A 3 Prong Infection Control
Strategy for Public Buildings
Based on the School Disinfection Workgroup
National Conference Call
Research and Document Collaboration
2009
Project Coordinated by: Lynn Rose
Training and Documents Written by: Lynn Rose and
Carol Westinghouse, Informed Green Solutions, Inc.
Funded by: the Massachusetts Toxics Use Reduction
Institute, University of Massachusetts, Lowell
1
Workgroup Members
National: Centers for Disease Control and
Prevention and Environmental Protection Agency
Massachusetts: Division of Occupational Safety,
Dept Public Health, MA Nurses Association,
MassCOSH, TURI Surface Solutions Lab
California: Dept of Public Health, California
Childcare Health Program, UCSF
Connecticut: University of Connecticut Health
Center
New England: Informed Green Solutions, Inc.
2
Objectives
http://www.vancouverdad.com/photos/germs1.jpg
 Facilitate adequate infection control while
minimizing the use of toxic cleaning products
and antimicrobial pesticides.
 Protect workers and building occupants from
exposure to hazardous disinfectants.
 Clarify the differences between cleaning and
disinfecting products and processes, and
when each is appropriate.
3
Presentation Overview
 Why be concerned?
 How is disease transmitted?
 How can Facility Managers safely reduce
disease transmission in their buildings?

Strategies and planning

Policies and procedures

Products and equipment

Training and resources
4
Why reduce use of disinfectants?
Chemical Hazards
 Disinfectants are actually
antimicrobial pesticides,
designed to kill microbes.
cide = kill
 Disinfectants do not clean, and
cleaners to do not disinfect.
 The active ingredients of common
disinfectants are among the most
toxic chemicals used in custodial
work.
5
Why reduce use of disinfectants?
Chemical Exposure Risks
 A single janitorial worker uses, on average, 194
lbs. of chemicals annually, approximately 25% of
which are hazardous substances
 Environmental Working Group tested 21 common
cleaning products used in California schools. They
found 457 chemicals were emitted into the air:



6 known asthmagens
11 known, probable or possible cancer-causing
agents
Others - health effects are unknown
6
Why reduce use of disinfectants?
Chemical Exposure Risks
 Children are at greater risk than adults when exposed
to toxins because:

They are exposed at higher levels as they eat more
food, breathe more air, drink more water

They metabolize and eliminate toxins more slowly

Their rapidly developing systems are more
sensitive

Play closer to the ground

Have significant hand-to-mouth activity
Why reduce use of disinfectants?
Occupational Hazards
 If not handled properly, some disinfectants
can cause serious injuries:

Eye damage

Chemical burns

Severe skin irritation
 Out of 100 janitors injured each year:


20% are serious burns to the eyes or skin
12% are a result of chemical vapors
8
Why reduce use of disinfectants?
Occupational Asthma
Products
# Cases
Unspecified
104
Bleach
43
Acids, bases,
oxidizers
23
Disinfectants
20
Carpet
cleaner
17
Floor stripper/
wax
16
Ammonia
14
Note:
12% of all Work Related Asthma
cases in 4 states were associated
with cleaning and disinfectant
products.
CA, MA, MI, NJ 1993-1997
Rosenman et al 2003 JOEM 45(5):556-63
9
Why reduce use of disinfectants?
Children’s Asthma
Students (K-12) with Asthma in
Massachusetts ESHS Programs
120
116.2
115
110
105.8
105
100
97.7
95
90
85
2006- 2007
2007- 2008
2008- 2009
S c h o o l Ye a r
St udent s wit h Ast hma ( per t housand st udent s )
Massachusetts Department of Public Health
Data on Student Asthma Rates
10
Myth Buster: Question
Do you always need to
use disinfect
to control infection?
11
Myth Buster: Answer
No, some alternatives include:
 An all purpose cleaner
and microfiber
 Equipment without
chemicals such as a steam
cleaning machine
12
3 Levels of Microbe Control:
Cleaning
Removing
Microbes
99%
Sanitizing
Killing
Bacteria
99.9 to 99.999%
Disinfecting
Killing
Microbes
99.99%
13
Breaking the Chain of Infection:
“3 Prong Approach ”
1. Personal Strategies
2. Cleaning for Health
3. Targeted Sanitization
and Disinfection
a. Hand Hygiene
b. Respiratory Hygiene
c. Cough Etiquette
d. Social Distancing
and Isolation
14
Understanding
the
Chain of Infection
A series of events that need to
occur before a person develops
an infectious disease.
15
What are Microbes?
Dispelling the “Fear Factor”
 Microbes are everywhere in the environment
– in the air, water, soil, plants and animals.
 We can’t live without them.
 Some are good for you, and other
pathogenic” microbes cause infections and
disease, commonly referred to as “germs”.
16
What are Microbes?
 Bacteria* – have their own cell walls, and can live
independently.
 Fungi* – grow on dead and decaying matter.
Common forms are yeast and molds.
 Viruses – live and multiply inside of cells of a living
host, and cannot live independently.
* Spores produced by some types of bacteria and fungi
can live in the environment for months or years.
17
How Are Microbes Transmitted?
Susceptible Host
Microbes make host sick
Infectious Microbes
Bacteria, Virus,
Fungi
Reservoir
Microbes adapt and multiply
(on animate & inanimate objects)
Chain of
Transmission
Portal of Entry:
Microbes enter new location
(e.g. mucous membranes)
Modes of Transmission:
Microbes are transported to new location
(by animate or inanimate objects)
Where people come in contact with them
Contact
Contact
Respiratory
18
Portal of Exit
Microbes leave
(e.g. sneeze or cough)
Reservoir
 Microbes live and multiply in a reservoir.
 Microbes prefer:

