IFH Newsletter – ACTION REQUIRED August 2018

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Contents

1. New IFH review – Do antibacterial products contribute to development of antibiotic resistance? – a survey of UK and US media coverage 1997 to 2017

2. Good germs, bad germs: how do the public see it? a crowd science study

3. Spreading Viruses in the Grocery Store via Reusable Grocery Bags

4. Use of hospital-grade disinfectants can reduce viral deposition on surfaces after toilet flushing

5. Pilot study of “Beat the Bugs” community education course on hygiene & antibiotics

6. Latest on Hand Hygiene

• Increased hygiene awareness is driving increased use of hand sanitizers
• Hand hygiene–related interventions can reduce antibiotic prescribing

7. Using disinfectants on high frequency touch surfaces could reduce spread of infections and drug resistant bacteria in hospital settings

8. Campylobacter: Facts and Prevention Strategies

9. Research shows a link between microbe exposure in early life and childhood leukaemia

 

1. New IFH review: Do antibacterial products contribute to antibiotic resistance? – a survey of UK and US media coverage 

This review covers 3 decades of media coverage about a possible relationship between exposure of domestic microbes to disinfectants/antibacterials used for hygiene, and development of antibiotic resistance. In all, 23 media articles published between 1997 and 2017 were analyzed together with consumer feedback.  The review illustrates the considerable amount of inaccurate or misleading reporting of this issue and suggests it is a cause of public misunderstanding and mistrust about hygiene. It also shows how inconsistent understanding of the term “antibacterial” has contributed to the confusion.  
Many early articles were prompted by the “explosion” in marketing of antibacterial products during the 1990s, including soaps, cleaners, dishwash liquids, and products impregnated with antibacterial agents such as chopping boards, cloths, etc.  This coincided with publications showing that exposing bacterial populations to residue-forming phenolic disinfectant triclosan produced reduced susceptibility to antibiotics.  In 14/23 of the articles, journalists were careful to use conditional terms such as “helps, may contribute, could lead to, but 4 articles implied that a link to antibiotic resistance in clinical practice was proven.    Quotes, reviewed in this report reflect the extent to which the experts and the public oppose use of these products because of concerns about resistance.

Opposition to microbiocidal products reflects lack of understanding of what is meant by resistance. In reality “antibiotic resistance” demonstrated in the lab studies is “reduced susceptibility” not “clinical resistance”. Although links have been shown iny lab studies, after nearly 20 years of investigation, there is still no valid evidence that home use is contributes to emergence of antibiotic resistant strains.   Confusion is also due to lack of clarity about the term antibacterial.  Some experts, expressing concern about “links between antibacterial use and antibiotic resistance” are talking only about residue-forming microbiocides such as triclosan, whilst others assume that the term applies to any disinfectant.  Since 15/23 articles were based on research using triclosan, this further tends to imply that all household disinfectants have the potential to induce antibiotic resistance.

This creates problems, because opposition to “antibacterials” is preventing objective assessment of evidence showing that, in risk situations, wiping or detergent-based cleaning is not enough, and that a disinfectant or hand santizer is required to break the chain of infection. For alcohol handrubs, data confirms that they are as effective as handwashing. Since alcohol and oxidizing biocides used in many surface disinfectants have a non-specific microbiocidal action and leave no active residue, they are unlikely to encourage resistance development.  There is little to suggest that risks outweigh health benefits – when disinfectants are used as part of targeted hygiene as necessary to break the chain of infection. A number of expert reports have been commissioned on this issue in the last 10 years. These stress the hygiene importance of microbiocides, but also the need to use them prudently, only in situations where there is identifiable risk of spread of harmful microbes. This view was also supported by experts in 9 of the 23 of the media articles

