E. Environmental Services

1. Principles of Cleaning and Disinfecting Environmental Surfaces

Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients. The transferral of microorganisms from environmental surfaces to patients is largely via hand contact with the surface.^{947, 948} Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces as appropriate is fundamental in reducing their potential contribution to the incidence of healthcare-associated infections.

The principles of cleaning and disinfecting environmental surfaces take into account the intended use of the surface or item in patient care. CDC retains the Spaulding classification for medical and surgical instruments, which outlines three categories based on the potential for the instrument to transmit infection if the instrument is microbiologically contaminated before use.^{949, 950} These categories are "critical," "semicritical," and "noncritical." In 1991, CDC proposed an additional category designated "environmental surfaces" to Spaulding's original classification⁹⁵¹ to represent surfaces that generally do not come into direct contact with patients during care. Environmental surfaces carry the least risk of disease transmission and can be safely decontaminated using less rigorous methods than those used on medical instruments and devices. Environmental surfaces can be further divided into medical equipment surfaces (e.g., knobs or handles on hemodialysis machines, x-ray machines, instrument carts, and dental units) and housekeeping surfaces (e.g., floors, walls, and tabletops).⁹⁵¹

The following factors influence the choice of disinfection procedure for environmental surfaces:

Cleaning is the necessary first step of any sterilization or disinfection process. Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation.^954–960 The physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces.⁹⁵⁷ If the surface is not cleaned before the terminal reprocessing procedures are started, the success of the sterilization or disinfection process is compromised.

Spaulding proposed three levels of disinfection for the treatment of devices and surfaces that do not require sterility for safe use. These disinfection levels are "high-level," "intermediate-level," and "low level." ^{949, 950}

The basis for these levels is that microorganisms can usually be grouped according to their innate resistance to a spectrum of physical or chemical germicidal agents (Table 22). This information, coupled with the instrument/surface classification, determines the appropriate level of terminal disinfection for an instrument or surface.

Table 22. Levels of disinfection by type of microorganism

+ indicates that a killing effect can be expected when the normal use-concentrations of chemical disinfectants or pasteurization are properly employed

– indicates little or no killing effect

* Material in this table compiled from references 2, 951.

† This class of microorganisms includes asexual spores but not necessarily chlamydospores or sexual spores.

The process of high-level disinfection, an appropriate standard of treatment for heat-sensitive, semi-critical medical instruments (e.g., flexible, fiberoptic endoscopes), inactivates all vegetative bacteria, mycobacteria, viruses, fungi, and some bacterial spores. High-level disinfection is accomplished with powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) that are not appropriate for use on housekeeping surfaces. These liquid chemical sterilants/high-level disinfectants are highly toxic.^961–963 Use of these chemicals for applications other than those indicated in their label instructions (i.e., as immersion chemicals for treating heat-sensitive medical instruments) is not appropriate.⁹⁶⁴Intermediate-level disinfection does not necessarily kill bacterial spores, but it does inactivate Mycobacterium tuberculosisvar. bovis, which is substantially more resistant to chemical germicides than ordinary vegetative bacteria, fungi, and medium to small viruses (with or without lipid envelopes). Chemical germicides with sufficient potency to achieve intermediate-level disinfection include chlorine-containing compounds (e.g., sodium hypochlorite), alcohols, some phenolics, and some iodophors. Low-level disinfection inactivates vegetative bacteria, fungi, enveloped viruses (e.g., human immunodeficiency virus [HIV], and influenza viruses), and some non-enveloped viruses (e.g., adenoviruses). Low-level disinfectants include quaternary ammonium compounds, some phenolics, and some iodophors. Sanitizers are agents that reduce the numbers of bacterial contaminants to safe levels as judged by public health requirements, and are used in cleaning operations, particularly in food service and dairy applications. Germicidal chemicals that have been approved by FDA as skin antiseptics are not appropriate for use as environmental surface disinfectants.⁹⁵¹

The selection and use of chemical germicides are largely matters of judgment, guided by product label instructions, information, and regulations. Liquid sterilant chemicals and high-level disinfectants intended for use on critical and semi-critical medical/dental devices and instruments are regulated exclusively by the FDA as a result of recent memoranda of understanding between FDA and the EPA that delineates agency authority for chemical germicide regulation.^{965, 966}Environmental surface germicides (i.e., primarily intermediate- and low-level disinfectants) are regulated by the EPA and labeled with EPA registration numbers. The labels and technical data or product literature of these germicides specify indications for product use and provide claims for the range of antimicrobial activity. The EPA requires certain pre-registration laboratory potency tests for these products to support product label claims. EPA verifies (through laboratory testing) manufacturers' claims to inactivate microorganisms for selected products and organisms. Germicides labeled as "hospital disinfectant" have passed the potency tests for activity against three representative microorganisms – Pseudomonas aeruginosa, Staphylococcus aureus, and Salmonella cholerae suis. Low-level disinfectants are often labeled "hospital disinfectant" without a tuberculocidal claim, because they lack the potency to inactivate mycobacteria. Hospital disinfectants with demonstrated potency against mycobacteria (i.e., intermediate-level disinfectants) may list "tuberculocidal" on the label as well. Other claims (e.g., "fungicidal," "pseudomonicidal," and "virucidal") may appear on labels of environmental surface germicides, but the designations of "tuberculocidal hospital disinfectant" and "hospital disinfectant" correlate directly to Spaulding's assessment of intermediate-level disinfectants and low-level disinfectants, respectively.⁹⁵¹

A common misconception in the use of surface disinfectants in health-care settings relates to the underlying purpose for use of proprietary products labeled as a "tuberculocidal" germicide. Such products will not interrupt and prevent the transmission of TB in health-care settings because TB is not acquired from environmental surfaces. The tuberculocidal claim is used as a benchmark by which to measure germicidal potency. Because mycobacteria have the highest intrinsic level of resistance among the vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e., an intermediate-level disinfectant) is considered capable of inactivating a broad spectrum of pathogens, including much less resistant organisms such the bloodborne pathogens (e.g., hepatitis B virus [HBV], hepatitis C virus [HCV], and HIV). It is this broad spectrum capability, rather than the product's specific potency against mycobacteria, that is the basis for protocols and OSHA regulations indicating the appropriateness of using tuberculocidal chemicals for surface disinfection.⁹⁶⁷

2. General Cleaning Strategies for Patient-Care Areas

The number and types of microorganisms present on environmental surfaces are influenced by the following factors:

Strategies for cleaning and disinfecting surfaces in patient-care areas take into account

a. Cleaning of Medical Equipment

Manufacturers of medical equipment should provide care and maintenance instructions specific to their equipment. These instructions should include information about

