Today is the Environment Network 2022 event: The Role of Surfaces and Surface Decontamination in Managing healthcare association infection (HCAI) and as @Girlymicro is busy running the show she has tagged in her willing PhD student Sam Watkin, and regular contributor Dr Claire Walker to live blog this event. Let’s get started #EN2022.

What Is the Environment Network?

The Environment Network works to support people in clinical, engineering and scientific roles who are interested in environmental infection control

Do you want to know more about what to do with your water screening and air sampling results?  Are you keen to understand the evidence behind equipment cleaning and the role of the environment in healthcare associated infection?

Then welcome to the Environment Network!  This is a network for people in clinical/scientific/engineering roles within the NHS and other associated organisations who are interested in the role of environmental infection prevention and control in preventing infection. 

The aim of the network is to support infection prevention and control professionals involved in commissioning, environmental audit, water, air and surface testing within their Trusts.  By working together we can share best practice between Trusts; as well as circulating the latest evidence and discussing personal experiences. 

We are so excited to be live blogging the wonderful EN conference this year. Dr Elaine Cloutman-Green BEM opens the conference setting the scene for a wonderful day of networking, learning and discussions with our clinical, industry and academic colleagues. We’ve all come here today create a friendly network of experts. Because sometimes we all need to phone a friend at 4.30 on a Friday when everything is going wrong, and this is the perfect opportunity to grab every experts number.

Morning Presentation Session

The esteemed Professor Jean-Yves Maillard from Cardiff University leads us through his thoughts on options for surface clean and surface decontamination. This topic is very much at the forefront of our minds in the EN, and whilst there has been huge progress in hand hygiene (thanks COVID!), Prof Maillard’s fascinating talk demonstrates how many factors have to be considered to really make a surface ‘safe’. There are so many variables to consider; what product to use, how effective a product is, what factors impact on that efficacy and unique multifaceted challenges we face in this field particularly when it comes to training and developing best practice across healthcare specialisms.

He raised a very interesting and important point when thinking abut surface decontamination – how do you define a “safe” surface? Let’s talk about norovirus – when we consider that it takes 10 virus particles make you sick and there are one billion virus particles per gram of vomit or faeces – you best hope your cleaning strategy works or the whole cruise ship (or worse hospital ward) is going down. The difference between looking clean and being safe is shown, just because it looks shiny doesn’t mean that you can eat your dinner off it!

As we come to discussing decontamination chemicals, the focus turns to compliance with surface decontamination protocols which are essential in maintaining environmental decontamination efficacy. Prof Maillard raised fascinating points on how products are used and why this matters. Different delivery methods, such as spray, foam or pre-wetted wipes, have significant impacts on the efficacy of compounds and their proper use is often hard to consistently achieve.

Further complicating the issue, different microbes have different susceptibilities to different decontamination agents. Wipes that can remove a Gram-negative pathogen can do very little against a Gram-positive. We know that some key pathogenic organisms like Clostridioides difficile require higher levels of disinfection compared to others, but other pathogens often have different requirements to each other. Multidrug resistant organisms can often be resistant to quaternary ammonium compounds meaning you may be able to clean off antibiotic-sensitive Klebsiella, but the drug-resistant ones could remain. Similarly, despite some company claims to the contrary alcohol gel does nothing against C.difficile spores.

Prof Maillard detailed just how important this is by describing some shocking cases of where cleaning has gone wrong. The use of inappropriate compound concentrations and a lack of consistent training on new products can have truly terrifying consequences in the hospital environment. In untrained hands, cleaning can actually make the situation worse not better, for example poor cleaning with can spread viruses around a patients room rather than remove them. We all have so much to learn from not taking detail for granted and how basic precautions like ‘one wipe, one direction, bin it‘ can prevent healthcare associated infections.

As the talk comes to a close we ask can we trust claims of residual activity of decontamination products? Does it really leave a surface ‘clean’ and ‘safe’ for 48 hours? Do these products really work as well as companies or their representatives claim? Prof Maillard says we really can’t trust everything we read. A disinfectant used improperly can select for microorganisms resistant to that product. This highlights not only the importance of choosing the right disinfectant compound, but on using it correctly too. With pandemics in the press, it’s more important than ever that we have an open dialog and solid evidence base for what we use, how we use it and when to use it to create safe environments for both patients and staff.

In our second presentation of the day Karren Staniforth from UKHSA explains the role of novel decontamination techniques in healthcare

It’s important to acknowledge that in decontamination, one box does not fit all. A high risk patient post chemotherapy has very different requirements to a healthy adult popping to the GP to ask for a repeat prescription. Furthermore, we know can’t sterilize everything. It simply doesn’t work that way, so we need to be decontaminating to an appropriate level for the site. If we can avoid high-level sterilization we should as they are expensive, potentially damaging to the site and generally involve harmful chemicals. So how do we manage surfaces categorized as ‘low risk’? For those of us who aren’t so familiar with disinfection in the low risk setting this means something that comes into contact with intact skin. A huge number of different products are available but today Karren is are talking about UV light, and gases and vapours – why we might want to use them and how we might automate these systems.

