Environmental cleaning and disinfection in South Africa- evidence or ritual

Prof Shaheen MehtarInfection Control Africa Network andStellenbosch University, Cape Town

DisclosureI have no financial relationships with commercial entities producing healthcare related products and/or services

DisclaimerThe content of this presentation references the recommendations in WHO guidance and other relevant documents. The content is subject to revision as new evidence on COVID-19 becomes available.

Objectives§ To present the statistics for COVID-19 in Western Cape

§ To review evidence based environmental cleaning and disinfection guidance in South Africa

§ Areas of contention or uncertainty.

South Africa (21 June 2020)

97302

1930

51608

53%

CFR- 1.8%

Western Cape Province

COVID-19 facilities at Tygerberg Hospital, Cape Town

• Total number of beds = 1374• Number of acute beds designated

for COVID-19= 1000 or more– Routine admissions restricted

• Additional COVID 19 beds = 60• Number of ICU for COVID-19= 60,

using 28 due to staff shortages• Acute staff shortages=

approximately 25-30% due to COVID-19 related matters

• Additional environmental cleaning staff = 20

Environmental cleaning and disinfection

Section 1: Standard Precautions

COVID-19: cleaning and disinfection

• SARS CoV2 - fragile enveloped virus. – easily destroyed by detergent, heat

and chemicals• Cleaning & disinfection frequency

– General areas – twice a day– ICU- 4 times a day

• Wipe over with disinfectant– 1000 ppm chlorine– 70% alcohol

• NO spraying of any surface• NO spraying of outdoor surfaces• NO spraying of humans (disinfection

tunnels

Available in: https://www.who.int/publications-detail/cleaning-and-disinfection-of-environmental-surfaces-inthe-context-of-covid-19

No touch technologies (WHO 2020)Vapourised hydrogen peroxide• No-touch technologies for applying chemical

disinfectants (e.g. vaporized hydrogen peroxide) in health-care settings such as fogging-type applications.

• These technologies developed for use in health-care settings are used during terminal cleaning (cleaning a room after a patient has been discharged or transferred), when rooms are unoccupied for the safety of staff and patients

• Used in prescribed fixed volume water or air requiring repeated exposure

Are there any no touch technologies used at TBH?

• No fogging of UV systems used in the clinical areas for COVID-19 (no evidence it works)• Used by engineers for their offices and rooms- fogging with alcohol!

Indications at TBH• Terminal cleaning is indicated for MDROs or C difficile (ICUs)

– Wash and clean the room and contents – Wipe over with disinfectant– Clear the room of all the equipment– Hydrogen peroxide used for fogging– Allow contact time– Ventilate the area– Restock.

• Not easy to do, laborious and time consuming

Impact of disinfectants

On humans

• Toxicity: Affecting eyes, skin and respiratory tract following exposure

• Children- contact dermatitis, exacerbation of asthma

• Chemical exposure from residual chemicals on surfaces after fogging

• No evidence of reduced transmission following environmental fogging or spraying

The environment

• Accumulation in water ways and detrimental effect on plants, birds and animals. e.g– Quaternary ammonium compounds– Triclosan– Chlorine (high concentrations)

• Increase in antimicrobial resistance– Cross resistance to antimicrobial agents– Increased resistance -Gram negative bacilli– Increased resistance in Staph aureus

(MRSA)

Disinfection tunnels and spraying of humansProblemDisinfectant tunnels at entrances to public transport (Gautrain and Soweto Taxi rank) have been installed. No evidence of spraying chemicals of humans reduces the risk of transmissionEvidence• A literature review, including WHO and PAHO recommendations, studies from West Africa during the

2016 Ebola outbreak, and chemical exposure amongst cleaning staff demonstrated toxic effects of chemicals, especially halogen based compounds causing skin, eye and respiratory irritation.