In the absence of manufacturers' instructions, non-critical medical equipment (e.g., stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination. Ethyl alcohol or isopropyl alcohol in concentrations of 60%–90% (v/v) is often used to disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials, and thermometers)^{952, 969} and occasionally external surfaces of equipment (e.g., stethoscopes and ventilators). However, alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are immersed, a factor that precludes its practical use as a large-surface disinfectant.⁹⁵¹ Alcohol may cause discoloration, swelling, hardening, and cracking of rubber and certain plastics after prolonged and repeated use and may damage the shellac mounting of lenses in medical equipment.⁹⁷⁰

Barrier protection of surfaces and equipment is useful, especially if these surfaces are

An example of this approach is the use of plastic wrapping to cover the handle of the operatory light in dental-care settings.^{936, 942} Coverings should be removed and discarded while the health-care worker is still gloved.^{936, 942} The health-care worker, after ungloving and performing hand hygiene, must cover these surfaces with clean materials before the next patient encounter.

b. Cleaning Housekeeping Surfaces

Housekeeping surfaces require regular cleaning and removal of soil and dust. Dry conditions favor the persistence of gram-positive cocci (e.g., coagulase-negative Staphylococcus spp.) in dust and on surfaces, whereas moist, soiled environments favor the growth and persistence of gram-negative bacilli.^{948, 971, 972} Fungi are also present on dust and proliferate in moist, fibrous material.

Most, if not all, housekeeping surfaces need to be cleaned only with soap and water or a detergent/disinfectant, depending on the nature of the surface and the type and degree of contamination. Cleaning and disinfection schedules and methods vary according to the area of the health-care facility, type of surface to be cleaned, and the amount and type of soil present. Disinfectant/detergent formulations registered by EPA are used for environmental surface cleaning, but the actual physical removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used.⁹⁷³ Therefore, cost, safety, product-surface compatibility, and acceptability by housekeepers can be the main criteria for selecting a registered agent. If using a proprietary detergent/disinfectant, the manufacturers' instructions for appropriate use of the product should be followed.⁹⁷⁴ Consult the products' material safety data sheets (MSDS) to determine appropriate precautions to prevent hazardous conditions during product application. Personal protective equipment (PPE) used during cleaning and housekeeping procedures should be appropriate to the task.

Housekeeping surfaces can be divided into two groups – those with minimal hand-contact (e.g., floors, and ceilings) and those with frequent hand-contact ("high touch surfaces"). The methods, thoroughness, and frequency of cleaning and the products used are determined by health-care facility policy.⁶ However, high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection-control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff.

Horizontal surfaces with infrequent hand contact (e.g., window sills and hard-surface flooring) in routine patient-care areas require cleaning on a regular basis, when soiling or spills occur, and when a patient is discharged from the facility.⁶ Regular cleaning of surfaces and decontamination, as needed, is also advocated to protect potentially exposed workers.⁹⁶⁷ Cleaning of walls, blinds, and window curtains is recommended when they are visibly soiled.^{972, 973, 975} Disinfectant fogging is not recommended for general infection control in routine patient-care areas.^{2, 976} Further, paraformaldehyde, which was once used in this application, is no longer registered by EPA for this purpose. Use of paraformaldehyde in these circumstances requires either registration or an exemption issued by EPA under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). Infection control, industrial hygienists, and environmental services supervisors should assess the cleaning procedures, chemicals used, and the safety issues to determine if a temporary relocation of the patient is needed when cleaning in the room.

Extraordinary cleaning and decontamination of floors in health-care settings is unwarranted. Studies have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning and has minimal or no impact on the occurrence of health-care associated infections.^{947, 948, 977–980} Additionally, newly cleaned floors become rapidly recontaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.^{971, 975, 981} Nevertheless, healthcare institutions or contracted cleaning companies may choose to use an EPA-registered detergent/disinfectant for cleaning low-touch surfaces (e.g., floors) in patient-care areas because of the difficulty that personnel may have in determining if a spill contains blood or body fluids (requiring a detergent/disinfectant for clean-up) or when a multi-drug resistant organism is likely to be in the environment. Methods for cleaning non-porous floors include wet mopping and wet vacuuming, dry dusting with electrostatic materials, and spray buffing.^{973, 982–984} Methods that produce minimal mists and aerosols or dispersion of dust in patient-care areas are preferred.^{9, 20, 109, 272}

Part of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools. Bucket solutions become contaminated almost immediately during cleaning, and continued use of the solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned.^{971, 981, 985} Cleaning solutions should be replaced frequently. A variety of "bucket" methods have been devised to address the frequency with which cleaning solutions are replaced.^{986, 987}Another source of contamination in the cleaning process is the cleaning cloth or mop head, especially if left soaking in dirty cleaning solutions.^{971, 988–990} Laundering of cloths and mop heads after use and allowing them to dry before re-use can help to minimize the degree of contamination.⁹⁹⁰ A simplified approach to cleaning involves replacing soiled cloths and mop heads with clean items each time a bucket of detergent/disinfectant is emptied and replaced with fresh, clean solution (B. Stover, Kosair Children's Hospital, 2000). Disposable cleaning cloths and mop heads are an alternative option, if costs permit.

Another reservoir for microorganisms in the cleaning process may be dilute solutions of the detergents or disinfectants, especially if the working solution is prepared in a dirty container, stored for long periods of time, or prepared incorrectly.⁵⁴⁷Gram-negative bacilli (e.g., Pseudomonas spp. and Serratia marcescens) have been detected in solutions of some disinfectants (e.g., phenolics and quaternary ammonium compounds).^{547, 991} Contemporary EPA registration regulations have helped to minimize this problem by asking manufacturers to provide potency data to support label claims for detergent/disinfectant properties under real- use conditions (e.g., diluting the product with tap water instead of distilled water). Application of contaminated cleaning solutions, particularly from small-quantity aerosol spray bottles or with equipment that might generate aerosols during operation, should be avoided, especially in high-risk patient areas.^{992, 993}Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the degree of bacterial contamination. Containers that dispense liquid as opposed to spray-nozzle dispensers (e.g., quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, "ready-to-use" detergent/disinfectant solution may be used if available.

c. Cleaning Special Care Areas

Guidelines have been published regarding cleaning strategies for isolation areas and operating rooms.^{6, 7} The basic strategies for areas housing immunosuppressed patients include

When preparing the cleaning cloths for wet-dusting, freshly prepared solutions of detergents or disinfectants should be used rather than cloths that have soaked in such solutions for long periods of time. Dispersal of microorganisms in the air from dust or aerosols is more problematic in these settings than elsewhere in health-care facilities. Vacuum cleaners can serve as dust disseminators if they are not operating properly.⁹⁹⁴ Doors to immunosuppressed patients' rooms should be closed when nearby areas are being vacuumed.⁹ Bacterial and fungal contamination of filters in cleaning equipment is inevitable, and these filters should be cleaned regularly or replaced as per equipment manufacturer instructions.