Opposition to microbiocides reflects a lack of understanding of how they work.  Antibiotics must be administered at low concentrations to avoid side effects, but declining drug levels between doses creates conditions favourable for emergence of resistance. By contrast disinfectants can be safely used at much higher concentrations, which rapidly kill microbes before they can enter the body thus obviating the need for antibiotic prescribing.  It is rarely considered that disinfectants or hand sanitizers, used as part of a targeted hygiene approach (right place, right time, right product) could combat antibiotic resistance by reducing the need for antibiotic prescribing. This is illustrated by the results of a new study, detailed below, which showed that using disinfectants on high frequency touch surfaces could reduce spread of infections and drug resistant bacteria in hospital settings

These examples demonstrate the importance of evaluating hygiene practices  involving disinfectants/antibacterials on a case by case basis according to the type of microbiocidal agent involved, where it is to be used and what alternative approaches tere are which will reduces contamination to a safe level in that situation.  This issue is discussed in a review by Bloomfield, Carling and Exner. The media review can be found here.

2. Good germs, bad germs: how do the public see it? – a crowd science study

An intriguing new article describes a new research project using participatory methodology involving DNA sequencing to engage the public with our microbial world (the microbiome) in relation to their perception of health and hygiene. The project focused on domestic kitchens and hygiene practices of a group of households in a community in Oxford, UK. The aim was to explore what people knew about bacteria that live in their kitchen, how they would investigate them to find out more, and how their perceptions and practices would change if kitchen microbiomes were made more visible.  Rather than educating them, an innovative engagement process was used, in which small groups learn to use scientific tools to address specific concerns. A key finding was the extent to which participants were attached to the idea of “bad” germs. Their understanding of risk associated with microbes was strongly informed by the germ theory of disease, and they continued to focus on presence of specific pathogens, despite the ability of the methodology to examine the wider microbial community.

An example of how the study changed perception was where cleaning cloths were used to clean surfaces.  The results showed that the range of bacterial communities found on kitchen surfaces after cleaning looked more like those found on the cleaning cloths than they did before cleaning. This might be unsurprising to a microbiologist, but was news to many in the group and led to a discussion about what people should do in their kitchens in order to be “clean” or “hygienic” (e.g. using paper towel rather than cleaning cloths). Participants also had anxiety about being too clean and a familiarity with the “hygiene” hypothesis. There was a tension between these two notions, often within rather than between individuals, and about which inclination to trust in order to stay healthy. Sometimes this played out by participants suggesting that it was more important to keep some sites (kitchens, bathrooms, surfaces) cleaner than others.

The other theme that emerged was the need for new metaphors to develop public understanding of microbial life. Participants were particularly attached to two, related perceptions of microbiomes. First, they tended to think in terms of “species”. There was incomprehension and even resistance to a conceptual model based on communities. Second, they tended to think in terms of “pathogenic species” in particular. More than a century of public health messages about the dangers of “germs” has created a deeply embedded perception.

The authors concluded that we need new metaphors to replace the dominant concepts of species and pathogens, or “bad germs”. A comparison can be made with macroecology and ideas about the “balance of nature.  The authors found that metaphors taken from macro-ecology had some traction—such as describing microbial ecologies as “deserts”, “rainforests” or “fields”; and metaphorically linking cleaning to gardening and keeping pathogenic bacterial “weeds” at bay through cultivating bacterial “lawns”. The social sciences and humanities could help to map public understandings of microbes and enable the collaborative development of new ways of seeing the microbial world. The study can be found at;  DOI 10.15252/embr.201845786| Published online 18.05.2018   (EMBO reports (2018) e45786)

