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UNC-Chapel Hill ENVR 890 - Disinfection and the prevention of infectious disease

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243Although several studies have established the effica-cy of disinfectants against microorganisms and theinterruption of transmission through surface disin-fection, controlled studies to establish the publichealth benefits of surface disinfection are difficultto conduct. “The intrinsic role of surfaces in dis-semination of a nosocomial pathogen … is some-times difficult to evaluate because of its intimateinteraction with other mechanisms of transmission,such as the direct patient-to-patient contact orthrough the hands of hospital personnel.”1Previously, infection control authorities believed thatthe environment played little or no role in the trans-mission of infectious disease. “By 1970, the Centersfor Disease Control [and Prevention] (CDC) and theAmerican Hospital Association were advocating thathospitals discontinue routine environmental cultur-ing, since rates of nosocomial infection had not beenrelated to levels of general microbial contaminationof air or environmental surfaces.…”2Until 1987,hospital isolation precautions were focused on thediagnosis of infected patients.3Subsequently, bodysubstance isolation was proposed as a means toprevent nosocomial infections. This method failedto address contact transmission from dry skin orenvironmental sources.Recently the role of the inanimate environment indisease transmission has been reconsidered. TheCDC stated that contact transmission—direct frombody surface to body surface or indirect transmis-sion via contaminated inanimate objects—is one ofthe main routes of microorganism transmission.3,4A survey of 369 infection control professionalsrevealed that 63% strongly or somewhat agreedthat the inanimate environment plays a role innosocomial transmission of organisms.4This diver-gence of opinion among infection control profes-sionals illustrates the need for evidence regardingthe role of environmental surface disinfection ininfection control.The purpose of this review was to survey literature toestablish whether the following occur: (1) disinfec-tants demonstrate efficacy against pathogens in lab-oratory and field settings; (2) environmental disinfec-tion interrupts the transmission of microbialDisinfection and the prevention ofinfectious diseaseAnn Cozad, BSRhonda D. Jones, BS, RM(AAM)Columbia City, IndianaThis article reviews published literature to determine the role environmental disinfection plays in the prevention of infec-tious disease. Health benefits from disinfection have been established through studies of applications such as criticalinstrument sterilization, water treatment, and food production. Guidelines by the Centers for Disease Control andPrevention, the Food and Drug Administration, the Environmental Protection Agency, and the International ScientificForum on Home Hygiene acknowledge the incidence of disease due to insufficient disinfection and that one of the meansfor prevention of disease is through proper disinfection. Studies conducted in day care centers, long-term care facilities,and laboratories show that disinfectants containing a variety of active ingredients demonstrated efficacy against a broadspectrum of pathogens and interrupted microbial transmission and that the use of disinfectants results in public healthbenefits. (Am J Infect Control 2003;31:243-54.)From Scientific & Regulatory Consultants, Inc.Reprint requests: Rhonda D. Jones, BS, RM(AAM), Scientific &Regulatory Consultants, Inc, PO Box 1014, Columbia City, IN 46725.Copyright © 2003 by the Association for Professionals in InfectionControl and Epidemiology, Inc.1096-6553/2003/$30.00 + 0doi:10.1067/mic.2003.49state of the science244Vol. 31 No. 4Cozad and Jonespathogens; and (3) through the reduction and inter-ruption of transmission of pathogens, environmentalsurface disinfection creates a public health benefit.A search of numerous electronic databases, includ-ing PubMed, PubSCIENCE, MEDLINE, and AGRICO-LA, was conducted. Search terms included but werenot limited to “biocides,” “hygiene,” “germicide,”“disinfection,” “sanitization,” “hard surface,” “alcohol,”“iodine,” “povidone-iodine,” “quaternary ammoni-um compounds,” “phenolic,” “glutaraldehyde,” “per-oxide,” “peracetic acid,” “antimicrobial,” “virucidal,”and “germicidal.” The electronic search was limitedto literature from the mid-1960s through the begin-ning of 2001 because of the construct of the data-bases used in this study. Through review of the liter-ature, publications preceding the mid-1960s weresecondarily collected and reviewed. For the purpos-es of our review, benefit was defined as a reductionin disease, reduction in transmission of disease-causing organisms, or reduction of disease-causingorganisms as measured in an in-use study. Literaturedescribing benefits derived from topical products ortopical test methods were excluded from the review.More than 400 pieces of literature were collectedthrough the search.PATHOGENIC ORGANISMS PERSIST INTHE ENVIRONMENTThe risk of infection from pathogenic microorganismson environmental surfaces derives not only from theirpresence but also from their ability to survive onmany surfaces. The persistence of pathogenicmicroorganisms has been established in studies oftheir survival on surfaces in institutional, commercial,and domestic settings.5-47Mbithi et al48showed thathepatitis A virus (HAV) can survive and be transferred4 hours after drying, while Noskin et al49determinedthat vancomycin resistant enterococci (VRE),Enterococcus faecium, and E faecalis could be recov-ered several days after inoculation on hospital sur-faces. Escherichia coli, Klebsiella aerogenes, K pneumo-niae, Pseudomonas aeruginosa, Salmonella species, Sabony, and Staphylococcus aureus were recovered 4hours after inoculation, whereas Salmonella and Saureus were recovered 24 hours after inoculation ontosimulated kitchen surfaces by Scott and Bloomfield.47Ward et al50reported rotavirus survival of up to 6 daysin distilled water, and a review by Doebbling51statedthat respiratory syncytial virus could survive on inan-imate objects for prolonged periods. Separate studiesby Boyce et al52and by Weber and Rutala53foundextensive environmental contamination in rooms ofpatients infected by methicillin-resistant S aureus(MRSA) and Enterococcus. An endemic Clostridium dif-ficile strain contaminated the patient environmentand was transmitted for 25 months in a hospital.1Thisoutbreak was linked to an


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UNC-Chapel Hill ENVR 890 - Disinfection and the prevention of infectious disease

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