Mats with tacky surfaces placed in operating rooms and other patient-care areas only slightly minimize the overall degree of contamination of floors and have little impact on the incidence rate of health-care– associated infection in general.^{351, 971, 983}An exception, however, is the use of tacky mats inside the entry ways of cordoned-off construction areas inside the health-care facility; these mats help to minimize the intrusion of dust into patient-care areas.

Special precautions for cleaning incubators, mattresses, and other nursery surfaces have been recommended to address reports of hyperbilirubinemia in newborns linked to inadequately diluted solutions of phenolics and poor ventilation.^995–997These medical conditions have not, however, been associated with the use of properly prepared solutions of phenolics. Non-porous housekeeping surfaces in neonatal units can be disinfected with properly diluted or pre-mixed phenolics, followed by rinsing with clean water.⁹⁹⁷ However, phenolics are not recommended for cleaning infant bassinets and incubators during the stay of the infant. Infants who remain in the nursery for an extended period should be moved periodically to freshly cleaned and disinfected bassinets and incubators.⁹⁹⁷ If phenolics are used for cleaning bassinets and incubators after they have been vacated, the surfaces should be rinsed thoroughly with water and dried before either piece of equipment is reused. Cleaning and disinfecting protocols should allow for the full contact time specified for the product used. Bassinet mattresses should be replaced, however, if the mattress cover surface is broken.⁹⁹⁷

3. Cleaning Strategies for Spills of Blood and Body Substances

Neither HBV, HCV, nor HIV has ever been transmitted from a housekeeping surface (i.e., floors, walls, or countertops). Nonetheless, prompt removal and surface disinfection of an area contaminated by either blood or body substances are sound infection-control practices and OSHA requirements.⁹⁶⁷

Studies have demonstrated that HIV is inactivated rapidly after being exposed to commonly used chemical germicides at concentrations that are much lower than those used in practice.^998–1003 HBV is readily inactivated with a variety of germicides, including quaternary ammonium compounds.¹⁰⁰⁴ Embalming fluids (e.g., formaldehyde) are also capable of completely inactivating HIV and HBV.^{1005, 1006} OSHA has revised its regulation for disinfecting spills of blood or other potentially infectious material to include proprietary products whose label includes inactivation claims for HBV and HIV, provided that such surfaces have not become contaminated with agent(s) or volumes of or concentrations of agent(s) for which a higher level of disinfection is recommended.¹⁰⁰⁷ These registered products are listed in EPA's List D – Registered Antimicrobials Effective Against Hepatitis B Virus and Human HIV-1, which may include products tested against duck hepatitis B virus (DHBV) as a surrogate for HBV.^{1008, 1009} Additional lists of interest include EPA's List C –Registered Antimicrobials Effective Against Human HIV-1 and EPA's List E – Registered Antimicrobials Effective Against Mycobacterium spp., Hepatitis B Virus, and Human HIV-1.

Sodium hypochlorite solutions are inexpensive and effective broad-spectrum germicidal solutions.^{1010, 1011} Generic sources of sodium hypochlorite include household chlorine bleach or reagent grade chemical. Concentrations of sodium hypochlorite solutions with a range of 5,000–6,150 ppm (1:10 v/v dilution of household bleaches marketed in the United States) to 500–615 ppm (1:100 v/v dilution) free chlorine are effective depending on the amount of organic material (e.g., blood, mucus, and urine) present on the surface to be cleaned and disinfected.^{1010, 1011} EPA-registered chemical germicides may be more compatible with certain materials that could be corroded by repeated exposure to sodium hypochlorite, especially the 1:10 dilution. Appropriate personal protective equipment (e.g., gloves and goggles) should be worn when preparing and using hypochlorite solutions or other chemical germicides.⁹⁶⁷

Despite laboratory evidence demonstrating adequate potency against bloodborne pathogens (e.g., HIV and HBV), many chlorine bleach products available in grocery and chemical-supply stores are not registered by the EPA for use as surface disinfectants. Use of these chlorine products as surface disinfectants is considered by the EPA to be an "unregistered use." EPA encourages the use of registered products because the agency reviews them for safety and performance when the product is used according to label instructions. When unregistered products are used for surface disinfection, users do so at their own risk.

Strategies for decontaminating spills of blood and other body fluids differ based on the setting in which they occur and the volume of the spill.¹⁰¹⁰ In patient-care areas, workers can manage small spills with cleaning and then disinfecting using an intermediate-level germicide or an EPA-registered germicide from the EPA List D or E.^{967, 1007} For spills containing large amounts of blood or other body substances, workers should first remove visible organic matter with absorbent material (e.g., disposable paper towels discarded into leak-proof, properly labeled containment) and then clean and decontaminate the area.^{1002, 1003, 1012} If the surface is nonporous and a generic form of a sodium hypochlorite solution is used (e.g., household bleach), a 1:100 dilution is appropriate for decontamination assuming that

A recent study demonstrated that even strong chlorine solutions (i.e., 1:10 dilution of chlorine bleach) may fail to totally inactivate high titers of virus in large quantities of blood, but in the absence of blood these disinfectants can achieve complete viral inactivation.¹⁰¹¹ This evidence supports the need to remove most organic matter from a large spill before final disinfection of the surface. Additionally, EPA-registered proprietary disinfectant label claims are based on use on a pre-cleaned surface.^{951, 954}

Managing spills of blood, body fluids, or other infectious materials in clinical, public health, and research laboratories requires more stringent measures because of

The use of an intermediate-level germicide for routine decontamination in the laboratory is prudent.⁹⁵⁴ Recommended practices for managing large spills of concentrated infectious agents in the laboratory include

A suggested technique when flooding the spill with germicide is to lay absorbent material down on the spill and apply sufficient germicide to thoroughly wet both the spill and the absorbent material.¹⁰¹³ If using a solution of household chlorine bleach, a 1:10 dilution is recommended for this purpose. EPA-registered germicides should be used according to the manufacturers' instructions for use dilution and contact time. Gloves should be worn during the cleaning and decontamination procedures in both clinical and laboratory settings. PPE in such a situation may include the use of respiratory protection (e.g., an N95 respirator) if clean-up procedures are expected to generate infectious aerosols. Protocols for cleaning spills should be developed and made available on record as part of good laboratory practice.¹⁰¹³Workers in laboratories and in patient-care areas of the facility should receive periodic training in environmental-surface infection-control strategies and procedures as part of an overall infection-control and safety curriculum.