3. Spreading Viruses in the Grocery Store via Reusable Grocery Bags

Hygiene promotion tends to focus on preventing cross contamination in the domestic kitchen, but overlooks the fact that cross contamination can occur from the moment we enter the supermarket to buy food. Reusable grocery bags (RGBs) are common these days, but a recent study sheds light on the potential for contaminated RGBs to spread viruses. Viruses such as norovirus are a major concern in food production, service and grocery retail industries. Researchers recruited shoppers in 3 California grocery stores and asked them to do their shopping using a polypropylene RGB provided by the researchers. The bags had been sprayed previously with a solution of the norovirus surrogate, MS2 bacteriophage. As they shopped, the surfaces they contacted were swabbed for microbial analysis. The highest concentration of MS2 was found on the hands of clerks and volunteer shoppers, followed by packaged food surfaces, and progressively lower levels on 12 other grocery store surfaces. These include unpackaged produce, trolley surfaces and customer checkout touch screens. Importantly, even the lowest average concentration of virus particles detected on any surface in the study (10,000 PFU1 /cm2 ) would represent a virus transmission risk Researchers note that although each shopper contacted only a small percentage of available store surfaces, the one surface touched by every shopper was the check-out stand. It was suggested that the check-out stand and grocery trolley could be ideal targets for new industry cleaning standards or new materials (such as antimicrobial surfaces). Given that hands were the most contaminated surfaces, the researchers concluded that in-store hand hygiene campaigns are needed and provision of hand-sanitizer dispensers at check-outs for use by the clerks and for wiping touch screens. Shoppers should be encouraged to wash and sanitize bags periodically. Additionally, shoppers (and in-store baggers) should be encouraged to take measures to avoid cross-contamination by separating raw meats, poultry and fish from ready-to-eat foods, such as fruits and vegetables as they bag purchases. The report is published in Journal of Environmental Health. 2018 Jun 1;80(10).

4. Use of hospital-grade disinfectants can reduce viral deposition on surfaces after toilet flushing

The aim of this study was to quantify viral contamination of surfaces in restrooms after toilet flushing, and the impact of disinfectants added to the toilet bowl prior to flushing in reducing surface contamination. Contamination of surfaces in the restroom was assessed with and without the addition of coliphage MS2 to the toilet bowl before flushing. The bowl water and various surfaces in the restroom were subsequently tested for the presence of the virus.
Results showed that toilet flushing resulted in extensive contamination of surfaces (toilet bowl rim, toilet seat top, and toilet seat underside) within the restroom. Addition of disinfectant to the toilet bowl prior to flushing reduced the level of contamination in the toilet bowl and on surfaces after flushing when the contact time was ≥15 minutes. Hydrogen peroxide produced very little reduction of virus in the toilet bowl (<1 log10). Peracetic acid and quaternary ammonium had the greatest log reductions on virus in the organic matter in the toilet. American Journal of Infection Control. 2018, 5, 507-511

5. Pilot study of “Beat the Bugs” community education course on hygiene & antibiotics

Beat the Bugs (available from www.e-Bug.eu/Beat-The-Bugs) is an interactive resource designed to target hard-to-reach groups in the community including vulnerable adults, young parents, guides, scouts etc, to increase awareness and change behaviour around hygiene, self-care and antibiotic use.  It is designed to be delivered to community groups by community leaders including school and public health nurses, health visitors and support workers. Messages are framed in a way that is accessible and appropriate to vulnerable adults, a group often underrepresented when interventions are developed.
The study piloted the education tool in two different groups. The first was conducted with adults with learning, physical and/or mental health difficulties in a community learning environment by a Community Leader who regularly delivers training to this group. The second was delivered in a children’s centre with young parents by a Family Support Worker who regularly gives training to parent groups

Session 1: Meet the Bugs was about microbes and explored types and shapes of microbes and discussed useful and harmful microbes. Both pilots reported the lowest baseline knowledge (40% and 42%) but overall this session had the greatest improvement in knowledge. Significant (P < 0.05) improvement was seen in every sessions except Food Bugs which was approaching significance (P = 0.06).

Session 2: Spreading Bugs was about spread of infection, learning how microbes are spread through sneezing and how hand-washing with soap can break the chain of infection. Both pilots reported baseline knowledge of > 50% and reported an improvement in knowledge by 24% and 25%, respectively. Results at six-week follow-up showed that participants could explain why it is important to wash hands and reported an increase in appropriate hand-washing behaviour and around using tissues when sneezing.

