PROFESSOR EMERITUS OF MICROBIOLOGY, FACULTY OF MEDICINE UNIVERSITY OF OTTAWA, OTTAWA, ONTARIO, CANADA

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1 THE ESSENTIAL ROLE OF ENVIRONMENTAL SURFACE DISINFECTANTS IN PERSONAL SERVICES SETTINGS: OPTIMIZING THE SELECTION AND USE OF AVAILABLE FORMULATIONS SYED A. SATTAR, MSc, Dip Bact, MS, PhD, RM (CCM), FAAM PROFESSOR EMERITUS OF MICROBIOLOGY, FACULTY OF MEDICINE UNIVERSITY OF OTTAWA, OTTAWA, ONTARIO, CANADA SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

2 ACKNOWLEDGEMENTS BARB McGILL, CIPHI CONFERENCE PLANNING COMMITTEE CHRISTIAN LAPENSEE, PUBLIC HEALTH INSPECTOR, OTTAWA MY STAFF & STUDENTS MY FAMILY SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

3 DISCLOSURE FUNDING FROM PUBLIC & PRIVATE SOURCES ADVISOR/CONSULTANT TO SEVERAL COMPANIES, GOVERNMENTS & INTERNATIONAL AGENCIES MEMBER, BOARD OF DIRECTORS, VIROX TECH. ANY MENTION OF PRODUCTS & SERVICES IS FOR INFORMATION PURPOSES ONLY & DOES NOT CONSTITUTE AN ENDORSEMENT BY ME OR MY UNIVERSITY. SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

4 WHAT IS THE ISSUE? LIFE-STYLE/DEMOGRAPHIC CHANGES & GREATER EXPOSURE & VULNERABILITY TO PATHOGENS FASTER TRAVEL, LONGER LIFE, IMMUNOSUPPRESSION, DRUG RESISTANCE NEW PATHOGENS (SARS) & NEW ROLES FOR PATHOGENS (HPV & CANCER) WELCOME REVIVAL OF INTEREST IN DISINFECTANTS AS GENERIC MEANS TO INTERRUPT ENVIRONMENTAL SPREAD OF INFECTIONS CORRESPONDING INCREASE IN CONCERNS OVER DISINFECTANT USAGE HUMAN & ENVIRONMENTAL SAFETY OF CHEMICALS, TESTING & LABEL CLAIMS PHENOMENAL INCREASE IN NUMBERS & TYPES OF PERSONAL SERVICES A CRITICAL LOOK AT CURRENT SITUATION SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

5 BASIC TERMS GERMICIDE (COLLOQUIAL) & BIOCIDE (TOO BROAD) ARE UNSUITABLE TERMS MICROBICIDE: A SELF-EXPLANATORY TERM MEANING ANY CHEMICAL OR PHYSICAL AGENT THAT CAN KILL MICROBES; MAIN CATEGORIES ARE: ANTISEPTICS: APPLIED TO LIVING SKIN OR MUCOUS MEMBRANES DISINFECTANTS: APPLIED TO ENVIRONMENTAL SURFACES, OBJECTS, MEDICAL DEVICES & AIR; LOW-, INTERMEDIATE- & HIGH-LEVEL DISINFECTANTS (MEDICAL DEVICES) STERILANTS: CAN KILL ALL LIFE FORMS TERM UNSUITABLE FOR LIQUIDS THAT CANNOT BE USED UNDER STERILE CONDITIONS DECONTAMINATION: COMBINED OUTCOME OF REMOVAL & KILLING TUBERCULOCIDE: TO BE REPLACED WITH MYCOBACTERICIDE HOSPITAL GRADE DISINFECTANT: A MEANINGLESS & MISLEADING TERM BROAD-SPECTRUM DISINFECTANT: MISLEADING TERM MEANING ACTIVITY AGAINST GRAM+ & GRAM- BACTERIAL SPECIES ONLY SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