Warm, dark environment

Moisture

Source of food
19
Droplet Transmission
 Large


droplets containing microbes are:
propelled short distances
(3-6 feet) through the air
from sneezing, talking, and
coughing.
deposited on a host’s mucous
membranes - eyes, nose or mouth
 Examples:

flu, cold, strep
20
Photo: 2009 Camfil Farr , http://www.camfilfarr.com/cou_us/industries/care/infection_transfer.cfm
Airborne Transmission
Photo: 2009
Camfil Farr ,
http://www.ca
mfilfarr.com/c
ou_us/industri
es/care/infecti
on_transfer.cf
m


Microbes in airborne droplets:
 Survive from evaporated droplets, and
 Remain in the air for long periods
(hours to days).
Examples:
 measles, TB, chickenpox
21
Contact Transmission: Indirect Contact
 Transfer of microbes from object to person
 Examples such as MRSA or Norovirus - transmitted
by:

Touching environmental
surfaces contaminated with
infectious blood or body fluids,
and

Then touching mucous
membranes (eyes, nose,
mouth) or touching an area
with broken skin.
22
Contact Transmission: Direct Contact
 Transfer of microbes from person to person.
 Examples such as MRSA or Norovirus -
transmitted by:

Touching infected area or
infectious body fluid on a
person, and

Then touching mucous
membranes or touching an
area with broken skin.
23
Means of Entry
 Breaks in the skin
 Respiratory tract
 Digestive tract
 Circulatory system
24
Susceptible Host
 Weakened Immune System - body not
able to fight off infection!
25
What Influences the Survival of Microbes
Outside of the Body?
Conditions of
Surrounding
Environment
Humidity, pH,
temperature,
microbes present,
ultraviolet light
exposure
Properties of the
Object
Microbe
Properties
Type of microbe
and type of
medium it is
suspended in
Adds up to
microbe
survival on
object
Porous or
nonporous,
How clean,
How much moisture
Adapted from Stephanie A. Boone* and Charles P.
Gerba, Significance of Fomites in the Spread of
Respiratory and Enteric Viral Disease. Applied and
Environmental Microbiology, March 2007, p. 1687-1696,
Vol. 73, No. 6
Breaking
the
Chain of Infection
Breaking any of the links of the chain can
interrupt the transmission of disease.
Example: Influenza
27
The Three Prong Approach
1. Personal Strategies and
Responsibilities

Prevent transmission
2. Cleaning for Health

Remove reservoir

Prevent transmission
3. Targeted Sanitizing/Disinfection

Remove reservoir

Prevent transmission
28
Personal Strategies:
Will Respiratory Hygiene and Cough Etiquette Reduce
Flu Transmission?
Yes. The CDC recommends:
 Covering the nose/mouth when coughing
or sneezing, and washing hands after.
 Coughing into the elbow when tissues are
not available.
 Using & disposing of tissues.
 Leaving a 3-6 foot buffer between yourself
and others when coughing or sneezing.
29
CDC Influenza Fact Sheet, http://www.cdc.gov/flu/professionals/pdf/resphygiene.pdf.
Personal Strategies:
Will Self-Isolation and Social Distancing Help Reduce
Flu Transmission?
Yes, and guidelines for sick people from the CDC
include:
 Staying home and away from people until at least
24 hours after they are free of fever (100° F), or
signs of a fever without the use of fever-reducing
medications.
 Limiting contact with others and maintaining a
distance of at least 6 feet from people.
 Wearing a surgical or N95 mask around other
people.
30
Personal Strategies:
Will Hand Hygiene Help Reduce
Flu Transmission?
 Yes, depending on the product and
process used.
 Hand washing with soap and water can
reduce infections by more than 50 % in
some cases!
31
Hand Hygiene: Product Types
 Soap will remove, not kill microbes.
 Anti-bacterial products kill bacteria
and some, but not all viruses.
 Anti-microbial products can kill or
suppress growth of bacteria, viruses or
fungi.
32
Hand Hygiene Products:
Hand Soap
 Soap is available in liquid, bar (not
recommended) and hand wipe forms.
 Soap and warm water remove microbes by
breaking down the oil and dirt that harbors
them, and washing them away.
 The CDC guidelines call for washing hands with
warm water and soap for 15 to 20 seconds to
effectively prevent infection.
33
Hand Hygiene Products:
Anti-bacterial Hand Soap
 Kills bacteria and some, but not
all viruses such as the common
cold, flu, stomach flu and blood
borne pathogens such as HIV
and Hepatitis B and C.
 A Federal Drug Advisory Panel concluded
in 2005 that, for general use, antibacterial
soaps are no more effective than regular
plain soap at removing germs.
Reference: http://www.cdc.gov/Features/HandWashing , August 28, 2008
Hand Hygiene Products:
Anti-bacterial Hand Soap
 The most common ingredients are triclosan and
triclocarban. Triclosan health issues include:

Can be absorbed
through skin, linked to
liver damage.

Detected in breast milk,
urine and blood.

Linked to hormone
disruption.
35
Hand Hygiene Products:
Anti-Microbial Hand Sanitizer
 Product that can kill or suppress growth
of viruses, bacteria or fungi.
 Available in foam, gel or hand wipes.
 Most common ingredient is alcohol,
which comes in 2 forms and different
strengths.
Note: Always replace product in dispenser, never
top off to prevent microbial growth in dispenser.
36
Hand Hygiene Products:
Alcohol Based Sanitizers - Concentrations
Concentration Required to Kill Specific Viruses
Virus
Ethyl Isopropyl
Alcohol Alcohol
Influenza A
30%
30%
Norovirus (stomach flu)
62%
95%
Rhinovirus (common cold) 62%
95%
Hepatitis A
62%
95%
Note: 70% Ethyl Alcohol would be better than 62%, but its hard to find.
Hand Hygiene Products:
Alcohol Based Sanitizers - Dangers
 Routes of Exposure for Children
 absorb
 lick
it through skin
it off their hands
 squirt
it into their mouths
38
Hand Hygiene Products:
Alcohol Based Sanitizers - Dangers
 Risks

3 squirts* can raise blood alcohol
level in a toddler to be legally
intoxicated .10, which is
comparable to someone that
size to drinking 120 proof alcohol.