4. Carpeting and Cloth Furnishings

a. Carpeting

Carpeting has been used for more than 30 years in both public and patient-care areas of health-care facilities. Advantages of carpeting in patient-care areas include

Compared to hard-surface flooring, however, carpeting is harder to keep clean, especially after spills of blood and body substances. It is also harder to push equipment with wheels (e.g., wheelchairs, carts, and gurneys) on carpeting.

Several studies have documented the presence of diverse microbial populations, primarily bacteria and fungi, in carpeting;^{111, 1017–1024} the variety and number of microorganisms tend to stabilize over time. New carpeting quickly becomes colonized, with bacterial growth plateauing after about 4 weeks.¹⁰¹⁹ Vacuuming and cleaning the carpeting can temporarily reduce the numbers of bacteria, but these populations soon rebound and return to pre-cleaning levels.^{1019, 1020, 1023} Bacterial contamination tends to increase with higher levels of activity.^{1018–1020, 1025} Soiled carpeting that is or remains damp or wet provides an ideal setting for the proliferation and persistence of gram-negative bacteria and fungi.¹⁰²⁶ Carpeting that remains damp should be removed, ideally within 72 hours.

Despite the evidence of bacterial growth and persistence in carpeting, only limited epidemiologic evidence demonstrates that carpets influence health-care associated infection rates in areas housing immunocompetent patients.^{1023, 1025, 1027} This guideline, therefore, includes no recommendations against the use of carpeting in these areas. Nonetheless, avoiding the use of carpeting is prudent in areas where spills are likely to occur (e.g., laboratories, areas around sinks, and janitor closets) and where patients may be at greater risk of infection from airborne environmental pathogens (e.g., HSCT units, burn units, ICUs, and ORs).^{111, 1028} An outbreak of aspergillosis in an HSCT unit was recently attributed to carpet contamination and a particular method of carpet cleaning.¹¹¹ A window in the unit had been opened repeatedly during the time of a nearby building fire, which allowed fungal spore intrusion into the unit. After the window was sealed, the carpeting was cleaned using a "bonnet buffing" machine, which dispersed Aspergillus spores into the air.¹¹¹ Wet vacuuming was instituted, replacing the dry cleaning method used previously; no additional cases of invasive aspergillosis were identified.

The care setting and the method of carpet cleaning are important factors to consider when attempting to minimize or prevent production of aerosols and dispersal of carpet microorganisms into the air.^{94, 111} Both vacuuming and shampooing or wet cleaning with equipment can disperse microorganisms to the air.^{111, 994} Vacuum cleaners should be maintained to minimize dust dispersal in general, and be equipped with HEPA filters, especially for use in high-risk patient-care areas.^{9, 94, 986} Some formulations of carpet-cleaning chemicals, if applied or used improperly, can be dispersed into the air as a fine dust capable of causing respiratory irritation in patients and staff.¹⁰²⁹ Cleaning equipment, especially those that engage in wet cleaning and extraction, can become contaminated with waterborne organisms (e.g., Pseudomonas aeruginosa) and serve as a reservoir for these organisms if this equipment is not properly maintained. Substantial numbers of bacteria can then be transferred to carpeting during the cleaning process.¹⁰³⁰ Therefore, keeping the carpet cleaning equipment in good repair and allowing such equipment to dry between uses is prudent.

Carpet cleaning should be performed on a regular basis determined by internal policy. Although spills of blood and body substances on non-porous surfaces require prompt spot cleaning using standard cleaning procedures and application of chemical germicides,⁹⁶⁷ similar decontamination approaches to blood and body substance spills on carpeting can be problematic from a regulatory perspective.¹⁰³¹ Most, if not all, modern carpet brands suitable for public facilities can tolerate the activity of a variety of liquid chemical germicides. However, according to OSHA, carpeting contaminated with blood or other potentially infectious materials cannot be fully decontaminated.¹⁰³² Therefore, facilities electing to use carpeting for high-activity patient-care areas may choose carpet tiles in areas at high risk for spills.^{967, 1032} In the event of contamination with blood or other body substances, carpet tiles can be removed, discarded, and replaced. OSHA also acknowledges that only minimal direct skin contact occurs with carpeting, and therefore, employers are expected to make reasonable efforts to clean and sanitize carpeting using carpet detergent/cleaner products.¹⁰³²

Over the last few years, some carpet manufacturers have treated their products with fungicidal and/or bactericidal chemicals. Although these chemicals may help to reduce the overall numbers of bacteria or fungi present in carpet, their use does not preclude the routine care and maintenance of the carpeting. Limited evidence suggests that chemically treated carpet may have helped to keep health-care– associated aspergillosis rates low in one HSCT unit, ¹¹¹ but overall, treated carpeting has not been shown to prevent the incidence of health-care associated infections in care areas for immunocompetent patients.

b. Cloth Furnishings

Upholstered furniture and furnishings are becoming increasingly common in patient-care areas. These furnishings range from simple cloth chairs in patients' rooms to a complete decorating scheme that gives the interior of the facility more the look of an elegant hotel.¹⁰³³ Even though pathogenic microorganisms have been isolated from the surfaces of cloth chairs, no epidemiologic evidence suggests that general patient-care areas with cloth furniture pose increased risks of health-care associated infection compared with areas that contain hard-surfaced furniture.^{1034, 1035} Allergens (e.g., dog and cat dander) have been detected in or on cloth furniture in clinics and elsewhere in hospitals in concentrations higher than those found on bed linens.^{1034, 1035} These allergens presumably are transferred from the clothing of visitors. Researchers have therefore suggested that cloth chairs should be vacuumed regularly to keep the dust and allergen levels to a minimum. This recommendation, however, has generated concerns that aerosols created from vacuuming could place immunocompromised patients or patients with preexisting lung disease (e.g., asthma) at risk for development of health-care associated, environmental airborne disease.^{9, 20, 109, 988} Recovering worn, upholstered furniture (especially the seat cushion) with covers that are easily cleaned (e.g., vinyl), or replacing the item is prudent; minimizing the use of upholstered furniture and furnishings in any patient-care areas where immunosuppressed patients are located (e.g., HSCT units) reduces the likelihood of disease.⁹

