliefs, are we in a position to address misunderstandings and tackle the issues they lead to.
The report can be found at: @policy_communications/documents/web_document/wtp059551.pdf">http://www.wellcome.ac.uk/stellent/groups/corporatesite/@policy_communications/documents/web_document/wtp059551.pdf
Evolution of antibiotic resistance selected by biocide exposure
A new study is reported to determine whether exposure of Salmonella to various biocides could act as a driver of antibiotic resistance. Salmonella was exposed to four biocides with differing modes of action. All antibiotic-resistant mutants were characterised phenotypically and genotypically. All biocides tested selected multidrug resistant (MDR) mutants with decreased antibiotic susceptibility; these occurred randomly throughout the experiments. Mutations that resulted in de-repression of the multidrug efflux pump AcrAB-TolC were seen in MDR mutants. A novel mutation in rpoA was also selected and contributed to the MDR phenotype. Other mutants were highly resistant to both quinolone antibiotics and the biocide triclosan. The authors concluded that exposure of bacteria to sub-optimal concentrations of biocides can select for antibiotic-resistant mutants and is mediated by clinically relevant mechanisms of resistance prevalent in human pathogens. The study can be found at:
J Antimicrob Chemother 2015; doi:10.1093/jac/dkv109
7. New Resources
New hand hygiene implementation guide from APIC
The APIC 2015 “Guide to Hand Hygiene Programmes for Infection Control” is a best-practices primer providing the tools needed to adapt national and international hand hygiene guidelines for specific environments. It provides a comprehensive overview of hand hygiene programmes and their key components based on the latest available research data.
It starts with a general section on hand hygiene, and why it is important, followed by a guide to hand hygiene formulations and hand hygiene monitoring. It also gives a review of methods for implementing Hand Hygiene Programmes and strategies for achieving behaviour change. It contains references to key scientific studies, guidelines etc.
This guide is a collaborative effort among expert infection preventionists with a passion for hand hygiene. In each section, authors synthesise best practice recommendations from research and an in-depth knowledge of the emerging trends with the goal of making the findings relevant for practice.
The guide can be found at:
http://www.apic.org/Resource_/EliminationGuideForm/9fae54e1-ebb9-44f9-a5b2-1079565d6c34/File/To download the PDF of Guide to Hand Hygiene Programs for Infection Prevention.pdf
Water, sanitation and hygiene in healthcare facilities in low- and middle-income countries and way forward
A new report prepared by WHO, United Nations’ Children’s Fund, presents, for the first time, a global assessment of the extent to which healthcare facilities provide essential water, sanitation and hygiene (WASH) services. Drawing on data from 54 low- and middle-income countries, the report concludes that 38% lack access to even rudimentary levels of water, 19% lack sanitation and 35% do not have water and soap for handwashing. When a higher level of service is factored in, the situation deteriorates significantly. A number of areas require urgent action and WHO will work with UNICEF, Governments and other partners to develop a global plan to address the most pressing needs and ensure that all healthcare facilities have WASH services.
The report can be downloaded from: http://www.who.int/water_sanitation_health/publications/wash-health-care...
Avoiding infection on farm visits – advice for the public
Visiting a farm is an enjoyable and educational experience for many people, particularly children. However, such visits can never be free from all risks. Farm animals may carry a number of infections that can be harmful to people.
This leaflet gives advice to the public on how to avoid infection. The resource can be found at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Publication Type: Newsletter