6 PATHOGENS IN THE ENVIRONMENT FRANK OR TRADITIONAL: ENTER THE ENVIRONMENT FROM SYMPTOMATIC, ASYMPTOMATIC & COLONIZED HOSTS (E.G., STAPHYLOCOCCUS AUREUS) PERIKAIROTIC OR ENVIRONMENT-BASED: LIVE & GROW IN ENVIRONMENTAL BIOFILMS, BUT CAN INFECT HUMANS (SATTAR & SPRINGTHORPE) MOSTLY OPPORTUNISTIC (E.G., NON-TUBERCULOUS MYCOBACTERIA OR NTM) NOT KNOWN TO CAUSE SECONDARY CASES! EMERGING PATHOGENS WITH RELEVANCE TO PERSONAL SERVICES (NTM) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

7 BREAKDOWN OF KNOWN HUMAN PATHOGENS (TAYLOR ET AL. 2001) TOTAL NUMBER OF KNOWN HUMAN PATHOGENS = BACTERIA (38%) 217 VIRUSES & PRIONS (15%) 287 HELMINTHES (20%) 66 PROTOZOA (5%) 307 FUNGI (22%) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

8 POTENTIAL SOURCES OF PATHOGENS IN PERSONAL SERVICES CLIENT S OWN FLORA (S. AUREUS) OPERATOR (HIV) INSTRUMENTS (HEPATITIS B) INKS & PIGMENTS (NTM) CLIENT SHARPS HEPATITIS C) MICROBICIDES (P. AERUGINOSA) ENVIRONMENTAL SURFACES (HEPATITIS A) WATER (NTM) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

9 HIERARCHY OF DISINFECTANT RESISTANCE OF HUMAN PATHOGENS* (SATTAR 2007) High SPORES (CLOSTRIDIUM TETANI) Disinfectant level Relative resistance MYCOBACTERIA (M. TUBERCULOSIS) FUNGI (ASPERGILLUS NIGER) VEGETATIVE BACTERIA (STAPHYLOCOCCUS AUREUS) ENVELOPED VIRUSES (HERPESVIRUSES) NON-ENVELOPED VIRUSES (ADENOVIRUSES) cold sterilant** high intermediate low Low *THE ORDER MAY CHANGE DEPENDING ON FORMULATION, SPECIES, CONTACT TIME & TEST METHOD **TERM UNSUITABLE FOR LIQUIDS UNLESS USED UNDER STERILE CONDITIONS. SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

10 DISINFECTANTS IN ENVIRONMENTAL CONTROL ( - ACCESSED AUG. 27, 2015) U.S. ENVIRON. PROTECTION AGENCY LISTS 275 DIFFERENT ACTIVES IN >5000 REGISTERED PRODUCTS 60% OF PRODUCTS USED AGAINST PATHOGENS 14 OF THE ACTIVES ARE IN >90% OF PRODUCTS THE PICTURE IS SIMILAR IN CANADA SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

11 DISINFECTANTS USED IN INDUSTRIAL &INSTITUTIONAL SETTINGS IN THE U.S. (MODIFIED FROM FU ET AL. 2007) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

12 USES OF MICROBICIDES IN PERSONAL SERVICES ENVIRONMENTAL SURFACES INFECTIOUS WASTE MICROBICIDES SKIN DEVICES SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

13 FACTORS AFFECTING LABEL CLAIMS OF MICROBICIDES CONTACT TIME MICROBICIDE TEST METHOD VOLUME TO SURFACE AREA CHOICE OF SURROGATE(S) PRE-CLEANING SHELF-LIFE LABEL CLAIMS WIPING ACTION USE-DILUTION PRODUCT DILUENT SOIL LOAD MICROBES LISTED TARGET SURFACE SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