5. Flowers and Plants in Patient-Care Areas

Fresh flowers, dried flowers, and potted plants are common items in health-care facilities. In 1974, clinicians isolated an Erwinia sp. post mortem from a neonate diagnosed with fulminant septicemia, meningitis, and respiratory distress syndrome.¹⁰³⁸ Because Erwinia spp. are plant pathogens, plants brought into the delivery room were suspected to be the source of the bacteria, although the case report did not definitively establish a direct link. Several subsequent studies evaluated the numbers and diversity of microorganisms in the vase water of cut flowers. These studies revealed that high concentrations of bacteria, ranging from 10⁴ –10¹⁰ CFU/mL, were often present, especially if the water was changed infrequently.^{515, 702, 1039} The major group of microorganisms in flower vase water was gram-negative bacteria, with Pseudomonas aeruginosa the most frequently isolated organism.^{515, 702, 1039, 1040} P. aeruginosa was also the primary organism directly isolated from chrysanthemums and other potted plants.^{1041, 1042} However, flowers in hospitals were not significantly more contaminated with bacteria compared with flowers in restaurants or in the home.⁷⁰² Additionally, no differences in the diversity and degree of antibiotic resistance of bacteria have been observed in samples isolated from hospital flowers versus those obtained from flowers elsewhere.⁷⁰²

Despite the diversity and large numbers of bacteria associated with flower-vase water and potted plants, minimal or no evidence indicates that the presence of plants in immunocompetent patient-care areas poses an increased risk of health-care associated infection.⁵¹⁵ In one study involving a limited number of surgical patients, no correlation was observed between bacterial isolates from flowers in the area and the incidence and etiology of postoperative infections among the patients.¹⁰⁴⁰ Similar conclusions were reached in a study that examined the bacteria found in potted plants.¹⁰⁴² Nonetheless, some precautions for general patient-care settings should be implemented, including

Some researchers have examined the possibility of adding a chemical germicide to vase water to control bacterial populations. Certain chemicals (e.g., hydrogen peroxide and chlorhexidine) are well tolerated by plants.^{1040, 1043, 1044} Use of these chemicals, however, was not evaluated in studies to assess impact on health-care associated infection rates. Modern florists now have a variety of products available to add to vase water to extend the life of cut flowers and to minimize bacterial clouding of the water.

Flowers (fresh and dried) and ornamental plants, however, may serve as a reservoir of Aspergillus spp., and dispersal of conidiospores into the air from this source can occur.¹⁰⁹ Health-care associated outbreaks of invasive aspergillosis reinforce the importance of maintaining an environment as free of Aspergillus spp. spores as possible for patients with severe, prolonged neutropenia. Potted plants, fresh-cut flowers, and dried flower arrangements may provide a reservoir for these fungi as well as other fungal species (e.g., Fusarium spp.).^{109, 1045, 1046} Researchers in one study of bacteria and flowers suggested that flowers and vase water should be avoided in areas providing care to medically at-risk patients (e.g., oncology patients and transplant patients), although this study did not attempt to correlate the observations of bacterial populations in the vase water with the incidence of health-care associated infections.⁵¹⁵ Another study using molecular epidemiology techniques demonstrated identical Aspergillus terreus types among environmental and clinical specimens isolated from infected patients with hematological malignancies.¹⁰⁴⁶ Therefore, attempts should be made to exclude flowers and plants from areas where immunosuppressed patients are be located (e.g., HSCT units).^{9, 1046}

6. Pest Control

Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector.^1047–1049 Arthropods recovered from health-care facilities have been shown to carry a wide variety of pathogenic microorganisms.^1050–1056 Studies have suggested that the diversity of microorganisms associated with insects reflects the microbial populations present in the indoor health-care environment; some pathogens encountered in insects from hospitals were either absent from or present to a lesser degree in insects trapped from residential settings.^1057–1060 Some of the microbial populations associated with insects in hospitals have demonstrated resistance to antibiotics.^{1048, 1059, 1061–1063}

Insect habitats are characterized by warmth, moisture, and availability of food.¹⁰⁶⁴ Insects forage in and feed on substrates, including but not limited to food scraps from kitchens/cafeteria, foods in vending machines, discharges on dressings either in use or discarded, other forms of human detritis, medical wastes, human wastes, and routine solid waste.^1057–1061Cockroaches, in particular, have been known to feed on fixed sputum smears in laboratories.^{1065, 1066} Both cockroaches and ants are frequently found in the laundry, central sterile supply departments, and anywhere in the facility where water or moisture is present (e.g., sink traps, drains and janitor closets). Ants will often find their way into sterile packs of items as they forage in a warm, moist environment.¹⁰⁵⁷ Cockroaches and other insects frequent loading docks and other areas with direct access to the outdoors.

Although insects carry a wide variety of pathogenic microorganisms on their surfaces and in their gut, the direct association of insects with disease transmission (apart from vector transmission) is limited, especially in health-care settings; the presence of insects in itself likely does not contribute substantially to health-care associated disease transmission in developed countries. However, outbreaks of infection attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in standard infection-control practices.¹⁰⁶³ Studies have been conducted to examine the role of houseflies as possible vectors for shigellosis and other forms of diarrheal disease in non-health–care settings.^{1046, 1067}When control measures aimed at reducing the fly population density were implemented, a concomitant reduction in the incidence of diarrheal infections, carriage of Shigella organisms, and mortality caused by diarrhea among infants and young children was observed.

Myiasis is defined as a parasitosis in which the larvae of any of a variety of flies use living or necrotic tissue or body substances of the host as a nutritional source.¹⁰⁶⁸ Larvae from health-care acquired myiasis have been observed in nares, wounds, eyes, ears, sinuses, and the external urogenital structures.^1069–1071 Patients with this rare condition are typically older adults with underlying medical conditions (e.g., diabetes, chronic wounds, and alcoholism) who have a decreased capacity to ward off the flies. Persons with underlying conditions who live or travel to tropical regions of the world are especially at risk.^{1070, 1071} Cases occur in the summer and early fall months in temperate climates when flies are most active.¹⁰⁷¹ An environmental assessment and review of the patient's history are necessary to verify that the source of the myiasis is health-care acquired and to identify corrective measures.^{1069, 1072} Simple prevention measures (e.g., installing screens on windows) are important in reducing the incidence of myiasis.¹⁰⁷²

From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities.^{1073, 1074} Modern approaches to institutional pest management usually focus on

Sealing windows in modern health-care facilities helps to minimize insect intrusion. When windows need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the outside can help with pest control. Insects should be kept out of all areas of the health-care facility, especially ORs and any area where immunosuppressed patients are located. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide information on possible adverse reactions of patients and staff to pesticides and suggest alternative methods for pest control, as needed.

