CONTENTS:
NEWS FEATURE
QUESTION OF THE MONTH
REGULATORY/LEGISLATIVE
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
NEWS AND ANNOUNCEMENTS
NEWS FEATURE
The Case for a One Minute Contact Time for Surface Disinfection in Healthcare Facilities
Noncritical items are those that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is "not critical." In the “draft” CDC HICPAC Guidelines for Disinfection and Sterilization, authored by William A. Rutala and David J. Weber, noncritical items are divided into noncritical patient care items and noncritical environmental surfaces. [1, 2] Examples of noncritical patient-care items are bedpans, blood pressure cuffs, crutches and computers. [3] In contrast to critical and some semicritical items, most noncritical reusable items may be decontaminated where they are used and do not need to be transported to a central processing area. There is virtually no documented risk of transmitting infectious agents to patients via noncritical items [24] when they are used as noncritical items and do not contact non-intact skin and/or mucous membranes. An important issue concerning the use of disinfectants for noncritical surfaces in healthcare settings is that the contact time specified on the label of the product is often too long to be practically followed. The labels of most products registered by the EPA for use against HBV, HIV, or M. tuberculosis specify a contact time of 10 minutes. Such a long contact is not practical for disinfection of environmental surfaces in a health-care setting because most healthcare facilities apply a disinfectant and allow it to dry (approximately 1 minute). However, multiple investigators have demonstrated the effectiveness of these disinfectants against vegetative bacteria (e.g., Listeria, Escherichia coli, Salmonella, vancomycin-resistant Enterococci [VRE], methicillin-resistant Staphylococcus aureus [MRSA]), yeasts (e.g., Candida), mycobacteria (e.g., M. tuberculosis), and viruses (e.g. poliovirus) at exposure times of 30 to 60 seconds. [4-22] In addition, the EPA will approve a shortened contact time for any product for which the manufacturer will submit confirmatory data. Currently, some EPA-registered disinfectants have contact times from one to three minutes. By law, all applicable label instructions on EPA-registered products must be followed (e.g., use-dilution, shelf-life, storage, material compatibility, safe use and disposal). If the user selects exposure conditions (e.g., exposure time) that differ from those on the EPA-registered products label, the user assumes liability from any injuries resulting from off-label use and is potentially subject to enforcement action under Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). [23]REFERENCES
1. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings-2003. MMWR 2003;52 (no. RR-17):1-67.
2. Sehulster L, Chinn RYW, Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. MMWR 2003;52:1-44.
3. Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial contamination of keyboards: Efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol 2006;27:372-7.
4. Sattar SA, Lloyd-Evans N, Springthorpe VS, Nair RC. Institutional outbreaks of rotavirus diarrhoea: potential role of fomites and environmental surfaces as vehicles for virus transmission. J. Hyg. (Lond). 1986;96:277-89.
5. Weber DJ, Rutala WA. Role of environmental contamination in the transmission of vancomycin-resistant enterococci. Infect. Control Hosp. Epidemiol. 1997;18:306-9.
6. Ward RL, Bernstein DI, Knowlton DR, et al. Prevention of surface-to-human transmission of rotaviruses by treatment with disinfectant spray. J. Clin. Microbiol. 1991;29:1991-6.
7. Tyler R, Ayliffe GA, Bradley C. Virucidal activity of disinfectants: studies with the poliovirus. J. Hosp. Infect. 1990;15:339-45.
8. Gwaltney JM, Jr., Hendley JO. Transmission of experimental rhinovirus infection by contaminated surfaces. Am. J. Epidemiol. 1982;116:828-33.
9. Sattar SA, Jacobsen H, Springthorpe VS, Cusack TM, Rubino JR. Chemical disinfection to interrupt transfer of rhinovirus type 14 from environmental surfaces to hands. Appl. Environ. Microbiol. 1993;59:1579-85.
10. Sattar SA, Jacobsen H, Rahman H, Cusack TM, Rubino JR. Interruption of rotavirus spread through chemical disinfection. Infect. Control Hosp. Epidemiol. 1994;15:751-6.
11. Rutala WA, Barbee SL, Aguiar NC, Sobsey MD, Weber DJ. Antimicrobial activity of home disinfectants and natural products against potential human pathogens. Infect. Control Hosp. Epidemiol. 2000;21:33-8.
12. Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of Candida species. Infect. Control Hosp. Epidemiol. 1999;20:676-84.
13. Best M, Sattar SA, Springthorpe VS, Kennedy ME. Efficacies of selected disinfectants against Mycobacterium tuberculosis. J. Clin. Microbiol. 1990;28:2234-9.
14. Best M, Kennedy ME, Coates F. Efficacy of a variety of
disinfectants against Listeria spp. Appl. Environ. Microbiol.
1990;56:377-80.
15. Best M, Springthorpe VS, Sattar SA. Feasibility of a combined carrier test for disinfectants: studies with a mixture of five types of microorganisms. Am. J. Infect. Control 1994;22:152-62.
16. Mbithi JN, Springthorpe VS, Sattar SA. Chemical disinfection of hepatitis A virus on environmental surfaces. Appl. Environ. Microbiol. 1990;56:3601-4.
17. Springthorpe VS, Grenier JL, Lloyd-Evans N, Sattar SA. Chemical disinfection of human rotaviruses: efficacy of commercially-available products in suspension tests. J. Hyg. (Lond). 1986;97:139-61.
18. Akamatsu T, Tabata K, Hironga M, Kawakami H, Uyeda M. Transmission of Helicobacter pylori infection via flexible fiberoptic endoscopy. Am. J. Infect. Control 1996;24:396-401.
19. Sattar SA, Springthorpe VS. Survival and disinfectant inactivation of the human immunodeficiency virus: a critical review. Rev. Infect. Dis. 1991;13:430-47.
20. Resnick L, Veren K, Salahuddin SZ, Tondreau S, Markham PD. Stability and inactivation of HTLV-III/LAV under clinical and laboratory environments. JAMA 1986;255:1887-91.
21. Weber DJ, Barbee SL, Sobsey MD, Rutala WA. The effect of blood on the antiviral activity of sodium hypochlorite, a phenolic, and a quaternary ammonium compound. Infect. Control Hosp. Epidemiol. 1999;20:821-7.
22. Rice EW, Clark RM, Johnson CH. Chlorine inactivation of Escherichia coli O157:H7. Emerg. Infect. Dis. 1999;5:461-3.
23. Pentella MA, Fisher T, Chandler S, Britt-Ohrmund T, Kwa BH, Yangco BG. Are disinfectants accurately prepared for use in hospital patient care areas? Infect. Control Hosp. Epidemiol. 2000;21:103.
24. Weber DJ, Rutala WA. Environmental issues and nosocomial infections. In: Wenzel RP, ed. Prevention and control of nosocomial infections. Baltimore: Williams and Wilkins, 1997:491-514.
Excerpted with permission from CDC HICPAC Guidelines for Disinfection and Sterilization, Rutala and Weber 2006.
QUESTION OF THE MONTH
OSHA Enforcement of the Annual Fit Testing Requirement
Q: Has there been any change to OSHA not enforcing the annual fit testing requirement?A: In the summer congressional session, the US House of Representatives voted against the Wicker Amendment. Rep. Roger Wicker (R-MS) had offered his “annual” fit testing amendment for TB that has prevented OSHA from using resources to enforce the fit-testing requirement of the General Industry Respiratory Protection Standard (GIRPS) to healthcare facilities.
Arguments made in favor of the amendment included a quote by CDC Director, Julie Gerberding saying that after an initial fit there is no data to recommend annual fit testing. Other reasons against it were that it is time consuming and expensive, and an undo regulation. On the other side of the argument, those against the amendment and thus in favor of fit testing, argued that NIOSH/OSHA experts were recommending the optimal level of protection for healthcare workers. OSHA had testified that 1-2% need a different size mask if tested annually and this increases to 6% with a 2 year interval.
APIC sent a notice to all legislative representatives and thanked all ICPs who called members of the Appropriations Committee. APIC states it is planning to continue attempts to reintroduce the amendment at a later date or possibly in the Senate. What this means for ICPs is that preparations for institutional annual fit testing programs need to be planned and put into action. OSHA may begin enforcing annual fit testing starting October 1, 2007.