Karren raises an important issue that automated decontamination techniques don’t remove human error, particularly as they generally require humans to set them up. We still need manual cleaning of rooms when using these, so they very much are there to support environmental cleaning and decontamination, not to replace manual decontamination. However, there are some incredible advantages to an automated system – not least that they are highly reproducible thus much easier to audit and, with proper calibration, should be highly precise and accurate.

Karren tells us why it is so important to use and understand what disinfectant efficacy really tells us, and why it is crucial to be sceptical and to question the manufacturers claims about their products. She details a fascinating history of working in infection prevention and control, and the journey from cleaned rooms actually causing MORE infections to introducing novel technologies and strategies that are proven efficacious. Her talk is peppered with wonderful real world experience of infection, prevention and control. Simple strategies like removal of felt notice boards from wards also had a huge impact in improving cleaning strategies to rid geriatric wards of C.difficile. As a member of the EN steering group (Claire), I am heartened to hear how sharing our stories can improve real world patient care.

Karren closes her talk with some fascinating points about cleaning frequency rather than specificity. We really need to thing about exactly what we are trying to achieve in each setting, and often a bespoke mixed-approach will be what fits the bill.

Post Coffee Talk Session

Claire has been let loose on her own now – with Sam giving his presentation next.

Revived by our coffee we move onto the much anticipated talk by our pal Sam who, with the knowledgeable Helen Rickard, is guiding us through monitoring microbial surface loads – how we should approach it in healthcare and some key findings from their exciting work. Monitoring let us pick up presence and movement of clinically relevant microorganisms in the hospital setting promoting surveillance and targeted treatment programs. This is done routinely in hospitals, but can be stepped up after an outbreak or when transmission is unexpected.

Sam gives us a step by step guide to the different samples and how you might process them to identify the microbial population present. His data demonstrate how important continual sampling is – just counts of microbial species are a snap shot of the situation, and when repeated sampling is done microbial persistence is revealed telling the whole story.

Helen Rickard walks us through why sink surfaces are so important in HCAI. Sinks are the perfect environment for microbes to thrive, and the presence of running water disperses and aerosolises bacteria. They are also often very close to patients. Helen is interested in the impact the patients will have on sink surfaces. Her exciting preliminary data reveals that numbers of organisms detected on sinks double when patients inhabit wards, and numbers of human commensals massively increase. We’re already excited for Helen to come back and tell us more when she is further along into her project.

Dr Marco-Felipe King from the University of Leeds is up next, telling us all about how one can model the impact of surface decontamination. Dr King’s work links airborne and surface contamination, looking at the impact of ventilation on surface contamination, and then transmission onto human fingers. We watch an incredible computer generated model depicting how viruses spread across a ward onto surfaces challenging the myth that viral particles don’t deposit on surfaces. Dr King’s enthusiasm for understanding microbial recontamination of surfaces (why microbial loads sometime increase after cleaning) is infectious. He showed several delightfully complicated formula to model these (and explained them very well!). In Dr King’s own words, “something funny is going on” with the data, which inspired lively discussion amongst all the delegates. He showed how much relative humidity matters for transferring organisms to hands when surfaces are touched – basically proving you should never lick your fingers when on the tube.

Dr Lena Ciric from University College London brings our morning session to a close with a fascinating talk all about the importance of surface loads, and how they differ in healthcare and the community.

Dr Ciric kicked her talk off by discussing the challenges of achieving low surface loadings in the healthcare setting, explaining that while we want microbially clean surfaces in hospital, we have evolved to live with microbes. She highlighted how few guidelines actually exist for surface loading levels, and the challenge this presents to standardisation. Dr Ciric’s data looked at colony forming units collected from a range of locations – hospital wards, the FA cup final, the Brits and even the Tube – to understand what a safe level of microorganisms on surfaces should be. Safe to say we are never touching a surface on the tube again. But it’s not simply a case of how much of something is there, we need to understand what microbial species are present. Her data on presence of SARS-CoV-2 presence showed that colony forming units (CFU) didn’t reflect how much SARS CoV-2 RNA was present on the tube, so whilst the CFU guidelines are interesting more work needs to be done. Really highlighting the importance of, in Dr Ciric’s own worlds, ‘you’ll find what you go looking for’!

Reflections on Surfaces

What an absolutely brilliant, informative and lively morning. It’s difficult to condense such a varied and thoughtful set of presentations into a few take home messages.

• The importance of moving past the marketing – we really need to question how good products are, validate them for use and develop sound guidelines.
• Human factors are hugely important – without proper training even the best tools are not helpful
• The overall takeaway for the transfer of organisms to people’s hands: “it depends”

TLDR: @girlymicro let Claire and Sam loose on her blog, who had lots of fun but she should definitely have provided a word count.

All opinion on this blog is my own