Session 3: Food Bugs looked at how easily harmful microbes in raw food can transfer to humans causing illness, and how to store foods to prevent microbes spreading from one food to another. Both pilots had high baseline knowledge (61% and 70%, respectively) allowing less opportunity to increase knowledge. Qualitative results at follow-up showed that participants could explain why it is important to store food correctly.

Session 5: Bug Busters gave an overview of what antibiotics are, when and how to take them correctly. Higher baseline knowledge was reported in Pilot 2 of parents (75%) compared to Pilot 1 of adults with learning difficulties (48%). Pilots saw a positive change in knowledge by 31% and 25%, respectively. In the antibiotics session, participant knowledge in Pilot 1 improved the most on the ‘right’ statements: ‘You should only take antibiotics if your doctor has prescribed them to you’ (50% to 100%). Participant knowledge in Pilot 2 improved the most on statement ‘Antibiotics affect other bacteria in your body, not just the ones which cause infection’ (0 to 100%). Qualitative results at follow-up showed that adults with learning difficulties struggled to explain what antibiotics where and when they should take them; however, they understood that they should only take antibiotics if they really needed them and should only take them as the doctor prescribed.

Session 6: Know Your Bugs: This session dealt with self-care for common infections, how to make decisions on your own health, think about your own antibiotic use and action plan for the future. Both pilots had high baseline knowledge (71% and 80%, respectively), probably because participants had already completed previous sessions. Participants reported an increase in knowledge following the session (22% and 10% respectively). Qualitative results at follow-up showed that participants had retained knowledge around self-care

Beat the Bugs is a valuable intervention to help increase individuals’ confidence and knowledge on managing their own infections and change behaviour around hygiene, self-care and antibiotic use. e-Bug is continuing to develop and promote resources to educate the public including hard to reach individuals about hygiene, self-care and antibiotics.

The report of this study can be found in: Journal of Infection Prevention 2018.
DOI: 10.1177/1757177418780990; http://journals.sagepub.com/doi/10.1177/1757177418780990

6. Latest on Hand Hygiene

Increased hygiene awareness is driving increased use of hand sanitizers

A global report shows that the hand sanitizer market is expected to grow at a rate of 8.59% pa from 2018 to 2022. Growth is being driven by increased consumer awareness of health and hygiene, combined with digital marketing and promotional activities to promote hand sanitizers. Educational efforts by agencies such as the U.S. Centers for Disease Control and Prevention, and the WHO are also motivating people to use sanitizers. The report has been prepared based on an in-depth market analysis with inputs from industry experts. It looks at the current market and its growth prospects over the coming years. The report revealed several key market trends, including the installation of touch-free dispensers in office spaces, hospitals, and hotels.

Hand hygiene–related interventions can reduce antibiotic prescribing

The aim of this study was to assess the impact of a hand hygiene program in nursing homes (NHs) in France. A bundle of hand hygiene-related measures were implemented over 1 year, including increased availability of alcohol-based handrub, hand hygiene promotion, staff education, and local work groups. The end points were incidence of acute respiratory infections and gastroenteritis, mortality, hospitalization, and antibiotic prescription rates. The overall handrub consumption was higher in the intervention then the control group. Hospitalizations did not differ between the 2 groups.  Although it was not possible, due to lack of data, to assess the impact on infection rates, the intervention group showed significantly lower mortality (2.10 vs. 2.65 per 100 residents per month, respectively. ; P = .003). The study also showed a reduction in rates of antibiotic prescribing in the intervention group (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < .001). American Journal of Infection Control, Volume 46 , Issue 2 , 173 – 179.