REGULATORY/LEGISLATIVE
Legislative Communicable Disease Report Cards (UPDATED - March 2007)
NC Communicable Diseases Reporting Law (G.S. 130A-135, 10A NCAC 41A, 0101) requires physicians of patients with suspected or confirmed communicable diseases to report basic patient information to the health department. This reporting of communicable diseases does not constitute a breach of patient confidentiality. It is specifically allowed under HIPAA. Furthermore, reporting is a legal requirement for all physicians.The new Communicable Disease cards are now green and were updated in March. Included in the updated card is an immediate reporting requirement for novel influenza virus infection. In addition, congenital toxoplasmosis was removed from the reporting requirement; and transmissible spongiform encephalopathies is now listed as Creutzfeldt-Jakob disease. Certain diseases require reporting to the local health department immediately (e.g., bioterrorist agents, novel influenza virus infections), some to be reported within 24 hours (e.g., meningococcal disease, E coli 0157:H7, pertussis), and the remaining diseases within 7 days. In order to report a disease immediately or within 24 hours, the physician must call the health department of the patient’s county of residence before submitting the card. Healthcare facilities can obtain the updated communicable disease cards from the local health department.
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
“Infection Control Part II: The ICP as an Environmentalist” was held in Chapel Hill September 17-21, 2007. Information about the 2007 course is available online. http://fridaycenter.unc.edu/pdep/icii/
"Infection Control in Long-Term Care Facilities” will be held October 15-17, 2007 in Chapel Hill . Information and registration for this course are available online.“Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections” will be held April 28-May 2, 2008. Information about the May 2007 course is online. http://fridaycenter.unc.edu/pdep/ici/
NEWS AND ANNOUNCEMENTS
New Pandemic Flu Guidance Released by OSHA
May 21, 2007. In an effort to prepare the healthcare industry for a possible influenza pandemic, OSHA officials on May 21 released new guidelines designed for healthcare workers. Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers provides healthcare workers with information and tools to prepare for pandemic-related issues such as surge, vaccination programs, and infection control measures. The 99-page guidance also highlights OSHA standards that will play a significant role in pandemic planning.
www.osha.gov/Publications/OSHA_pandemic_health.pdf
Organizations Change Names
Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006
Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 is a new Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline. Multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and certain gram-negative bacilli (GNB) have important infection control implications that either have not been addressed or received only limited consideration in previous isolation guidelines. Increasing experience with these organisms is improving understanding of the routes of transmission and effective preventive measures. Although transmission of MDROs is most frequently documented in acute care facilities, all healthcare settings are affected by the emergence and transmission of antimicrobial-resistant microbes. . . . The prevention and control of MDROs is a national priority - one that requires that all healthcare facilities and agencies assume responsibility. . . The discussion and recommendations are provided to guide the implementation of strategies and practices to prevent the transmission of MRSA, VRE, and other MDROs.
(from the Introduction to the guideline)
www.cdc.gov/ncidod/dhqp/index.html
Immunization Recommendations
December 1, 2006. General Recommendations on Immunization. - Recommendations of the Advisory Committee on Immunization Practices (ACIP). Periodically, the Advisory Committee on Immunization Practices (ACIP) updates its recommendations on immunizations in the United States. This report is a revision of the 2002 general recommendations. It provides technical guidance about common vaccination concerns for clinicians and other health-care providers who administer vaccines. Recommendations and Reports Volume 55, No. RR-15 www.cdc.gov/mmwr/PDF/rr/rr5515.pdf
Immunization Strategy to Eliminate Transmission of Hepatitis B Virus
December 8, 2006. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States - Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: Immunization of Adults. This report, the second of a two-part statement from the Advisory Committee on Immunization Practices (ACIP), provides updated recommendations to increase hepatitis B vaccination of adults at risk for HBV infection. The first part of the ACIP statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously (CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices [ACIP]. Part 1: immunization of infants, children, and adolescents. MMWR 2005;54[No. RR-16]:1-33.
Recommendations and Reports. Volume 55, No. RR-16 www.cdc.gov/mmwr/PDF/rr/rr5516.pdf
North Carolina to Receive More Equitable Funding for Individuals Infected with HIV/AIDS
December 2006. The Senate passed H.R. 6143, the Ryan White CARE Act Reauthorization legislation. The bill will provide more equitable distribution of Ryan White CARE Act funds to states with elevated rates of new HIV/AIDS infections, including North Carolina. The Ryan White CARE Act was initiated in 1990 to provide treatment and care for individuals suffering from HIV/AIDS who are in the greatest need of assistance. The Reauthorization legislation would provide more equitable distribution of CARE Act funds to emerging HIV/AIDS populations. Currently, Southern states, which account for a majority of HIV/AIDS cases in the nation, are being shortchanged in CARE Act funding.
Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic
October 2006. The Centers for Disease Control and Prevention (CDC) is aware of no new scientific information related to the transmission of influenza viruses since the drafting of the HHS Pandemic Influenza Plan (www.hhs.gov/pandemicflu/plan/). As stated in the plan, the proportional contribution and clinical importance of the possible modes of transmission of influenza (i.e., droplet, airborne, and contact) remains unclear and may depend on the strain of virus ultimately responsible for a pandemic. Nevertheless, in view of the practical need for clarification, CDC has re-reviewed the existing data, and has prepared interim recommendations on surgical mask and respirator use. The purpose of this document is to provide a science-based framework to facilitate planning for surgical mask and respirator use in health care settings during an influenza pandemic. www.pandemicflu.gov/plan/healthcare/maskguidancehc.html
Pandemic Flu Checklists
The federal government website has information and planning checklists for various groups at pandemicflu.gov These checklists are intended to aid preparation for a pandemic in a coordinated and consistent manner across all segments of society. The information is also available in Spanish at these web sites.
September 22, 2006. These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1--10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1--62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63--85). www.cdc.gov/mmwr/PDF/rr/rr5514.pdf
Standard Allows Administration of Flu and Pneumococcal Vaccines without Physician Order
Effective January 1, 2007, Joint Commission standard MM.3.20 will include an element of performance that allows the administration of influenza and pneumococcal polysaccharide vaccines according to a physician order or, as permitted by law and regulation, according to specific organization protocol(s). This addition to the standard was created following the elimination in 2002 by the Centers for Medicare and Medicaid Services of the federal requirement that the physician responsible for the care of the patient write an order for each administration of influenza or pneumococcal vaccine. The new requirement complements the CMS action by allowing appropriate staff—other than physicians—to administer influenza and pneumococcal vaccines without an individual physician order. Such administration is permitted only if authorized by physician- or organization-approved protocols and if allowed by law and regulation. The new requirement is in-line with current CMS requirements, and is intended to facilitate the administration of influenza and pneumococcal vaccines in efforts to prevent these diseases. It’s estimated by the Centers for Disease Control and Prevention that 36,000 Americans die annually from influenza and its complications, and more than 5,000 Americans die annually from pneumococcal pneumonia. (from JCAHO Online)
CMS Issues Letter Supporting Use of Alcohol-Based Surgical Skin Preps
On January 12, 2007, CMS published guidance to all state surveyors, supporting the use of alcohol-based skin preps in surgical settings based on NFPA fire prevention strategies. This CMS guidance removes the risk of individual states banning their use. (from Premier Safety)
OSHA Unveils New Guidance on Preparing Workplaces for Pandemic Flu
On Feb. 6, 2007, OSHA unveiled a new workplace safety and health guidance document that will help employers prepare for an influenza pandemic. Developed in coordination with the U.S. Department of Health and Human Services, Guidance on Preparing Workplaces for an Influenza Pandemic provides general guidance for all types of workplaces, describes the differences between seasonal, avian and pandemic influenza, and presents information on the nature of a potential pandemic, how the virus is likely to spread and how exposure is likely to occur. http://www.osha.gov/Publications/influenza_pandemic.html
FDA Clears First Respirators for Use in Public Health Medical Emergencies
May 8, 2007. The U.S. Food and Drug Administration (FDA) today cleared for marketing the first respirators that can help reduce the user's exposure to airborne germs during a public health medical emergency, such as an influenza pandemic. These two filtering facepiece respirators, manufactured by St. Paul, Minn.-based 3M Company (and called the 3M Respirator 8612F and 8670F), will be available to the general public without a prescription. The devices are also certified as N95 filtering facepiece respirators by the National Institute for Occupational Safety and Health (NIOSH). NIOSH certifies respirators for use in occupational settings in accordance with an appropriate respiratory protection program. An N95 filtering facepiece respirator is a type of face mask that fits tightly over the nose and mouth. It is made of fibrous material that is designed to filter out at least 95 percent of very small airborne particles. The filter and a proper fit determine the effectiveness of the product.