14 QUANTITATIVE CARRIER TEST (QCT) FOR DISINFECTANTS (SPRINGTHORPE & SATTAR 2005) EACH METALLIC DISK GETS 10 µl OF MICROBIAL SUSPENSION & DRIED DISK PLACED IN A VIAL & OVERLAID WITH 50 µl OF TEST FORMULATION DISINFECTANT NEUTRALIZED AFTER CONTACT TIME, DISK ELUTED & ELUENT ASSAYED FOR VIABLE MICROBES LOG 10 OR PERCENT REDUCTIONS CALCULATED AGAINST CONTROL METHOD SUITABLE FOR TESTING LIQUIDS, SPRAYS & GASES AGAINST ALL MAJOR CLASSES OF HUMAN & ANIMAL PATHOGENS NOW A STANDARDS OF ASTM INTERNATIONAL; HEALTH CANADA ACCEPTS DATA BASED ON IT; EPA MAY FOLLOW SOON POTENTIAL INTERNATIONAL STANDARD (OECD) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

15 THEORETICAL BASIS FOR INTERRUPTING ENVIRONMENTAL SPREAD OF PATHOGENS IN PERSONAL SERVICES ENVIRONMENTAL FACTORS PATHOGEN CONTAMINATION SURVIVAL TRANSFER TO OTHER VEHICLES CLEANING, ANTISEPSIS, DISINFECTION & STERILIZATION INTERRUPTION INOCULATION INFECTION (DISEASE) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

16 HAZARDS IN DISINFECTANT USE TOXICITY FOR OPERATOR & CLIENT (DERMATITIS, ASTHMA) ENVIRONMENTAL HAZARDS (AIR & WATER POLLUTION, HORMONE DISRUPTION) LACK OF MATERIALS COMPATIBILITY (CORROSION, DISCOLORATION) MICROBIOLOGICAL HAZARDS (CROSS RESISTANCE, MICROBIAL GROWTH) CHEMICAL HAZARDS (FIRES, EXPLOSIONS, MIXING OF INCOMPATIBLES) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

17 WHICH PATHOGENS TO FOCUS ON? HIGH-PROFILE ONES (E.G., HIV, INFLUENZA- & SARS VIRUS) UNSUITABLE TARGETS ( FEAR-FACTOR!) LESS STABLE, LESS RESISTANT & POOR SPREAD VIA CONTAMINATED SURFACES TARGETING THE MORE RESISTANT SHOULD COVER THE WEAKER ONES! GREATER FOCUS ON THOSE THAT ARE MORE STABLE & RESISTANT (E.G., NON-ENVELOPED VIRUSES, MRSA, VRE & ACINETOBACTER BAUMANNII EVIDENCE FOR RECOVERY FROM ENVIRONMENTAL SURFACES SELECTING SURROGATES FOR TESTING BASED ON HIERARCHY OF MICROBIAL RESISTANCE TO DISINFECTANTS (SATTAR 2007) GLOBAL AGREEMENT NEEDED ON CHOICE OF SURROGATES SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

18 WHICH ENVIRONMENTAL SURFACES TO TARGET? PRINCIPAL CONSIDERATION IS POTENTIAL OF A GIVEN SURFACE TO HARBOR & DONATE PATHOGENS DURING ROUTINE/CASUAL CONTACT MUST INCLUDE: PROBABILITY OF CONTAMINATION WITH PATHOGENS ABILITY TO ALLOW FOR PATHOGEN SURVIVAL RELEASE OR DONATE PATHOGENS WITH RELATIVE EASE LOCATION & FREQUENCY OF DIRECT CONTACT WITH HANDS AND/OR MUCOUS SURFACES HIGH-TOUCH ENVIRONMENTAL SURFACES (HITES) AS PRIMARY TARGETS FOR ROUTINE DECONTAMINATION SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

19 WHAT ABOUT WIPING OF HITES? INCREASING POPULARITY OF COMMERCIAL WIPES INSUFFICIENT TRAINING & MONITORING OF STAFF CURSORY WIPING MAY ACTUALLY SPREAD CONTAMINATION! APPLICATOR HAS ITS OWN DISINFECTANT DEMAND CONTACT TIME ONLY SECONDS; MINISCULE VOLUMES OF DISINFECTANT DEPOSITED CURRENT METHODS TO TEST ROLE OF WIPING HAVE LIMITATIONS SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