7. Special Pathogen Concerns

a. Antibiotic-Resistant Gram-Positive Cocci

Vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and S. aureus with intermediate levels of resistance to glycopeptide antibiotics (vancomycin intermediate resistant S. aureus [VISA] or glycopeptide intermediate resistant S. aureus [GISA]) represent crucial and growing concerns for infection control. Although the term GISA is technically a more accurate description of the strains isolated to date (most of which are classified as having intermediate resistance to both vancomycin and teicoplanin), the term "glycopeptide" may not be recognized by many clinicians. Thus, the label of VISA, which emphasizes a change in minimum inhibitory concentration (MICs) to vancomycin, is similar to that of VRE and is more meaningful to clinicians.¹⁰⁷⁶ According to National Nosocomial Infection Surveillance (NNIS) statistics for infections acquired among ICU patients in the United States in 1999, 52.3% of infections resulting from S. aureus were identified as MRSA infections, and 25.2% of enterococcal infections were attributed to VRE. These figures reflect a 37% and a 43% increase, respectively, since 1994–1998.¹⁰⁷⁷

People represent the primary reservoir of S. aureus. ¹⁰⁷⁸ Although S. aureus has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal.^1079–1082 S. aureuscontamination of surfaces and tanks within burn therapy units, however, may be a major factor in the transmission of infection among burn patients.¹⁰⁸³

Colonized patients are the principal reservoir of VRE, and patients who are immunosuppressed (e.g., transplant patients) or otherwise medically at-risk (e.g., ICU patients, cardio-thoracic surgical patients, patients previously hospitalized for extended periods, and those having received multi-antimicrobial or vancomycin therapy) are at greatest risk for VRE colonization.^1084–1087 The mechanisms by which cross-colonization take place are not well defined, although recent studies have indicated that both MRSA and VRE may be transmitted either

In one survey, hand carriage of VRE in workers in a long-term care facility ranged from 13%–41%.¹⁰⁹⁸ Many of the environmental surfaces found to be contaminated with VRE in outbreak investigations have been those that are touched frequently by the patient or the health-care worker.¹⁰⁹⁹ Such high-touch surfaces include bedrails, doorknobs, bed linens, gowns, overbed tables, blood pressure cuffs, computer table, bedside tables, and various medical equipment.^{22, 1087, 1094, 1095, 1100–1102} Contamination of environmental surfaces with VRE generally occurs in clinical laboratories and areas where colonized patients are present,^{1087, 1092, 1094, 1095, 1103} but the potential for contamination increases when such patients have diarrhea¹⁰⁸⁷ or have multiple body-site colonization.¹¹⁰⁴ Additional factors that can be important in the dispersion of these pathogens to environmental surfaces are misuse of glove techniques by healthcare workers (especially when cleaning fecal contamination from surfaces) and patient, family, and visitor hygiene.

Interest in the importance of environmental reservoirs of VRE increased when laboratory studies demonstrated that enterococci can persist in a viable state on dry environmental surfaces for extended periods of time (7 days to 4 months)^{1099, 1105} and multiple strains can be identified during extensive periods of surveillance.¹¹⁰⁴ VRE can be recovered from inoculated hands of health-care workers (with or without gloves) for up to 60 minutes.²² The presence of either MRSA, VISA, or VRE on environmental surfaces, however, does not mean that patients in the contaminated areas will become colonized. Strict adherence to hand hygiene/handwashing and the proper use of barrier precautions help to minimize the potential for spread of these pathogens. Published recommendations for preventing the spread of vancomycin resistance address isolation measures, including patient cohorting and management of patient-care items.⁵ Direct patient-care items (e.g., blood pressure cuffs) should be disposable whenever possible when used in contact isolation settings for patients with multiply resistant microorganisms.¹¹⁰²

Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control of MRSA, VISA, or VRE transmission. The major focus of a control program for either VRE or MRSA should be the prevention of hand transfer of these organisms. Routine cleaning and disinfection of the housekeeping surfaces (e.g., floors and walls) and patient-care surfaces (e.g., bedrails) should be adequate for inactivation of these organisms. Both MRSA and VRE are susceptible to several EPA-registered low- and intermediate-level disinfectants (e.g., alcohols, sodium hypochlorite, quaternary ammonium compounds, phenolics, and iodophors) at recommended use dilutions for environmental surface disinfection.^{1103, 1106–1109}Additionally, both VRE and vancomycin-sensitive enterococci are equally sensitive to inactivation by chemical germicides,^{1106, 1107, 1109} and similar observations have been made when comparing the germicidal resistance of MRSA to that of either methicillin-sensitive S. aureus (MSSA) or VISA.¹¹¹⁰ The use of stronger solutions of disinfectants for inactivation of either VRE, MRSA, or VISA is not recommended based on the organisms' resistance to antibiotics.^1110–1112 VRE from clinical specimens have exhibited some measure of increased tolerance to heat inactivation in temperature ranges <212°F (<100°C);^{1106, 1113}however, the clinical significance of these observations is unclear because the role of cleaning the surface or item prior to heat treatment was not evaluated. Although routine environmental sampling is not recommended, laboratory surveillance of environmental surfaces during episodes when VRE contamination is suspected can help determine the effectiveness of the cleaning and disinfecting procedures. Environmental culturing should be approved and supervised by the infection-control program in collaboration with the clinical laboratory.^{1084, 1087, 1088, 1092, 1096}

Two cases of wound infections associated with vancomycin-resistant Staphylococcus aureus (VRSA) determined to be resistant by NCCLS standards for sensitivity/resistance testing were identified in Michigan and Pennsylvania in 2002.^{1114, 1115}These represented isolated cases, and neither the family members nor the health-care providers of these case-patients had evidence of colonization or infection with VRSA. Conventional environmental infection-control measures (i.e., cleaning and then disinfecting surfaces using EPA-registered disinfectants with label claims for S. aureus) were used during the environmental investigation of these two cases;^1110–1112 however, studies have yet to evaluate the potential intrinsic resistance of these VRSA strains to surface disinfectants.

Standard procedures during terminal cleaning and disinfection of surfaces, if performed incorrectly, may be inadequate for the elimination of VRE from patient rooms.^{1113, 1116–1118} Given the sensitivity of VRE to hospital disinfectants, current disinfecting protocols should be effective if they are diligently carried out and properly performed. Health-care facilities should be sure that housekeeping staff use correct procedures for cleaning and disinfecting surfaces in VRE-contaminated areas, which include using sufficient amounts of germicide at proper use dilution and allowing adequate contact time.¹¹¹⁸

b. Clostridium difficile

Clostridium difficile is the most frequent etiologic agent for health-care associated diarrhea.^{1119, 1120} In one hospital, 30% of adults who developed health-care associated diarrhea were positive for C. difficile.¹¹²¹ One recent study employing PCR-ribotyping techniques demonstrated that cases of C. difiicile-acquired diarrhea occurring in the hospital included patients whose infections were attributed to endogenous C. difficile strains and patients whose illnesses were considered to be health-care– associated infections.¹¹²² Most patients remain asymptomatic after infection, but the organism continues to be shed in their stools. Risk factors for acquiring C. difficile-associated infection include

Of all the measures that have been used to prevent the spread of C. difficile-associated diarrhea, the most successful has been the restriction of the use of antimicrobial agents.^{1129, 1130}

C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulating when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur.¹¹³¹ The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients.^{1024, 1132–1136} However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients' bathrooms (e.g., light switches) have been implicated as sources of infection.^{1130, 1135, 1136, 1138}

Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure.^{24, 1133, 1139} Standard isolation techniques intended to minimize enteric contamination of patients, health-care–workers' hands, patient-care items, and environmental surfaces have been published.¹¹⁴⁰ Handwashing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another.