“Ingesting as little as an ounce or two of this
product could be fatal to a toddler,” says Heidi
Kuhl, health educator, Central NY Poison Control
Center.
* Purell and Germ-X contain 62% Ethyl Alcohol
39
Reference: http://www.snopes.com/medical/toxins/sanitizer.asp
Hand Hygiene:
Alcohol Based Sanitizers - Dangers
 Class 1 - Flammable Liquid
 Follow 527 CMR storage guidelines
 State Fire Marshal reissued an Advisory for
Alcohol Based Hand Sanitizers containing
60% - 95% ethanol or isopropanol.
 Posted: SFO website  Fire Prevention  SFO Advisory
40
Hand Hygiene: Product Limits
 Dirt: antimicrobial and alcohol based
products don’t necessarily remove dirt on
hands, which compromises their ability to
kill microbes.
 Proteins: soap is more effective
at removing proteins from hands
than alcohol sanitizers.
41
Do Hand Sanitizers
Replace Hand Washing?
No, hand-washing is the first and most
important step, especially if hands are visibly
soiled.
CDC Recommendations:
When hand washing is not an option (e.g.
school bus or field trip), “alcohol-based hand
cleaners are also effective.”
Sources: 1) City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and 2) Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging Infectious Diseases, by Dr.
42
Elaine Larson, prof pharmaceutical & therapeutic research, & prof of epidemiology, Columbia Univ School of Nursing
Infection Control
Strategy
as part of
A Cleaning for Health Program
43
Cleaning for Health Program
Cleaning that protects public health, without adversely
affecting the staff, building occupants and the
environment.
 A comprehensive program to:
 prevent proliferation of dirt and microbes
 use safe cleaning products and work practices
 Sample strategies include:
 More frequent cleaning of high-touch surfaces
 Cleaning with color coded microfiber mops/cloths
 Using floor/vacuuming equipment with HEPA filters
44
Three Levels of Microbe Control
1. Cleaning
Microbes
99%
2. Sanitizing
Bacteria
99.9 – 99.999%
3. Disinfecting
Microbes
99.99%
Level 1: General Surface Cleaning

Physically remove viruses, fungi and
bacteria and the conditions they need
to survive (e.g. organic matter).

Accomplished with water, detergent,
and abrasion of the surface.

Microfiber can enhance this process
by removing up to 99% of microbes.
45
Three Levels of Microbe Control
1. Cleaning
Microbes
99%
2. Sanitizing
Bacteria
99.9 – 99.999%
3. Disinfecting
Microbes
99.99%
Level 2. Sanitizing
 Reduces (kills) 99.9% to 99.999% of tested
bacteria to levels considered safe for public health.
 May not have claims for killing viruses or fungi.
 Some products can be both a sanitizer and a
disinfectant, depending on specified concentration.
46
References: Infection Control for Dummies, J. Darrel Hicks, REH, http://www.epa.gov/iaq/glossary.html#S, http://www.epa.gov/iaq/glossary.html#D, and Source:
Cleaning for Health, Inform, Inc, and presentation by Marcie Tidd on Disinfectants, Sanitizers, and Product Labeling, Overview of EPA’s Antimicrobial Registration Process,
Women's Voices for the Earth Conference Call, February 4 th, 2009
Three Levels of Microbe Control
Level 2. Sanitizing
 Registered by EPA for use on
porous and nonporous
surfaces:
 Food contact surfaces:
sanitizing rinses for
surfaces such as dishes
and cooking utensils.
 Non-food contact surfaces:
carpet, laundry, toilet bowl,
etc.
47
References: Infection Control for Dummies, J. Darrel Hicks, REH, http://www.epa.gov/iaq/glossary.html#S,
http://www.epa.gov/iaq/glossary.html#D, and Source: Cleaning for Health, Inform, Inc
Three Levels of Microbe Control
1. Cleaning
Microbes
99%
2. Sanitizing
Bacteria
99.9 – 99.999%
3. Disinfecting
Microbes
99.99%
Level 3. Disinfecting
 Destroys 99.99% of all forms of
microbial life, but not
necessarily their spores.
 Use on hard nonporous surfaces,
which have higher transmission
rates.
48
Disinfectants: Claims
 All disinfectants do not kill all types
of microbes.
 EPA categorizes & registers products by their
Disinfectant Claims based on what they kill:
Limited
Broad
Spectrum,
General
Hospital,
Medical Use
49
Disinfectants: Claims
 Hospital / Medical Use Disinfectant:

meets the requirements for a general
disinfectant

also effective against the
Pseudomonas aeruginosa

does not necessarily kill TB or HIV
50
Disinfectants: Claims


To comply with OSHA BBP
Standard, use:

a tuberculocide, or

A product that lists the specific
BBP viruses - HIV and hepatitis B
For MRSA and other specific
diseases, check the label.
51
Disinfecting:
Consult the Label & EPA’s Website
Listings of EPA’s
registered
antimicrobial
products for
specific diseases:
http://www.epa.go
v/oppad001/chemr
egindex.htm
52
Disinfectants:
Claims for H1N1 and Influenza A
EPA’s position
October 22, 2009
An influenza A virus label
claim is sufficient to support
label claims against 2009 H1N1
influenza A virus.
53
Disinfectants: Selection
Are they ranked for safety?
 EPA Design for the Environment
program is implementing a 2 year pilot
project Safer Product Labeling Program.
 Products
restricted to EPA registered
disinfectants.
 Evaluates
critical health and environmental
standards, and is available at:
http://www.epa.gov/dfeprojects/gfcp/.
54
Disinfectants: Selection
EPA’s Pilot Program
 Identified the following active ingredients as being
least-toxic:
Accelerated Hydrogen Peroxide
 Lactic Acid
 Citric Acid