20 POSSIBLE WAYS TO DECONTAMINATE HIGH-TOUCH ENVIRONMENTAL SURFACES BY WIPING (SATTAR & MAILLARD, 2013) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

21 TESTING OF DISINFECTANT-PRESOAKED WIPES AVAILABLE METHODS DO NOT SIMULATE FIELD USE WELL A DEVICE ( WIPERATOR ) INVENTED TO ADDRESS THE GAP TESTING UNDER PRECISE CONTROL OF PRESSURE, WIPERATOR CONTACT TIME & NUMBER & TYPE OF WIPING MOTIONS CAN TEST BOTH MICROBIAL REMOVAL & TRANSFER RECENTLY BECAME AN INTERNATIONAL STANDARD (ASTM) A PAPER BASED ON AN INTERNATIONAL COLLABORATIVE SOON TO APPEAR IN J. HOSPITAL INFECT. (SATTAR ET AL., 2015) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

22 REMOVAL & TRANSFER OF STAPH AUREUS AFTER FIVE-SECONDS OF WIPING WITH DIFFERENT TYPES OF WIPES USING THE WIPERATOR (SATTAR ET AL. UNPUBLISHED DATA) LOG 10 CFU RECOVERED LOG10 CFU RECOVERED NO BACTERIA RECOVERED TRANSFER A B C D REMOVAL NO BACTERIA RECOVERED Baseline A B C D SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

23 HOW GOOD ARE PRODUCTS IN USE IN PERSONAL SERVICES? A PRODUCT IS AS GOOD AS THE METHOD USED TO TEST IT PURCHASING DECISIONS MOST OFTEN BASED ON COST ALONE MANY CURRENT TEST METHODS LACK CHALLENGES OF FIELD USE A DRUG IDENTIFICATION NUMBER (DIN) COULD BE MORE MEANINGFUL! CERTAIN COMMON DISINFECTANTS HAVE NO DIN (E.G., ETHANOL OR BLEACH) TESTING & LABEL CLAIMS OFTEN WITHOUT WIPING ACTION ALSO, END-USERS MAY NOT USE AVAILABLE PRODUCTS OPTIMALLY ALL THIS TOGETHER CAN SERIOUSLY UNDERMINE POTENTIAL BENEFITS OF DISINFECTANTS WHILE GENERATING A FALSE SENSE OF SECURITY SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

24 WHAT IS AN IDEAL DISINFECTANT? SHOULD BE AS SAFE AS POSSIBLE FOR HUMANS & THE ENVIRONMENT FREE OF VOLATILES (VOCs) FOR LOWER IMPACT ON INDOOR AIR QUALITY FREE FROM PUNGENT ODORS FOR BETTER OPERATOR ACCEPTABILITY FAST-ACTING AS CONTACT TIMES ARE OFTEN QUITE SHORT IN FIELD BROAD-SPECTRUM MICROBICIDAL ACTIVITY FOR TARGET PATHOGENS ARE OFTEN UNKNOWN IN THE FIELD HIGH MATERIALS COMPATIBILITY FOR SAFETY OF DEVICES & SURFACES EASY TO USE WITH CLEAR LABEL DIRECTIONS COST-EFFECTIVE (?) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

25 PROBLEMS REMAIN AT THE GLOBAL LEVEL! MANY MICROBICIDES IN CURRENT USE ARE SLOW-ACTING, INEFFECTIVE & POTENTIALLY HARMFUL TO US & THE ENVIRONMENT PRODUCT REGISTRATION SLOW & COSTLY, WHERE AVAILABLE LABELS NEED TO BE MORE USER-FRIENDLY & ACCURATE WIPING IS COMMON, BUT ITS CONTRIBUTION RARELY ASSESSED MARKETING OF GREEN PRODUCTS & TECHNOLOGIES TO BE BETTER CONTROLLED TRAINING & MONITORING OF STAFF NEEDS TO BE BETTER SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