The degree to which the environment becomes contaminated with C. difficile spores is proportional to the number of patients with C. difficile-associated diarrhea,^{24, 1132, 1135} although asymptomatic, colonized patients may also serve as a source of contamination. Few studies have examined the use of specific chemical germicides for the inactivation of C. difficile spores, and no well-controlled trials have been conducted to determine efficacy of surface disinfection and its impact on health-care associated diarrhea. Some investigators have evaluated the use of chlorine-containing chemicals (e.g., 1,000 ppm hypochlorite at recommended use-dilution, 5,000 ppm sodium hypochlorite [1:10 v/v dilution], 1:100 v/v dilutions of unbuffered hypochlorite, and phosphate-buffered hypochlorite [1,600 ppm]). One of the studies demonstrated that the number of contaminated environmental sites was reduced by half,¹¹³⁵ whereas another two studies demonstrated declines in health-care associated C. difficile infections in a HSCT unit¹¹⁴¹ and in two geriatric medical units¹¹⁴² during a period of hypochlorite use. The presence of confounding factors, however, was acknowledged in one of these studies.¹¹⁴²

The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using EPA-registered products specific for inactivating C. difficile spores as appropirate. Thus, combined use of appropriate hand hygiene, barrier precautions, and meticulous environmental cleaning, and use of an EPA-registered product that is appropriate for the level of risk, should effectively prevent spread of the organism. [LIST K: EPA's Registered Antimicrobial Products Effective against Clostridium difficile Sporesexternal icon]

c. Respiratory and Enteric Viruses in Pediatric-Care Settings

Although the viruses mentioned in this guideline are not unique to the pediatric-care setting in healthcare facilities, their prevalence in these areas, especially during the winter months, is substantial. Children (particularly neonates) are more likely to develop infection and substantial clinical disease from these agents compared with adults and therefore are more likely to require supportive care during their illness.

Common respiratory viruses in pediatric-care areas include rhinoviruses, respiratory syncytial virus (RSV), adenoviruses, influenza viruses, and parainfluenza viruses. Transmission of these viruses occurs primarily via direct contact with small-particle aerosols or via hand contamination with respiratory secretions that are then transferred to the nose or eyes. Because transmission primarily requires close personal contact, contact precautions are appropriate to interrupt transmission.⁶ Hand contamination can occur from direct contact with secretions or indirectly from touching high-touch environmental surfaces that have become contaminated with virus from large droplets. The indirect transfer of virus from one persion to other via hand contact with frequently-touched fomites was demonstrated in a study using a bacteriophage whose environmental stability approximated that of human viral pathogens (e.g., poliovirus and parvovirus).¹¹⁴⁴ The impact of this mode of transmission with respect to human respiratory- and enteric viruses is dependent on the ability of these agents to survive on environmental surfaces. Infectious RSV has been recovered from skin, porous surfaces, and non-porous surfaces after 30 minutes, 1 hour, and 7 hours, respectively.¹¹⁴⁵ Parainfluenza viruses are known to persist for up to 4 hours on porous surfaces and up to 10 hours on non-porous surfaces.¹¹⁴⁶ Rhinoviruses can persist on porous surfaces and non-porous surfaces for approximately 1 and 3 hours respectively; study participants in a controlled environment became infected with rhinoviruses after first touching a surface with dried secretions and then touching their nasal or conjunctival mucosa.¹¹⁴⁷ Although the efficiency of direct transmission of these viruses from surfaces in uncontrolled settings remains to be defined, these data underscore the basis for maintaining regular protocols for cleaning and disinfecting of high-touch surfaces.

The clinically important enteric viruses encountered in pediatric care settings include enteric adenovirus, astroviruses, caliciviruses, and rotavirus. Group A rotavirus is the most common cause of infectious diarrhea in infants and children. Transmission of this virus is primarily fecal-oral, however, the role of fecally contaminated surfaces and fomites in rotavirus transmission is unclear. During one epidemiologic investigation of enteric disease among children attending day care, rotavirus contamination was detected on 19% of inanimate objects in the center.^{1148, 1149} In an outbreak in a pediatric unit, secondary cases of rotavirus infection clustered in areas where children with rotaviral diarrhea were located.¹¹⁵⁰Astroviruses cause gastroenteritis and diarrhea in newborns and young children and can persist on fecally contaminated surfaces for several months during periods of relatively low humidity.^{1151, 1152} Outbreaks of small round-structured viruses (i.e., caliciviruses [Norwalk virus and Norwalk-like viruses]) can affect both patients and staff, with attack rates of ≥50%.¹¹⁵³Routes of person-to-person transmission include fecal-oral spread and aerosols generated from vomiting.^1154–1156 Fecal contamination of surfaces in care settings can spread large amounts of virus to the environment. Studies that have attempted to use low- and intermediate-level disinfectants to inactivate rotavirus suspended in feces have demonstrated a protective effect of high concentrations of organic matter.^{1157, 1158} Intermediate-level disinfectants (e.g., alcoholic quaternary ammonium compounds, and chlorine solutions) can be effective in inactivating enteric viruses provided that a cleaning step to remove most of the organic matter precedes terminal disinfection.¹¹⁵⁸ These findings underscore the need for proper cleaning and disinfecting procedures where contamination of environmental surfaces with body substances is likely. EPA-registered surface disinfectants with label claims for these viral agents should be used in these settings. Using disposable, protective barrier coverings may help to minimize the degree of surface contamination.⁹³⁶

d. Severe Acute Respiratory Syndrome (SARS) Virus

In November 2002 an atypical pneumonia of unknown etiology emerged in Asia and subsequently developed into an international outbreak of respiratory illness among persons in 29 countries during the first six months of 2003. "Severe acute respiratory syndrome" (SARS) is a viral upper respiratory infection associated with a newly described coronavirus (SARS-associated Co-V [SARS-CoV]). SARS-CoV is an enveloped RNA virus. It is present in high titers in respiratory secretions, stool, and blood of infected persons. The modes of transmission determined from epidemiologic investigations were primarily forms of direct contact (i.e., large droplet aerosolization and person-to-person contact). Respiratory secretions were presumed to be the major source of virus in these situations; airborne transmission of virus has not been completely ruled out. Little is known about the impact of fecal-oral transmission and SARS.

