Reinventing Hygiene for the 21st

Century

Charles P. Gerba
Departments of Soil, Water and Environmental
Science
And
Epidemiology and Biostatistics
Univeristy of Arizona
Tucson, AZ
 Challenges in Infection Control
Good hygiene had more impact on human
health than the development of vaccines
and human health
Infectious diseases are the 3rd leading
cause of death in the United States today.
They are 1st in the developing world.
Continued emergence and re-emergence
of pathogens (SARS, MRSA, bird flu, etc)
 What are Fomites?
Inanimate objects i.e. desk tables, door
knobs, pencils, toilet seats involved in
disease transmission
 Did you know??
80% of all common infections (colds, flu,
diarrhea) are spread through the
environment (air,water,food,fomites)
Hand Contact Plays a Key Role

Every three minutes, a child brings his/

her hand to nose or mouth
Every 60 seconds, a working adult in an
office touches as many as 30 objects
 Role of fomites in transmission of a disease

Person picks up pathogen

through contaminated fomite. Person touches nose or eyes
Pathogen falls on fomites with Contaminated fingers and
e.g. phone, computer Becomes infected with pathogen.

Sick person sneezes, coughs and pathogens

falls on fomite or get aerosolized.
Percentage of Disease Due to Transmission Route

Animal to Person to
Human Person
?% ?% Aerosols
Drinking ?%
Water ?%
?% ?% ?%

Food
Fomite Recreation
 Life in the 21st Century
Most of our time is spent indoors
More people work in offices than ever before
We travel more than ever before
We spend less time cleaning than the last
generation
We are less clean (e.g. laundry practices)
We spend more time in public places
We are more mobile and have more electronic
equipment (e.g. cell phones, Ipods)
We share more common surfaces (fomites) with
more people than ever before
 Bringing More People together in
the 21st Century in One Place
Emergency situations
z Housing
z Medical care
z Transport
Cruise ships
Sporting events
Recreational/Holiday groups
z Houseboats
z Rafting trips
 Why Study Fomites?
Fomites are believed to play a significant
role in transmission of respiratory and
enteric viruses
Fomites play a role in the cross-
contamination of foodborne pathogens in
the food service industry and in the home
Fomites may allow for the amplification of
bacteria and fungi (sponge/dishcloths)
 Why Study Fomites?
Allow us to identify areas where greatest
risk of transmission can occur
Identify areas for the development of
targeted products for the consumer/food
and health care industry
Allows application of Quantitative Microbial
Risk Assessment (QMRA) to determine
risks of infection and success of
interventions in reduction of risk
 Enteric Bacteria (Coliforms) in
7
the Home by Location
Geometric mean per cm or per mL

6
5
4
2

3
2
1
0
-1
-2
Sponge Kitchen Bath Cutting Kitchen Bath Bath Toilet
Sink Sink Board Floor Floor Counter Seat
Disseminators
Vacuum Cleaners Meals on Wheels
for Bacteria
Concentrate bacteria
and food in one place
E. coli detected on
50% of brushes
E. coli and
Salmonella growth in
collection bag or
container
Wash your hands
after emptying
 Study Findings
No bacterial
Contamination
was found in
soap dispensed
from sealed
systems!
 Geometric mean per cm2 or per mL

-2
-1
0
1
2
3
4
5
6
Sponge/dishcloth 7
Kitchen sink drain
Bath sink drain
Cutting board
Kitchen floor
Bath floor
Bath countertop
Toilet seat
Control Period

Sponge/dishcloth
Kitchen sink drain
Kitchen faucet handle
Bath sink drain
Kitchen floor
Bath floor
Bath countertop
Toilet seat
1st Intervention
disinfectant cleaners

Sponge/dishcloth
Kitchen sink drain
Flush handle
Bath sink drain
Refrigerator handle
Control = existing cleaning practices .

Kitchen countertop
Bath countertop
1st intervention = with disinfectant cleaners

Toilet seat
2nd Intervention
2nd intervention = required cleaning events with
 Conclusions
The kitchen is more heavily contaminated than
the bathroom.

Ordinary cleaning practices do little to reduce

the microbial load.

Use of hypochlorite cleaning products resulted in a

significant reduction in HPC, coliforms, and fecal
coliforms both in average and peak values.

Risk of infection could be reduced by greater than

99.99% on cutting boards and kitchen counter-
tops by use of hypochlorite cleaning products.
 Day Care Study Results
Percentage of Positive Surfaces

80

60

40

20

0
Sept Oct Nov March April May

Month

Samples positive in daycare for influenza A by month.

Germs in Your Laundry
 Occurrence of Coliforms and Fecal
Coliforms in Wash Water After
Laundering
Coliform Arithmetic Fecal Coliform
Average Arithmetic Average
Type of Washer Per Washer Per
Clothing Load Item Load Item
Underwear 5.2 x 106 4.5 x 105 5.6 x 105 7.4 x 104
Jeans 7.2 x 105 1.07 x 105 1.5 x 104 2.24 x 103
Bath Towels 1.2 x 106 1.77 x 103 <1.6 x 104 ND
Virus Reduction by Laundering

% Reduction
After After After Washing After
Virus Washing Drying* w/ Bleach Drying

Adeno 40 97 99.9 99.99 99.996

HAV 96 99.8 99.0 99.8

Rota 87 98.6 99.7 99.99

* 28 minutes drying
 % Surfaces Positive
D

0
5
10
15
20
25
30
35
40
45
50
ay
ca
P re
la
yg

46
ro
un
ds
B

36
us
tr
av
el
35

P
ar
k
29

G
ym
28

Th
ea
te
r
26

P
oo
R l
es
14

ta
ur
an
t
14
With Body Fluids

W
D or
oc
to k
11

r's
of
fic
e
10
Environments Most Contaminated
Bacteria in Offices
 Parainfluenza on Office Fomites
Fall, 2004
P e r c e n ta g e o f F o m ite s P o s itiv e fo r P a r a in flu e n z a

70

60
C o n fe re n c e
Room s
50 O ffic e s

40
C u b ic a ls

30

20

10

0
N e w Yo rk San A tla n ta C hic a g o Tuc s o n T o ta l
F ra n s i c o
 Germiest Office Jobs
#1 Elementary School Teachers
#2 Accountants
#3 Bankers
#10 Physicians
 Classrooms (Grades 4-6)
Areas most contaminated with bacteria
z Pencil sharpener
z Student desk top
z Computer
z Sink in classroom
Viruses isolated
z Influenza
z Norovirus
z Parainfluenza
 Impact of Disinfectant Wipes on
Absenteeism
Study
z Two school semesters
z 3rd and 4th graders
Intervention
z Childrens desk wiped with a disinfectant wipe
at the end of each school day
Results
z 50% reduction in absenteeism
 Coliform Bacteria Isolation from
Shopping Carts Los Angeles, CA
Parking Lots
z 47%
Recovery form homeless persons on the
street
z 70%
 Microorganisms Associated with
Outbreaks in Public Toilets

Shigella Diarrhea
Salmonella Diarrhea
Hepatitis A virus Liver Disease
Norovirus Vomiting and Diarrhea
 Aerosols are Produced during
Toilet Flushing
Fecal bacteria and
viruses are ejected
from the toilet during
flushing.
The droplets settle
out in the restroom,
contaminating the
restroom with fecal
microorganisms
 Commodeograph
Water sensitive paper held over toilet seat when
flushed. Purple spots represent water droplets.
E.coli Detected in Droplets
Petri dishes held over
toilet when flushed.
Dark spots are
colonies of E. coli.
 % Time Coliform Bacteria Detected
(public restrooms)
Top of the toilet seat 20
Flush handle 6
Wall behind toilet 9
Floor in front of toilet 64
Sink 61
Tap 15
 % Time Coliform Bacteria Detected
(public restrooms)
Urinal inside 30
Urinal flush handle 0
Sanitary napkin disposal outside 57
Door knob 4
 Coliform and E.coli in Public
Restrooms
Female restrooms
were significantly
more contaminated
that mens restrooms
The middle stall was
more contaminated
Airports were the
most contaminated
and hospitals the
least
 Determine occurrence and identification of
bacteria in open, refillable (bulk) soap
dispensers in public facilities
Microbial contamination of soap has been
linked to infections and outbreaks in
hospitals
 Study Findings
Total Number of Number of Samples Number of Samples
Open Refillable with Bacteria with Coliforms
Soap Samples (usually > 1,000,000/mL)

541 133 (25%) 87 (16%)

 No bacterial
Contamination
was found in
soap dispensed
from sealed
systems.
Microbiology of Automobiles
Dash board has the
most germs followed
by drink and change
holders
Most bacteria
detected in cars was
Florida
Most molds in cars
was detected in
Chicago
The Forgotten Fomites Critical
Control Points?
Phone (cell phone)
TV remote
Computer keyboard
Computer mouse
Sink taps/handles
Sponges/cleaning clothes
Laundry
The Spread of MRSA by Fomites - a case
example
Girlfriend
Child 14 MRSA 14 MRSA -
MRSA skin Cell Skin
infection Phone infection

Mother works MRSA

MRSA
in elder TV remote
Phone in
care Make-up kit
kitchen
facility Phone
 Occurrence of MRSA in the
Community
Cars (2% of all sites tested)
z Steering wheel
z Car seat
Offices (2%)
z phones
Fire houses
z Living quarters (~25%)
Homes with infected individual (30%)
z Phone
z Make-up kit
z TV remote
z Hair brushes (50%)
 Occurrence of fecal bacteria on the
hand (United States)

Preparing a meal Greatest

Children after playing

Doing the laundry Least

Person exiting a toilet

 Bacterial Reduction

Product % Reduction
in Bacteria

Plain soap 92
Chlorhexidine 99.6
Alcohol gels 99.8
 Soap and H20
Can reduce disease transmission by 50%
Best option when hands are visibly dirty
Dont always have access to running water
Alcohol-Based Hand Sanitizers
z Biggest innovation since soap
z More efficaciousreduced absenteeism by
20-50%
z Easier on the hands
z More convenient
z Increases compliance
z Use soap and water when hands are visibly
dirty
Impact of Hand Washing on
Absenteeism in Schools
 Hand Washing
Tucson, Arizona

--95% of people say they wash their

hands after using a public washroom
--67% actually wash their hands
--33% of those use soap
--16% really wash long enough
 Reducing Risk of Infection from
Fomites
Hand washing
z 30 to 50 % reduction in illness
Alcohol gel sanitizers
z 30 to 50% reduction in absenteeism
Disinfection of fomite surfaces
z 50% reduction in absenteeism in schools
Use of bleach and hot water in laundering
z reduces risk of transmission
 Summary
z Environmentally transmitted pathogens
will always be with us
z Good hygiene is not cleaning more, but
focused targeted use of disinfectants and
anti-microbial cleaning tools/fomites
z Hand sanitizers are as good as than hand
washing in reducing germs
Simple Test Media for Bacteria