 Products with these ingredients will not be approved:
 Quaternary ammonium compounds
 Sodium hypochlorite (bleach)
 Ortho-phenylphenol (2 phenylphenol)
 Thymol
55
Disinfectants: Selection
Are they ranked for safety?
 EcoLogo - in Canada does certify
disinfectants. Not all products are
available in the US, or are EPA
registered.
 MA Operational Service Division -
Environmental Preferable Products
Contract FAC 59 provides a fact sheet
on several uncertified antimicrobial
products available through contract
vendors.
56
Disinfectants: Selection
Are they ranked for safety?
Toxicity
Health: EPA Toxicity Rating (1-4)
Acute Toxicity Category
Signal Word Required
Category I
Danger/Poison
Category II
Warning
Category III
Caution
Category IV
Caution
(or none required if all routes are Cat IV)
57
Disinfectant: Selection
Hazardous Options - Bleach
 Hazard Level

CDC Disinfection Level - Intermediate Level

EPA Toxicity Category - Category I
 Claims

most bacteria and some viruses

registered as effective against HIV, HBV, H1N1
(Influenza A), MRSA, TB
Note: Can’t be stored longer than 3 months for disinfecting.
When diluted, is only effective as a disinfectant for 24 hours.
58
Disinfectant: Selection
Hazardous Options - Bleach
(5.25% and 6% Sodium Hypochlorite)
 Health Effects

Corrosive to eyes and skin

Respiratory irritant

Suspected cardiovascular, gastrointestinal or
liver, kidney, central nervous system, respiratory,
and skin or sense organ toxicant
59
Using Bleach Safely
Note: Although the project does not advocate the use
of bleach as there are much safer alternatives, we
provide these guidelines for those who continue to use
bleach.
 The dilution rate will vary depending on the
strength of the original product 5.25% or 6%
and intended uses. Check the label.
60
Using Bleach Safely
 Use different dilutions for specific uses,
such as:

Sanitizing food surfaces

Disinfecting non-blood or body fluids,
disinfecting shared sports equipment (mats,
etc.), sinks, etc.

Disinfecting blood, vomit spills (after
cleaning)
61
Disinfectant: Selection
Hazardous Options - Phenols
 Hazard Level


CDC Disinfection Level - Some are
intermediate and some are low level.
Check the label.
EPA Toxicity Category - Category I or II
 Claims

Read product label for specific microbes
62
Disinfectant: Selection
Hazardous Options - Phenol
 Health Effects

Recognized carcinogens (CA Prop. 65)

Suspected toxicant - cardiovascular,
developmental, neurological, reproductive,
respiratory, skin, sense organ

Corrosive to eyes and skin
Absorbed through the skin and by inhalation.
63
Disinfectant: Selection
Hazardous Options - Quaternary Ammonium Compounds
 Hazard Level

CDC Disinfection Level - Low Level

EPA Toxicity Category - Category III
 Claims

Generally effective against a broad spectrum of
microbes including MRSA and H1N1 (Influenza A),
but not spores

Read product label for effectiveness against TB
64
Disinfectant: Selection
Hazardous Options - Quaternary Ammonium Compound
 Health Effects

Can cause contact dermatitis and nasal irritation.

Ammonium quaternary compounds* are
respiratory sensitizers and are associated with
asthma.
*Includes: benzalkonium chloride, dodecyl-dimenthyl-benzyl ammonium
chloride and lauryl dimethyl benzyl ammonium chloride.
65
Disinfectant: Selection
Less Hazardous Options - Accelerated Hydrogen Peroxide
 Claims - as a disinfectant & sanitizer (non-food contact)



Viruses – e.g., Hep B & C, HIV
Bacteria – e.g., TB & MRSA
Fungi – e.g., athletes feet
 Ease of Use