The epidemiology of SARS-CoV infection is not completely understood, and therefore recommended infection control and prevention measures to contain the spread of SARS will evolve as new information becomes available.¹¹⁵⁹ At present there is no indication that established strategies for cleaning (i.e., to remove the majority of bioburden) and disinfecting equipment and environmental surfaces need to be changed for the environmental infection control of SARS. In-patient rooms housing SARS patients should be cleaned and disinfected at least daily and at the time of patient transfer or discharge. More frequent cleaning and disinfection may be indicated for high-touch surfaces and following aerosol-producing procedures (e.g., intubation, bronchoscopy, and sputum production). While there are presently no disinfectant products registered by EPA specifically for inactivation of SARS-CoV, EPA-registered hospital disinfectants that are equivalent to low- and intermediate-level germicides may be used on pre-cleaned, hard, non-porous surfaces in accordance with manufacturer's instructions for environmental surface disinfection. Monitoring adherence to guidelines established for cleaning and disinfection is an important component of environmental infection control to contain the spread of SARS.

e. Creutzfeldt-Jakob Disease (CJD) in Patient-Care Areas

Creutzfeldt-Jakob disease (CJD) is a rare, invariably fatal, transmissible spongiform encephalopathy (TSE) that occurs worldwide with an average annual incidence of 1 case per million population.^1160–1162 CJD is one of several TSEs affecting humans; other diseases in this group include kuru, fatal familial insomnia, and Gerstmann-Sträussler-Scheinker syndrome. A TSE that affects a younger population (compared to the age range of CJD cases) has been described primarily in the United Kingdom since 1996.¹¹⁶³ This variant form of CJD (vCJD) is clinically and neuropathologically distinguishable from classic CJD; epidemiologic and laboratory evidence suggests a causal association for bovine spongiform encephalopathy (BSE [Mad Cow disease]) and vCJD.^1163–1166

Although about 90% of CJD cases occur sporadically, a limited number of cases are the result of a direct exposure to prion-containing material (usually central nervous system tissue or pituitary hormones) acquired as a result of health care (iatrogenic cases). These cases have been linked to

In the cases involving instruments and depth electrodes, conventional cleaning and terminal reprocessing methods of the day failed to fully inactivate the contaminating prions and are considered inadequate by today's standards.

Prion inactivation studies involving whole tissues and tissue homogenates have been conducted to determine the parameters of physical and chemical methods of sterilization or disinfection necessary for complete inactivation;^{1170, 1186–1191}however, the application of these findings to environmental infection control in health-care settings is problematic. No studies have evaluated the effectiveness of medical instrument reprocessing in inactivating prions. Despite a consensus that abnormal prions display some extreme measure of resistance to inactivation by either physical or chemical methods, scientists disagree about the exact conditions needed for sterilization. Inactivation studies utilizing whole tissues present extraordinary challenges to any sterilizing method.¹¹⁹² Additionally, the experimental designs of these studies preclude the evaluation of surface cleaning as a part of the total approach to pathogen inactivation.^{951, 1192}

Some researchers have recommended the use of either a 1:2 v/v dilution of sodium hypochorite (approximately 20,000 ppm), full-strength sodium hypochlorite (50,000–60,000 ppm), or 1–2 N sodium hydroxide (NaOH) for the inactivation of prions on certain surfaces (e.g., those found in the pathology laboratory).^{1170, 1188} Although these chemicals may be appropriate for the decontamination of laboratory, operating-room, or autopsy-room surfaces that come into contact with central nervous system tissue from a known or suspected patient, this approach is not indicated for routine or terminal cleaning of a room previously occupied by a CJD patient. Both chemicals pose hazards for the healthcare worker doing the decontamination. NaOH is caustic and should not make contact with the skin. Sodium hypochlorite solutions (i.e., chlorine bleach) can corrode metals (e.g., aluminum). MSDS information should be consulted when attempting to work with concentrated solutions of either chemical. Currently, no EPA-registered products have label claims for prion inactivation; therefore, this guidance is based on the best available evidence from the scientific literature.

Environmental infection-control strategies must based on the principles of the "chain of infection," regardless of the disease of concern.¹³ Although CJD is transmissible, it is not highly contagious. All iatrogenic cases of CJD have been linked to a direct exposure to prion-contaminated central nervous system tissue or pituitary hormones. The six documented iatrogenic cases associated with instruments and devices involved neurosurgical instruments and devices that introduced residual contamination directly to the recipient's brain. No evidence suggests that vCJD has been transmitted iatrogenically or that either CJD or vCJD has been transmitted from environmental surfaces (e.g., housekeeping surfaces). Therefore, routine procedures are adequate for terminal cleaning and disinfection of a CJD patient's room. Additionally, in epidemiologic studies involving highly transfused patients, blood was not identified as a source for prion transmission.^1193–1198 Routine procedures for containing, decontaminating, and disinfecting surfaces with blood spills should be adequate for proper infection control in these situations.^{951, 1199}

Guidance for environmental infection control in ORs and autopsy areas has been published.^{1197, 1199} Hospitals should develop risk-assessment procedures to identify patients with known or suspected CJD in efforts to implement prion-specific infection-control measures for the OR and for instrument reprocessing.¹²⁰⁰ This assessment also should be conducted for older patients undergoing non-lesionous neurosurgery when such procedures are being done for diagnosis. Disposable, impermeable coverings should be used during these autopsies and neurosurgeries to minimize surface contamination. Surfaces that have become contaminated with central nervous system tissue or cerebral spinal fluid should be cleaned and decontaminated by

The optimum duration of contact exposure in these instances is unclear. Some researchers recommend a 1-hour contact time on the basis of tissue-inactivation studies,^{1197, 1198, 1201} whereas other reviewers of the subject draw no conclusions from this research.¹¹⁹⁹ Factors to consider before cleaning a potentially contaminated surface are

The agent associated with CJD is a prion, which is an abnormal isoform of a normal protein constituent of the central nervous system.^1167–1169 The mechanism by which the normal form of the protein is converted to the abnormal, disease-causing prion is unknown. The tertiary conformation of the abnormal prion protein appears to confer a heightened degree of resistance to conventional methods of sterilization and disinfection.^{1170, 1171}