26 CONCLUDING REMARKS GREATER AWARENESS ON HEALTH IMPACTS OF PATHOGENS MOUNTING RECOGNITION OF BENEFITS OF DISINFECTANTS WITH NEED FOR BETTER & SAFER DISINFECTANTS BEING RECOGNIZED MAJOR STRIDES IN TESTING DISINFECTANTS AS MICROBICIDES MORE VACCINES AVAILABLE (E.G., HBV & HPV) BETTER CHEMOTHERAPIES (E.G., HCV) BETTER PUBLIC EDUCATION & REGULATION OF PSS BETTER EDUCATION & TRAINING OF PUBLIC HEALTH INSPECTORS SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

27 html (ACCESSED ON AUG. 27, 2015) SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

28 PARTING THOUGHT THE ENVIRONMENT SHOULD BE CONSIDERED A SUBSTANTIAL FACTOR IN INFECTION CONTROL PRACTICES, AND RESOURCES SHOULD BE DIRECTED TO IMPROVING OUR UNDERSTANDING OF THE INTERACTION OF PATHOGEN SURVIVAL, DISINFECTION, HAND HYGIENE, AND HAI RISK. - CHEMALY ET AL., 2014 SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

29 LITERATURE CITED CHEMALY RF ET AL. (2014). THER ADV INFECT DIS 2: FU E. ET AL. (2007). CHEMICAL DISINFECTION OF HARD SURFACES: HOUSEHOLD, INDUSTRIAL AND INSTITUTIONAL SETTINGS. CHAPTER F1; HANDBOOK OF CLEANING/DECONTAMINATION OF SURFACES. IN JOHANSSON & P. SOMASUNDARAN (EDS.); ELSEVIER. PAGES SATTAR SA (2007). J AOAC INTERNATIONAL 90: SATTAR ET AL. (2015). J. HOSP. INFECT. ACCEPTED. SATTAR SA & MAILLARD J-Y (2013). THE CRUCIAL ROLE OF WIPING IN DECONTAMINATION OF HIGH-TOUCH ENVIRONMENTAL SURFACES: REVIEW OF CURRENT STATUS AND DIRECTIONS FOR THE FUTURE. AJIC 41;S97-S104. SATTAR & SPRINGTHORPE (2004). CONTRIBUTION OF THE ENVIRONMENT TO INFECT. DIS. TRANSMISSION. IN DISINFECTION, STERILIZATION & ANTISEPSIS: PRINCIPLES, PRACTICES, CHALLENGES, & NEW RESEARCH. APIC CONF. PROC., WASHINGTON, DC SPRINGTHORPE & SATTAR (2005). J. AOAC INTERNATIONAL 88: TAYLOR ET AL (2001). PHIL. TRANS. R. SOC. LOND. B. 2001; 356: SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT

30 SUGGESTED FURTHER READING DANCER SJ. (2014). CONTROLLING HOSPITAL-ACQUIRED INFECTIONS: FOCUS ON THE ROLE OF THE ENVIRONMENT AND NEW TECHNOLOGIES FOR DECONTAMINATION. CLIN. MICROBIOL. REV. 2014, 27(4): OTTER JA. ET AL. (2011). THE ROLE PLAYED BY CONTAMINATED SURFACES IN THE TRANSMISSION OF NOSOCOMIAL PATHOGENS. INFECT CONTROL HOSP EPIDEMIOL 32: SATTAR SA. (2010). PROMISES AND PITFALLS OF RECENT ADVANCES IN CHEMICAL MEANS OF PREVENTING THE SPREAD OF NOSOCOMIAL INFECTIONS BY ENVIRONMENTAL SURFACES. AM J INFECT CONTROL 38:S WEBER DJ ET AL. (2010). ROLE OF HOSPITAL SURFACES IN THE TRANSMISSION OF EMERGING HEALTH CARE-ASSOCIATED PATHOGENS: NOROVIRUS, CLOSTRIDIUM DIFFICILE, & ACINETOBACTER SPP. AM J INFECT CONTROL 38:S SYED A. SATTAR, CIPHI CONFERENCE, OTTAWA, CANADA, SEPT