• Chlorine and other chemicals converts to hydrochloric acid (HCL) leading to damage of the airways. • Respiratory damage can potentially increase the risk of SARS-CoV2 acquisition and may enhance

disease.South African legislation protecting humans and the environment: Hazardous Substance Act (1973); Occupational Health & Safety Act (1993); National Environmental Management Act (1998)

Recommendations.1. There is no evidence that spraying of humans prevents transmission. 2. Chemical spraying of humans by any route, including disinfectant tunnels is strongly condemned as it is damaging to eyes, skin and the respiratory tract and increases the risk of acquisition of SARS-CoV2.

Safe handling of linen and food services, waste Wear appropriate PPE for the taskLinen: Washed at 50 o C or higher. – Automated washing machines recommended– Hand washing with soap and water as high as can be tolerated. (gloves)

Food: cutlery & crockery: disposable crockery not necessary. – Automatic dish washer– Hand washing in hot water and detergent as can be tolerated (gloves)

Healthcare waste: infectious waste– PPE – Disposable medical devices– Send via usual route of infectious waste

• Purpose: Review of challenges with environmental contamination in LMICS• Source(s) of contamination- associated with poor governance– Inadequate infrastructure- (non compliance with WASH)– Human resources– Inadequate funding– Poor understanding of transmission of pathogens and lack of IPC measuress– Low awareness and priority given to the role of the environment

Summary§ A fragile virus- remember the route of transmission§ Do not need extensive disinfection§ Keep the environment clean and dry with frequent cleaning§ Disinfection following cleaning- wipe. Do not spray§ Maintain safety of staff with good hand hygiene, appropriate PPE and

frequent education

References1 WHO. (2020). Coronavirus disease (COVID-19) advice for the public: Myth busters

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters 2 Mehtar, S., Bulabula, A. N., Nyandemoh, H., & Jambawai, S. (2016). Deliberate exposure of humans to chlorine-the aftermath of Ebola in West Africa. Antimicrobial resistance and infection control, 5, 45. https://doi.org/10.1186/s13756-016-0144-1 3 Trina Wood. (2017). Common Antiseptic Ingredients De-Energize Cells and Impair Hormone Response https://www.ucdavis.edu/news/common-antiseptic-ingredients-de-energize-cells-and-impair-hormone-response/ 4 C. Federico Molina, Walter D. Machado, Federico Marquetti y Eugenio A. Quaia. Toxicidad del amonio cuaternario para microorganismos utilizados en el tratamiento biológicoanaerobio de efluentes. http://www.eeaoc.org.ar/upload/publicaciones/archivos/357/20131204135727000000.pdf5 Alicia Culver, Chris Geiger, Deanna Simon. SF Environment. Safer products and practices for disinfecting and sanitizing surfaces. https://sfenvironment.org/sites/default/files/fliers/files/sfe_th_safer_products_and_practices_for_disinfecting.pdf6 UNICEF, WHO. (2020). Water, sanitation, hygiene, and waste management for the COVID-19 virus. 7 EPA. (2020). List N: Products with Emerging Viral Pathogens AND Human Coronavirus claims for use against SARS-CoV-2 https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 8 R.F. Kahrs. Principios generales de la desinfección. Rev. sci. tech. Off. Int. Epiz. (1995). 14 (1), 143-163. https://www.oie.int/doc/ged/D8972.PDF9. PAHO/CDE/CE/COVID-19/20-0012 • © Pan American Health Organization, 2020 THE USE OF TUNNELS AND OTHER TECHNOLOGIES FOR DISINFECTION OF HUMANS USING CHEMICAL ASPERSION OR UV-C LIGHT10. WHO: Cleaning and disinfection of environmental surfaces in the context of COVID-19, interim guidance, 15 May, 2020. https://www.who.int/publications-detail/cleaning-and-disinfection-of-environmental-surfaces-inthe-context-of-covid-1911. South African laws governing safety of workers (humans) and the environment• Hazardous Substance Act (1973); • Occupational Health & Safety Act (1993); • National Environmental Management Act (1998)

12 MMWR /April 24, 2020/ Vol. 69 /No 16. Cleaning and disinfectant Chemical Exposures and Temporal Association with COVID-19- National Poison Data System, United States, Jan 1 to March 31, 2020