Many companies make N95 respirators for workplaces, including health care settings. However, the 3M respirators are the first devices to receive FDA clearance for use by the public during public health medical emergencies to reduce exposure to airborne germs. (FDA News) www.fda.gov/bbs/topics/NEWS/2007/NEW01630.html
New North Carolina Unified Isolation Signage
North Carolina is the first state to have a "voluntary" unified color scheme for isolation signage. The new signs can be used across the spectrum of healthcare providers in the state, including acute care hospitals, rehabilitation and long-term care facilities, and ambulatory/surgical centers. The timing is right with the recently released revisions in late June of the Centers for Disease Control and Prevention (CDC), Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, prepared by the Healthcare Infection Control Practices Advisory Committee (HICPAC).
The SPICE isolation signs are available and encouraged for use in all North Carolina healthcare facilities, although use is voluntary. Healthcare facilities may choose to use the color scheme only, or to modify the statewide signage per facility policy. Signs are downloadable on the SPICE website: www.unc.edu/depts/spice/isolation.html
RECOGNITIONS:
1. Wanda W. Lamm, RN, BSN, CIC, Infection Control Coordinator from the Nash Health Care System in Rocky Mount, has been selected as a 2008 Hero by APIC. She will be featured in the 2008 calendar, as well as receive complimentary registration for the APIC national meeting in Denver and recognition at the annual awards ceremony held in conjunction with the conference.
She was nominated for this honor by Libbe Sasser. In her nomination letter, Libbe stated “… it is her devotion and tenaciousness to educate our hospital staff and community on Pandemic Flu preparedness that I nominate Wanda W. Lamm. Mrs. Lamm has been the driving force in our county to establish and maintain a community-wide committee to address the issues of bioterrorism and pandemic flu.”
”In August 2001, Mrs. Lamm organized a bioterrorism community-wide drill that has continued to evolve and expand. The agencies that participated in the first drill formed a bioterrorism committee but have expanded to the Nash County Disaster Preparedness Committee, which includes all forms of terrorism; and the Nash County Pandemic Flu Preparedness Committee. These committees include hospital staff, County and City law enforcement, fire, EMS, home health, Nash County Public Health, Red Cross, United Way, local businesses, and the public school system………Mrs. Lamm has gone further to educate the public in our community on Pandemic Flu Preparedness by presenting at local businesses, churches, community service organizations like Ruritan Club and Girl Scout Leaders, physician offices, and our Area L AHEC…..” Congratulations, Wanda!
2. Vickie Brown, RN, MPH, CIC, Associate Director of the Infection Control Program at UNC Healthcare System in Chapel Hill, is also to be congratulated for her selection to the APIC national program planning committee. Vickie has already participated in the organization of the San Jose Conference.
3. Judie Bringhurst, RN, CIC, Infection Control Professional at Duke University has been selected to the editorial staff of the new Ambulatory Care newsletter published by AHC Media.
4. Eva Clontz, the Program Coordinator for SPICE for 20 years, retired June 30, 2007. Congratulations to our colleague Eva P. Clontz for 20 years of exceptional service, support and commitment to infection prevention to the SPICE Program. While at SPICE, Eva published several peer-reviewed papers, book chapters and abstracts in the area of infection control and infection control education. She, in collaboration with her SPICE colleagues, planned, coordinated and lectured in about 70 courses to about 3,000 infection control professionals and she participated in the training of about ~85% of the ICPs in NC hospitals. Eva excelled in course preparation and all aspects of her job and performed her difficult job quietly without anyone noticing or appreciating the complexity of her job and without her seeking praise. In her 20 years with SPICE, Eva achieved an unblemished record of kindness, gentleness, competence, integrity, generosity of spirit and skilled professionalism.
Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A. Rutala, PhD, MPH; David J. Weber, MD, MPH; Eva P. Clontz, MEd., Debby Pyatt
Report of the Month is also available on the home page of the Statewide Program for Infection Control and Epidemiology at http://www.unc.edu/depts/spice/. The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by the General Assembly of North Carolina to serve the State. The SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.
Sent October 2007
Copyright 2007 Statewide Infection Control Program