Rinsing not required, except for
allowable food surfaces
 Hazard Level


Non flammable, not hazardous
Acidic - pH 2.5–3.5
Ingredient in
several products.
This product is
registered by EPA
as a Disinfectant
66
Sanitizer: Selection
Less Hazardous Options - Ionized Water
Process involves:
1. Charging - a battery applies an
electrical charge to water.
2. Transforming - charged water
passes through an ion exchange
membrane, creating positive and
negative nano-bubbles.
3. Cleaning - activated water now
attracts dirt like a magnet and
lifts it from the surface, enabling
it to be wiped away.
67
Equipment used: Ionator
Disinfectant: Selection Criteria
 EPA registered
 Broad spectrum
 Health - EPA toxicity rating (1-4), select the
relatively non-toxic (4 preferable)
 Storage - stable shelf life, nonflammable
 Ease of Use – whether rinsing is required, short
dwell time, no PPE
 Environmentally preferable
68
Disinfection Application Process:
Selection Criteria
 Using the most appropriate application for
the job.
 Preventing cross contamination.
 Preventing exposure to workers and
occupants.
 Conserving resources.
 Protecting the environment.
69
Disinfection Application Process: Comparison
Criteria
Conventional Microfiber
Mop and
Mop Pads
Bucket
and Bucket
Effectiveness at
Capturing, or
Killing
Microbes
Captured
30%
microbes in
a hospital
setting
study.
Solution
must be
changed
regularly to
maintain
efficacy.
Reusable
Microfiber
Cloths
Reusable
Cotton Cloths
Disposable
Pre-Saturated
Cotton or
Wipes for
Paper Towels Surfaces
Superior –
captured
99%
microbes in
a hospital
study.
Penetrate
into cracks
that other
materials
cannot
reach.
Significantly Significantly Significantly
less than
less than
less than
microfiber.
microfiber. microfiber.
The type of
microfiber
affects
efficacy,
with 0.13
denier the
highest.
Increased
fiber surface
area & static
electric
charge
enable it to
attract,
capture &
hold
particulates
better.
Depends on
saturation of
wipe and
ability to
stay wet on
the surface.
Solution
remains
stable in
presence of
the wipe
material.
70
Disinfection Application Process: Comparison
Criteria
Conventional Microfiber
Reusable
Mop and
Mop Pads and Microfiber
Bucket
Bucket
Cloths
Ability to
Maintain
Adequate
Contact/
Dwell
Time to
Kill
Microbes
Good
Superior microfiber
cloths have
such a high
density and
surface area,
they can
absorb up to 7
times their
weight in
water and
retain that
moisture.
Reusable
Disposable
Cotton Cloths Cotton or
Paper Towels
Superior Good
microfiber
cloths have
such a high
density and
surface area,
they can
absorb up to
7 times their
weight in
water and
retain that
moisture.
Cotton is
better than
paper, but
retains less
moisture than
microfiber.
Pre-Saturated
Wipes for
Surfaces
Can dry out
on surface.
Although
wipes are
designed to
provide a
premeasured
amount of
solution, the
possible
uneven
saturation
level in
container may
compromise
this.
71
[i]
Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002
[ii] Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002
Disinfection Application Process: Comparison
Criteria
Conventional
Mop and
Bucket
Microfiber
Reusable
Mop Pads and Microfiber
Bucket
Cloths
Reusable
Disposable
Pre-Saturated
Cotton Cloths Cotton or
Wipes for
Paper Towels Surfaces
Cross
Contamination (CC)
Advantages
and
Disadvantages
Solutions must
be changed
regularly.
Mop must be
cleaned and
dried or
microbes will
colonize on the
fibers.
A bucket
divided for
clean and dirty
water prevents
CC when mops
are dipped
back into
solution.
Disinfecting
mop is
difficult.
Prevents CC if
a color coding
system is used
and if a new
mop head is
used for new
uses or rooms.
Since the mop
head is not
dipped back
into the
solution, there
is no CC of
solution in
bucket.
Increased
fiber surface
area & static
electric charge
enable it to
better hold
microbes.
Can serve as
a breeding
ground for
microbes and
cause CC if
not laundered
and dried
before reuse.
Prevents CC
if changed
regularly and
when uses or
rooms
change.
Increased
fiber surface
area & static
electric
charge enable
it to better
hold
microbes.
It dries faster
than cotton so
there is less
chance for
microbes to
proliferate.
CC may
occur
between
towel
dispenser
handle and
dispensers,
especially if
located in
splash zone.
Microbes can
survive on the
cloth and can
cause CC.
Avoids CC
that might
occur from
dipping cloths
back into
solution.
72
Developing Protocols
Criteria to Consider
73
Disinfecting: Developing a Protocol
A written procedure should provide guidelines
that answer the following questions:
 When and how often it should be done.
 What products and tools should be used.
 How to use and manage products/equipment.
 How to protect oneself and building
occupants.
74
Protocol: Determine when to Clean,
Sanitize or Disinfect
 What is the surface to be managed – porous
or non-porous?
 What is the level of occupant contact with the
surface:
 Minimal – floors, walls, etc.
 Frequent – high touch or high risk
 Are there any regulations requiring
disinfection or sanitization?
75
Protocol: Determine Management of Surfaces
High Touch Surfaces - Touched by a Variety of Hands
CDC Position: “does not believe any additional
disinfection of environmental surfaces beyond the
recommended routine cleaning is required.”
Project Recommendation: clean more
frequently during the day with a
microfiber cloth and third-party
certified* all-purpose cleaner.
* Certification: a third party (e.g. Green Seal and EcoLogo) gives written
assurance that a product or service conforms to specified requirements.
76
Protocol: Determine Management of Surfaces
High Touch Surfaces - Touched by a Variety of Hands
 Restroom examples:
 Faucet
handles, toilet handles, towel
dispensers, hand driers.
 Break Room and Cafeteria examples:
 Coffee
pots, microwave doors,
refrigerator doors
 Vending machines
 Water fountains
77
Protocol: Determine Management of Surfaces
High Touch Surfaces - Touched by a Variety of Hands
 Office examples:
 Shared
desks or work areas
 Shared
computer mice and
keyboards
 Fax
machines, copiers, printers
78
Protocol: Determine Management of Surfaces
High Touch Surfaces - Touched by a Variety of Hands
 Custodial examples:
Shared cleaning equipment.
 Product containers and
dispensers in custodial closets.

 Public Ways examples:

Doorknobs, elevator buttons,
light switches, door push bars,
handrails.
79
Protocols: Determine Management of Surfaces High Risk Areas
 Some surfaces in the following locations may
require disinfecting:

Shower and locker rooms

Rest rooms

Nurse’s office

SPED

Preschool
80
Protocol: Determine Management of
Non-Contact Surfaces - Floors
 Routine disinfection of floors is not
supported by epidemiology, unless there is
a Bloodborne Pathogens (BBP) spill or as
required in certain areas of athletic
facilities.
 Clean floors with a microfiber
mopping system and a 3rd party
certified floor care product.
81
Protocols:
Ensuring Product Effectiveness
 Water Hardness:

Some disinfectants can be neutralized in hard
water. The label on quats may specify its
effectiveness in hard water.
 Temperature:
Can degrade product during storage.
 Can enhance or reduce product effectiveness
during use.

 Product Concentration:

Less concentrated than directed will not be
effective.
82
Protocols:
Ensuring Product Effectiveness
 Type and amount of microbes:
 Product must have ingredients registered by EPA
to kill target microbes.
 Shelf-life of disinfectant:

Diluted products have shorter shelf life.
 Length of time solution sits in bucket and
number of times used:

Efficacy can be reduced, and microbes can
reproduce.
83
Protocols:
Ensuring Product Effectiveness
 Contact time (AKA – kill or dwell time):
Product must stay wet. Times varies for each product.
 Material on the surface:
Cleaning product residues, protein and dirt can interfere
with disinfectant activity.
 Compatibility of product and surfaces:
Incompatible materials can damage surface.
 Physical configuration of the object (e.g. crevices):
Difficult to remove debris or ensure disinfectant comes in
contact with all areas of a surface.
84
Protocol: Dispensing Disinfectants
Diluting Product:
 Measure concentrates before adding them to the
dilution tank.
 Follow dilution rate instructions exactly for
specific uses as products are tested and only
guaranteed at specific concentrations. More is
not necessarily better, it can be more hazardous.
85
Protocol: Dispensing Disinfectants
Required information on labels of secondary containers:
 Brand name of the product or the name as listed
on the MSDS.
 Hazard warnings:

Health Hazard – including affects on target organs
(heart, liver, kidneys, nervous system, etc).

Physical Hazard – flammable, corrosive, reactive
Health
Flammability
Reactivity
PPE
HMIS Labels - an “at a glance” warning to alert workers of the
degree of hazard, particularly for those who do not speak English.
86
Protocol: Dispensing Disinfectants
Sample Label on Secondary Bottle
CLOROX LIQUID BLEACH
WARNING: STRONG OXIDIZER!
STORE IN A COOL, DRY PLACE.
DO NOT GET IN EYES OR ON SKIN.
DO NOT MIX W/OTHER HOUSEHOLD CHEMICALS.
ACUTE: CAUSES SEVERE BUT TEMPORARY EYE INJURY.
MAY IRRITATE SKIN.
MAY CAUSE NAUSEA & VOMITING IF INGESTED.
EXPOSURE TO VAPOR OR MIST MAY IRRITATE NOSE, THROAT & LUNGS.
Recommend adding date prepared, and dilution rate.
87
Protocol:
Preventing Cross Contamination
Cross Contamination:
 Is the transfer of infectious
microbes from one surface,
object or person to
another.
 Involves understanding Chain of Infection:

where microbes live and multiply, and

how they are transferred to a new location.
88
Protocol:
Preventing Cross Contamination
Sources of Cross-Contamination:
 Used cloth or mop head,
especially if left soaking in dirty
solutions.
 Solutions of disinfectants,
prepared in a dirty container,
stored for long periods of time, or
prepared incorrectly.
 Contaminated hands or gloves.
89
Protocol:
Preventing Cross Contamination
 Allow laundered mop
heads and cloths to dry
before re-use.
 Replace cloths and mop
heads each time a bucket
of disinfectant is emptied
and replaced.
90
Protocol:
Preventing Cross Contamination
Tools, Equipment and Supplies to Prevent
Cross Contamination from:
 Surface to surface – change
cloths or mop heads when
moving to a new surface
(e.g. toilet to sink). Color
coded microfiber systems
help with this.
91
Protocol:
Preventing Cross Contamination
 Personal Protection:
wear and change
gloves and wash
hands between
tasks.
 Custodial Closets:
clean equipment
after use.
92
Protocol: Pre-Cleaning
Why?
 Soil and organic matter can reduce
effectiveness of disinfectant by:
 Providing shelter for the
microbes to hide.
 Absorbing ingredients.
Disinfectants need to be in
contact with microbes to kill
them!
 Changing the chemical nature of
the disinfectant.
http://www.goductpro.co
m/images/microbes.gif
93
Protocol: Pre-Cleaning
Why?
 Biofilm can form when
microbes develop a protective
matrix on wet surfaces over
time.
 Disinfectants cannot penetrate them to kill
microbes.
 Biofilm needs to be physically abraded or penetrated
by the use of steam vapor device to reach microbes .
Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
94
Protocol: Pre-Cleaning
Key locations for a biofilm to form are in
areas that are wet on a regular basis:

Plumbing facilities such as under rims of
toilets and urinals, in sinks, in distribution
pipes, etc.

Wet areas that surround
them such as backsplashes,
drain areas, etc.
95
Protocol:
Separating Pre-cleaning & Disinfecting Tasks
 Disinfectant/Cleaner Products:
 There
are 2 types of products
registered by EPA to clean and
disinfect.
 They
contain a disinfectant and a
detergent.
96
Protocol:
Separating Pre-cleaning & Disinfecting Tasks
1. One Step Cleaner/Disinfectants
 Work
only on surfaces with a moderate
amount of organic soil.
 Labeled
as a one-step cleaner/disinfectant:
“effective in the presence of 5% body
fluids”
97
Protocol:
Separating Pre-cleaning & Disinfecting Tasks
2. Two Step Cleaner/Disinfectant
that are not “effective in the
presence of 5% body fluids”.
 Products
 Labeled
and used as a two step process.
98
References: Infection Control for Dummies, J. Darrel Hicks, REH, and What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
Protocol:
Separating Pre-cleaning & Disinfecting Tasks
 All other disinfectants require surfaces to be
pre-cleaned using a detergent.
 We recommend using two different types of
products to reduce the use of hazardous
ingredients:
 One
nontoxic one to clean
 A disinfectant to disinfect
References: Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
99
Protocol: Disinfecting
 Allow time for disinfectants to react with the
microbes to kill them (AKA - dwell, contact or
kill time): follow directions for time required
for the disinfectant to be wet on the surface.
 Reduce quantity: use the smallest possible
amount of disinfectant as recommended.
 Rinse: rinse high-touch areas, if required on
the label. Any residue may be hazardous
when it comes in contact with skin.
100
Protocol: Disinfecting
Protect Workers & Building Occupants:
 Direct workers to spray product on
cloth when possible, not into the air.
 Require adequate ventilation. The HVAC system
should be operating while disinfecting is conducted.
 Schedule use of disinfectants when there are the
fewest occupants, e.g. tasks conducted once daily.
101
Protocol: Worker Safety
Require use of Personal Protective Equipment:
 Non Latex Gloves


Resistant to chemicals
(check label for type)
Prevent allergic reactions
 Facial Protection (if needed)

Chemically Resistant Masks/Goggles (safety glasses
with side piece)
Disposable face shield
102

Protocol: Worker Safety
Always wear chemically resistant gloves!
If….
Then….
You could be splashed Goggles or safety glasses,
in the face?
and a mask or a disposable
face shield is required
You could be splashed An apron is required
on your body?
If you could step in it
and track it around?
Booties are required
103
Protocol:
Designating Roles & Responsibilities
 Restrict the use of disinfectants to
trained and approved staff for:

Targeted disinfecting and sanitizing.

Regulated disinfecting and
sanitizing.

Events – BBP, body fluids and
infectious disease outbreaks (when
required).
104
Policy and Procedures:
Providing Guidance and Resources
All staff using disinfectants & sanitizers need:
 Training.
 Clear guidance on when, where
and how to use and handle.
 Labeled containers of approved
products.
 Chemical storage equipment.
 Personal Protective Equipment.
105
Equipment: Microfiber
Infection Control Attributes
 Requires Less Chemicals: reduces need for
disinfectants for most cleaning tasks since the
fiber removes a high % of organic matter.
 Controls Cross-Contamination:
by color coding & changing mop
pads after each room.
 Prevents Aersolization of Dust: The fibers have a
static electric charge that attracts dust and holds it
when dry dusting. (Dust can transmit microbes.)
106
Equipment: Microfiber
Infection Control Attributes
 Minimizes Microbial Growth: dries more quickly,
which helps to prevent microbe growth inside fiber.
 Captures Microbes: more effective than cotton.
Use of microfiber mops in UC Davis Medical
Center 2002 hospital study found 99% reduction
in bacteria versus only 30% reduction using a
conventional wet mop system.
107
Source: EPA Fact Sheet, November 2002 - Using Microfiber Mops in Hospitals
Equipment: Microfiber
Infection Control Attributes
 Absorption Ability: The increased surface area of
the fibers and their shape enable them to absorb up
to 7-8 times their weight in liquid, reducing
conditions for microbe survival.
108
Photo: http://media.primetimesolutions.net/themes/shopmicrofiber.com/images/microfiberCleansBetter.gif
Equipment: Facility
Minimize Occupant Exposure
 Bathroom




Hands free towel dispenser or hand dryer
Hands free soap dispenser
Hands free faucet and toilet controls
Hands free trash can
 Office and Public Areas


No-touch trash cans
Sneeze guards
Note shields between public and
employee behind counter
109
Equipment: Custodial
Minimize Occupant Exposure
Examples:
 Steam Cleaners and
Steam Vapor Cleaners
 No Touch Cleaning
Equipment
http://www.anaguard.com/images/kai_equipment.png
110
Equipment:
Ventilation to Reduce Exposure
During outbreaks transmitted through airborne
transmission, increasing ACH can reduce
airborne microbes.
An example, note
that increasing
ACH from 6 to 15
will 'clean' the air
to a 99% removal
rate in 18 minutes
as opposed to 46.
111
Reference: SARS & Air Filter Recommendations
http://www.filterair.info/articles/article.cfm/ArticleID/D4EB5EEC-ACCD-4AF7BB92BD9B3DFE9581
Facility Manager
Roles and Responsibilities
Flu Example
112
What role do Facility Managers play?
 Reducing Transmission:

Risks to staff from their
work.

Risks between staff,
building occupants and
the public.
113
How could a flu outbreak affect my
workplace and workforce?
 Absenteeism – could affect up to 40 % of
workforce during pandemic peak periods.
 Change in demand for custodial services –
may increase with additional infection
control tasks.
 Change in patterns of building use - the
public may come in at off-peak hours.
 Interrupted supply/delivery - shipments of
items maybe delayed or cancelled.
114
What is involved in fulfilling these
responsibilities?
 Developing Policies:


Cleaning and Disinfecting
for Infection Control
Absenteeism
 Stockpiling and providing items to occupants:



Soap, tissue, hand sanitizer
Cleaning supplies, microfiber cloths
PPE
115
What is involved in fulfilling these
responsibilities?
Providing training on:
 Job related transmission routes & exposure risks.
 Exposure Prevention



Protective behaviors (e.g. cough
etiquette, hand hygiene)
Protective supplies (PPE)
Work practices
 Cleaning and disinfection plans to be followed
during outbreaks.
116
Summary: Breaking the Chain of Infection
117
Additional Resources
 MA Operational Services Division
Environmentally Preferable Products
Program
http://www.mass.gov/ - type in EPP

EPP FAC 59 Contract

FAC59 Criteria for Disinfectants, Sanitizers
and Mold/Mildew Remediation
118
Additional Resources
 Cleaning Product Certification Organizations

Green Seal - http://www.greenseal.org/

EcoLogo - http://www.terrachoicecertified.com/en/index.asp
 Green Cleaning - www.greencleaningnetwork.org
 Center for a New American Dream,
Responsible Purchasing Network
http://www.newdream.org/work/rpn.php
119
Resources: Project Handbook for Schools
Disinfection Overview
•
•
Definitions
The Science of Disinfection and Infection
Control
Development of Protocols
•
•
•
•
•
•
•
•
•
•
•
•
Writing a Procedure for Disinfection
Choosing the Right Level of Microbe Control
Managing Surfaces for Infection Control
Dispensing Disinfectants
Labeling Secondary Containers
Pre-Cleaning Surfaces and Using Disinfectant
Cleaners
Identifying Factors that Compromise
Disinfectant Efficacy
Preventing Cross Contamination
Storing Disinfectants
Disposing of Wastes
Taking Precautions
Assigning Roles and Responsibilities, and
Educating School Staff
Selection of Products, Dispensing Equipment
and Application Systems
• Selecting Products for Infection Control:
Decision Making Flow Chart
• Comparing Disinfectants: Comparison Chart for
EPA Registered Hard Surface Disinfectants
• Using the Disinfectant Label Information to
Make Informed Decisions
• Using Information from Hazardous Materials
Rating Systems for Product Selection
• Using Information from Material Safety Data
Sheets for Product Selection
• Selecting the Disinfectant Application System
• Choosing Between Concentrated Products and
Ready To Use Products
• Selecting and Installing Product Dispensing
Systems
120
Resources: Project Handbook for Schools
Safe Use Practices
•
•
•
•
Using Bleach (Sodium Hypochlorite)
Hazard Overview of Bleach
Protocol for Safe Use of Bleach
Using Disinfectants
Classroom, Nurse and Custodial Guidelines
and Posters
• Sample Classroom Policies
• Cleaning Surfaces for Infection Control for
School Custodians – Poster
• Sample School Nurse Polices
Infection Control Practices
• Cleaning for Healthy Schools: Best Practices
• Understanding Hand Hygiene: Products and
Practices
• Cleaning Up Blood and Body Fluid Spills:
Protocol Poster
• Blood Spill Kit: Sample Memo with List of
Kit Items
Equipment for Infection Control
• Using Devices to Eliminate Chemical Use:
Ionator, Steam Technology and Hands-Free
Technology
• Using Microfiber Mops and Cloths for
Infection Control
• Using Ventilation to Reduce Microbe
Populations
Resources
• Organizations
• Green Product Certification and Labeling:
Appendices
• Selecting Greener Disinfectants
• Program Planning Handout: Cleaning for
Healthy Schools and Infection Control
• Interpreting the Disinfectant Label:
• Interpreting Information From Hazardous
Materials Rating Systems: NFPA /HMIS
• EPA's Toxicity Categories
• Selecting Disinfectants for Hard Surfaces:
• Regulatory Categories
• Cleaning for Health: Program Components
121
• Using Ventilation for Microbe Control
Project Contact Information
 Lynn Rose, Project Coordinator
[email protected]
1-413-774-6540
 Carol Westinghouse, President
Informed Green Solutions, Inc.
[email protected]
informedgreensolutions.org
1-802-626-8643
 Joy Onasch, Community Program Manager
Toxics Use Reduction Institute
[email protected]
http://www.turi.org/community
1-978-934-4343
122
References
1.
Infection Control Best Practices for Laundry and Housekeeping
Professionals, Nicole Kenny, B.Sc., Virox Technology, Inc
2.
A Guide to Selection and Use of Disinfectants, BC Centre for
Disease Control, 2003
3.
Taking the Mystery Out of Chemical Disinfection, Nicole Kenny,
B.Sc., Director of Professional and Technical Services, Virox
Technology, Inc
4.
Infection Control for Dummies, J. Darrel Hicks, REH,
5.
What Microbes Are We Killing? Testing and Classifying
Disinfectants, by Allen Rathey, The Housekeeping Channel
6.
Indoor Air Chemistry: Cleaning Agents, Ozone and Toxic Air
Contaminants, Final Report, Prepared for the California Air
Resources Board and CA EPA
123
References
1.
Cleaning for Health, Inform, Inc
2.
City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and
3.
Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging
Infectious Diseases, by Dr. Elaine Larson, prof pharmaceutical,
therapeutic research & epidemiology, Columbia Univ School of
Nursing
4.
1Didier Pittet, “Clean hands reduce the burden of disease,” The
Lancet, www.thelancet.com, Vol. 366, July 16 2005, pgs 185 – 187.
5.
www.flu.gov
6.
CDC - http://www.cdc.gov/h1n1flu/guidance/exclusion.htm,
7.
CDC - http://www.socialdistancing.org/determining-your-socialdistance-group-plan/
124
Self Isolation
Poster
Source: CDC
Preparation
for Home Stay
Checklist:
http://healthvermo
nt.gov/panflu/famil
y_checklist.aspx
125
Hand Washing Guidelines
 Wet your hands with warm running
water and apply liquid soap.
 Rub hands together to make a lather
and scrub all surfaces for 20 seconds.
 Rinse hands in running water.
 Dry your hands using a paper towel or
air dryer.
 Use paper towel to turn off faucet.

1Didier Pittet, “Clean hands reduce the burden of disease,” The Lancet, www.thelancet.com, Vol. 366, July 16 2005, pgs
185 – 187.
126
126
Combination
Poster:
Respiratory
Etiquette and
Handwashing
http://organizedwis
dom.com/Special:O
W_Special_Nugget/
HandwashingPoster
_Engl_Spanish2006_1_copy.pdf/26
9/363068
127
Cough Etiquette
Posters & Flyers
available from the
CDC
Website
in many languages
http://www.cdc.gov/fl
u/protect/covercough.
htm
128
Alcohol Based Hand Sanitizer
Available as foam rubs, gels, or wipes.
To be most effective,
a dime-size dollop of
alcohol gel should be
rubbed into the hands
for 30 seconds.
If hands are dry after
only 10-15 seconds, it is
likely that not enough
sanitizer was used.
Reference: http://edis.ifas.ufl.edu/fy732
129
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