7. Using disinfectants on high frequency touch surfaces could reduce spread of infections and drug resistant bacteria in hospital settings

This new study evaluates whether daily use of a peracetic acid/hydrogen peroxide pre-impregnated wipe in place of the existing standard practice (detergent cleaning with cloth soaked in 1,000 ppm chlorine) led to a significant reduction in microbial contaminants on high frequency hand contact surfaces. The dry preimpregnated (sporicidal) wipe generates peracetic acid/hydrogen peroxide when activated with water. The study was performed on 2 wards in a 1,000-bed teaching hospital. Surfaces were decontaminated with the wipe or a cloth soaked in chlorine following a 5-week baseline assessment of surface bioburden. A total of 1,566 samples were taken from high frequency contact surfaces (toilet flush handle, toilet seat and grab handle, bed rails, tray table, and locker etc)

Overall, there were significant differences in recovery of aerobic bacteria and total anaerobic bacteria between wards and between different parts of the study. Generally, impregnated wipes produced the largest reduction in aerobic and anaerobic counts, compared with baseline data or using 1,000 ppm chlorine. Training plus daily wipe disinfection significantly reduced multidrug-resistant organisms recovered from surfaces. The authors suggest that greater efficacy of the preimpregnated wipe may be due to its ability to retain and not transfer microbial burden to multiple surfaces, as demonstrated in other studies.

Reintroduction of using detergent and chlorine following the use of preimpregnated wipe saw a significant increase in aerobic count in some (toilet flush handle, tray table, and locker) but not in all sites sampled. Since hands cannot be kept hygienic all the time, the study shows that use of disinfectants on high frequency contact surfaces could contribute to reducing infection transmission. American Journal of Infection Control 2018. https://doi.org/10.1016/j.ajic.2018.03.020

8. Campylobacter: Facts and Prevention Strategies

RSPH have launched a new e learning programme. The programme is recommended for anyone wanting to learn more about Campylobacter, and particularly useful for Environmental Health Officers. The demo version of the programme here https://rsph.gomocentral.com/content/5b5313c9-da06-4027-9b68-4d4d562815ef/webcan be viewed here. The programme explores the relating to campylobacter, including symptoms and long-term health effects as well as examining the means of control. The programme covers:
•         What is Campylobacter?
•         History and prevalence of Campylobacter
•         Sources of Campylobacter
•         Changing behaviour
The programme can be completed in 3 hours, worth 3 CPD points, and on completion users can request an electronic CPD certificate from RSPH. The programme is priced at £10 per user, alternately, for £20 users will receive access to the programme and Associate Membership of the RSPH for one year. Accounts can be purchased directly through the RSPH online shop.  Alternatively, if you would like to purchase accounts in bulk then please email the RSPH E-learning Team (elearning@rsph.org.uk) or call 0207 265 7384.

9. Research shows a link between microbe exposure in early life and childhood leukaemia

Following what is described as a landmark study by the Institute of Cancer Research, London, Prof Mel Greaves says he now believes that childhood leukaemia is preventable by ensuring that babies are exposed to protective bacteria which lower the risk of the disease in children born with an “accidental” pre-leukaemia mutation.  In the study he identified four protective factors - attending day care centres and socialising with other children in the first year, having older siblings, being breast fed and having a vaginal birth. If children are deprived of these protective bacteria, their first common infection as a toddler can trigger a second mutation which causes leukaemia.
All of the “protective factors” are known to help add protective bacteria to a child’s gut microbiome in the crucial first months of life. The gut bacteria have a lifelong role in regulating everything from body weight and temperature to the immune system and emotions. Prof Greaves’ team has now shown that mice born with the initial genetic mutation, kept in a sterile environment in infancy and then exposed to a respiratory bacteria were much more likely to develop leukaemia.
BUT – as we have seen before, so many times this important story became distorted by misleading media headlines which picked up from the reference to mice kept in a sterile environment with headlines such as “The kids are too clean! Landmark study finds germ-free environment in first year can CAUSE Leukaemia”. Why Oh Why do we have to put up with this, when the evidence increasingly points to the conclusion that the protective factors are lifestyle, diet and excessive antibiotic use – that it is possible to raise mice in sterile conditions, but NOT humans - and that home cleanliness per se is a red herring. Coverage of this issue is also set out in a short IFH review.: