Hygiene in context with corona

Dr. Schumacher’s online portal is aimed at hygiene managers and specialists working in healthcare facilities. Contributions from research and practice are intended to provide well-founded information during the current COVID-19 pandemic – for better implementing hygiene and infection prevention measures.

Frequent Hospital Transmission
Publications // Studies
03.12.2020

SARS-CoV-2: Frequent Hospital Transmission

Current studies from England are showing that the risk of being infected with SARS-CoV-2 is high in healthcare facilities. One of the studies shows that the mortality rate of COVID-19 patients who become infected in hospital is lower than in patients admitted to hospital who had already contracted COVID-19.

According to the National Health Service England (NHS), currently 17.6% of COVID-19 infections in England are most likely due to infection in healthcare facilities. In the North West of England the rate is up to 25% and it is rising further in other parts of the country. Healthcare-associated COVID-19 infection in hospitals is defined by the NHS as being present when the diagnosis is made 7 days after admission. [1]

These figures are supported by a study conducted by King’s College London. According to the survey, at least 12.5% of COVID-19 hospital patients became infected with the coronavirus during their stay in hospital. The majority of the affected patients had been in hospital for a long time already. In the study, an infection was defined as acquired in hospital if it occurred 15 days after patient was admitted. [2]

Importance of timely clinical treatment

The King’s College study also compared the treatment outcomes of COVID-19 patients infected outside of hospital with those who had contracted the infection in hospital. The result: Taking into account age, pre-existing health conditions and the severity of the infection, those who became infected in hospital were less likely to die than comparable patients who became infected outside of hospital. [2]

The researchers suspect that the better outcomes for patients infected with coronavirus in hospital can be attributed to closer monitoring, faster diagnosis and timely clinical treatment. According to experts, the results also suggested that patients who became infected in hospital recovered better than patients who had already been hospitalized with a COVID-19 infection due to the rapid clinical treatment they received. [2]

Sources:

1.Heneghan C, Howdon D, Oke J, Jefferson T The Ongoing Problem of UK Hospital Acquired Infections
October 30, 2020, https://www.cebm.net/covid-19/the-ongoing-problem-of-hospital-acquired-infections-across-the-uk/ (Letzter Zugriff am 03.11.2020).

2. Carter et al. (2020) Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial study (COVID in Older People). Journal of Hospital Infection. DOI: 10.1016/j.jhin.2020.07.013.

Current studies from England are showing that the risk of being infected with SARS-CoV-2 is high in healthcare facilities. One of the studies shows that the mortality rate of COVID-19 patients who become infected in hospital is lower than in patients admitted to hospital who had already contracted COVID-19.

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  • Risk due to poor oral hygiene
    Hygiene management // Oral hygiene
    22.07.2020

    Risk due to poor oral hygiene

    COVID-19 patients have an increased risk of contracting bacterial co-infections. Triggers of this may include oral bacteria that accumulate in the oral cavity. They can spread from there to other areas of the body and cause infections. Older people are particularly vulnerable. In order to guard against this, it is important to practice thorough oral hygiene.

    Viral respiratory tract infections make patients more susceptible to bacterial co-infections. [1] The co-infections in turn lead to increased disease severity and mortality. A Chinese study demonstrates that during the coronavirus pandemic, 50% of deceased COVID-19 patients had concurrent, secondary bacterial infections. [2] Another Chinese study identified both bacterial and fungal co-infections. [3]

    Oral bacteria as triggers of co-infections

    The development of co-infections in COVID-19 patients is promoted by oral bacteria that spread throughout the body. Analyses of genomic material from patients with SARS-CoV-2 showed high values of cariogenic and periodontal pathogenic bacteria. This confirms the view that there is a link between the oral microbiome and COVID-19 complications. [4]

    In addition, there is evidence that periodontal pathogenic bacteria are involved in the onset and development of respiratory diseases associated with COVID 19. Moreover, these bacteria are associated with chronic-inflammatory systemic diseases including type 2 diabetes, hypertension and cardiovascular diseases. These diseases are therefore often comorbidities, which increase the risk of severe complications and death in cases of COVID-19. [4]

    Oral hygiene is particularly important for the elderly

    In contrast, other studies demonstrate that the clinical outcomes considerably improve and the mortality decreases for patients suffering from pneumonia when they implement improved oral hygiene. [5] One in ten pneumonia-related deaths among elderly care home residents aged 65 years and older are deemed avoidable thanks to improved oral hygiene. [6]

    Conclusion: These connections illustrate just how important thorough oral hygiene is for infection prevention. Good oral hygiene is particularly vital for older patients and residents in nursing facilities in order to reduce the germs in the oral cavity and to prevent the spread of oral bacteria to other parts of the body.

    Sources:

    1. Cox M J et al. Co-infections: potentially lethal and unexplored in COVID-19, Correspondence.
    www.thelancet.com/microbe Vol 1 May 2020.

    2. Zhou F. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054–62.

    3. Chen N et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507–13.

    4. Patel J / Sampson V The role of oral bacteria in COVID 19, Correspondence. www.thelancet.com/microbe Vol 1 July 2020.

    5. Manger D et al. Evidence summary: the relationship between oral health and pulmonary disease. Br Dent J 2017; 222: 527–33.

    6. Sjögren P et al. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56: 2124–30.

    COVID-19 patients have an increased risk of contracting bacterial co-infections. Triggers of this may include oral bacteria that accumulate in the oral cavity. They can spread from there to other areas of the body and cause infections. Older people are particularly vulnerable. In order to guard against this, it is important to practice thorough oral hygiene.

    COVID-19 patients have an increased risk of contracting bacterial co-infections. Triggers of this may include oral bacteria that accumulate in the oral cavity. They can spread from there [...]

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    The main problems reported by nursing staff
    Hygiene management // Personnel protection
    22.07.2020

    The main problems reported by nursing staff

    In order to prevent the spread of SARS-CoV-2, nursing staff must frequently disinfect their hands and in cases of presumed or actual contact with COVID-19, they must consistently wear respirator masks, goggles or visors. A study of 542 nurses in Hubei, China investigated the effect of preventive measures on skin health.

    Work-related skin conditions are widespread among health professionals. Between 20 and 30 percent of all people working in patient and elderly care develop hand eczema [1]. The main cause of this is so-called 'wet work'. Wearing gloves for long periods of time and frequent contact with water and soap compromises the natural skin barrier and leads to skin damage on the hands. During this period of coronavirus, skin conditions seem to be increasing. It is not just the hands that are affected, but also parts of the face such as the bridge of the nose, cheeks and forehead.

    The bridge of the nose is affected particularly often

    A study at a tertiary care hospital in Hubei, China with over 500 nurses [2] came to the conclusion that wearing different respirator masks also left marks on the nurses' skin. According to a questionnaire evaluation, 97% of those asked, who were treating COVID-19 patients, had skin problems. The most common symptoms were a feeling of tightness, dryness, flaky skin and redness. Nearly 70% complained of damage to the skin on the bridge of their nose due to wearing a FFP2 mask. The number of nurses who observed damage to the skin on the bridge of their nose increased considerably when the FFP2 mask was worn for longer than 6 hours, rising to 81.1%.

    Wearing time of less than 6 hours recommended

    Over half of the study participants complained of skin irritation on their forehead caused by wearing a protective visor. The number of people affected increased by 10% when the protective visors were worn for longer than 6 hours. Only gloves did not show any difference between the extent of the skin irritation and the duration of wear: even after 6 hours, the skin irritation caused by gloves was not significantly worse than after a shorter duration of wear, but it was at an overall high level of 76%.

    Preventing skin damage

    Hand hygiene was named as the cause of the skin irritation by 60% of the nurses who availed of up to 10 opportunities for hand hygiene. More than 10 hand hygiene opportunities led to skin irritation in almost 80% of the nurses. The study did not mention which products were used for hand hygiene. For the prevention of skin irritation on the bridge of the nose, the authors refer to another study that had positive results through the preventive use of hydrocolloid dressings.

    Conclusion:

    Barrier nursing with respirator masks, protective visors (if applicable) and consistent hand hygiene is essential to prevent the transmission of SARS-CoV-2 when caring for COVID-19 patients. If possible, the nursing staff should not wear the masks for longer than 6 hours. The protective effect of FFP2 masks lasts for a maximum of 8 hours. This duration of wear for FFP2 masks should only be fully utilized in case of a shortage of masks and in emergency situations.

    The Robert Koch Institute [3] and the AKTION Saubere Hände [4] recommend focusing in particular on the skin compatibility of hand disinfectants. This is usually the case with comprehensively examined products, e.g. by means of VAH certification. However, on the basis of the general according to the Federal Institute for Occupational Safety and Health (Bundesanstalt für Arbeitsschutz und Arbeitsmedizin, BAuA), not all hand disinfectants have sufficient care properties and thus sufficient skin compatibility.

    Sources:

    1. Skudlik C, Dulon M, Wendeler D, John SM, Nienhaus A.
    Hand Eczema in Geriatric Nurses in Germany – Prevalence and Risk Factors.
    Contact Dermatitis, accepted 22. Oct. 2008

    2. Juan Tao. Skin damage among health care workers managing coronavirus disease-2019. Research Letter. J AM ACAD DERMATOL, Mai 2020, Volume 82, No. 5.

    3. Robert Koch-Institut. Händehygiene in Einrichtungen des Gesund­heits­wesens (2016). www.rki.de. (Letzter Zugriff 21.07.2020)

    4. Wissenschaftlicher Beirat der AKTION Saubere Hände. Positionspapier Verträglichkeit von Händedesinfektionsmitteln. November 2010. Letzter Zugriff 21.07.2020)

    In order to prevent the spread of SARS-CoV-2, nursing staff must frequently disinfect their hands and in cases of presumed or actual contact with COVID-19, they must consistently wear respirator masks, goggles or visors. A study of 542 nurses in Hubei, China investigated the effect of preventive measures on skin health.

    In order to prevent the spread of SARS-CoV-2, nursing staff must frequently disinfect their hands and in cases of presumed or actual contact with COVID-19, they must consistently wear res [...]

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    Disinfect several times daily
    Hygiene Management // Surface Disinfection
    28.05.2020

    Disinfect several times daily

    With its new interim guidance regarding surface hygiene in connection with COVID-19, the World Health Organization (WHO) wants to “reduce any role that contaminated surfaces may play in the transmission of SARS-CoV-2”. Surfaces in rooms where a patient with a suspected or confirmed COVID-19 infection is present must, according to the experts, be cleaned and disinfected several times. In this regard, the sequence of cleaning or disinfection is also important.

    The role that surfaces which have been contaminated with SARS-Cov-2 play in the transmission of the novel pulmonary disease is not yet fully understood. Previous studies that investigated the survival of the novel coronaviruses were based on experimental studies and laboratory experiments. Now, studies on the real contamination of surfaces in Chinese COVID-19 hospitals and laboratories prove that frequently touched surfaces in particular pose a transmission risk.

    Increased frequency of cleaning

    With this in mind, the World Health Organization (WHO) has published new interim guidance on surface cleaning and disinfection in connection with COVID-19. Surfaces in facilities associated with the care of suspected or confirmed COVID-19 patients should be cleaned or disinfected up to three times daily. In the guidance published, the WHO goes beyond the daily wipe disinfection recommended by the Robert Koch Institute (RKI).



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    Source

    World Health Organization (WHO). Cleaning and disinfection of environmental surfaces in the context of COVID-19. Interim guidance
    15 May 2020

    With its new interim guidance regarding surface hygiene in connection with COVID-19, the World Health Organization (WHO) wants to “reduce any role that contaminated surfaces may play in the transmission of SARS-CoV-2”. Surfaces in rooms where a patient with a suspected or confirmed COVID-19 infection is present must, according to the experts, be cleaned and disinfected several times. In this regard, the sequence of cleaning or disinfection is also important.

    With its new interim guidance regarding surface hygiene in connection with COVID-19, the World Health Organization (WHO) wants to “reduce any role that contaminated surfaces may pla [...]

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  • The new normal
    Hygiene Management // Standard Care
    15.05.2020

    The new normal

    At the moment, routine operations are gradually being carried out again – even the outpatient departments are filling up more and more. The German Society for General and Visceral Surgery (DGAV e.V.) has given recommendations on how to prevent so-called “nosocomial infection clusters”. Ward modules help to manage the different groups of patients.

    With courses of infection that come in waves and different infection frequencies in the general population – as long as there is no vaccine available, COVID-19 patients are part of everyday hospital life. Healthcare facilities will have to live and work with the risk of nosocomial spread of SARS-CoV-2 in the near future. The German Society for General and Visceral Surgery (DGAV e.V.) has issued recommendations that summarize how infections can be prevented as far as possible during the gradual return to standard care.

    Ward management during the COVID-19 pandemic

    The new normal – working with the coronavirus: Clinics must prepare to treat patients who have different issues or who are not affected by COVID-19 at all – and at the same time keep an eye out for the risk of a nosocomial coronavirus outbreak. Even a single cluster of patients within a hospital can paralyze an entire clinic.

    At organizational level, the DGAV experts are suggesting different ward modules for caring for different groups of patients. Depending on the size of the clinic, these can be organized as separate units or as isolation areas within a specialist department. The different units correspond to the groups of patients affected by other issues or not affected by COVID-19: In addition to the isolation area for COVID-19 patients, having wards for COVID-19 positive patients, but also for COVID-19 asymptomatic patients (i.e. those patients who come into hospital treatment due to other indications) are useful. In addition, wards for patients without COVID-19 will have to be managed. The concept reflects the diversity of patient care during the coronavirus pandemic and, at the same time, makes it possible to provide risk-adapted infection protection.

    Ward modules or units in specialist departments:

    • The holding area
      New admissions wait for their swab results in the admission unit for inpatients. The patients and all employees shall wear face masks. If the swab is negative, the patients can be admitted by the respective specialist units.
    • The suspected COVID-19 ward
      Here the patients are cared for exclusively under consideration of the barrier care.
    • Ward for patients who test positive for COVID-19
      Isolation ward with barrier care. Depending on the leading clinical symptoms, the isolation ward can be further divided into subareas:
      - internal (COVID-19 patients) or e.g.
      - surgical department (patients who are also COVID-19 positive)
    • Patients without COVID-19
    • Intensive care unit/intermediate care
      - COVID-19 isolation
      - COVID-19 negative area

    Furthermore, the professional association recommends that occupancy should not be based on the number of beds available. Rather, the possible capacity of surgical and interventional units (e.g. endoscopy, catheter laboratory, radiology) should be taken as a basis. The number of patients admitted daily is adjusted to the daily capacities. If a renewed increase of COVID-19 patients is noted, this should be included in the overall occupancy planning.


    Source:
    German Society for General and Visceral Surgery (DGAV e.V.) COVID-19 recommendations. Friday, April 24, 2020. https://www.awmf.org Last accessed on 05/14/2020

    At the moment, routine operations are gradually being carried out again – even the outpatient departments are filling up more and more. The German Society for General and Visceral Surgery (DGAV e.V.) has given recommendations on how to prevent so-called “nosocomial infection clusters”. Ward modules help to manage the different groups of patients.

    At the moment, routine operations are gradually being carried out again – even the outpatient departments are filling up more and more. The German Society for General and Visceral S [...]

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    Standard products vs. general decree formulations: What should be considered?
    Hygiene Management // Disinfectants
    07.05.2020

    Standard products vs. general decree formulations

    In order to eliminate gaps in supply chains for hand sanitizers and surface disinfectants, the Federal Institute for Occupational Safety and Health (BAuA) issued a general decree which has been updated several times. This authorizes pharmacies and companies in the pharmaceutical and chemical industry to manufacture biocide products that can be used as hand sanitizers and surface disinfectants. Specialist for hygiene and environmental medicine, Prof. Dr. Günter Kampf, explains what healthcare facilities should keep in mind.

    What exactly is the reasoning for the general decrees issued by the Federal Institute for Occupational Safety and Health (BAuA) for the approval of biocidal products for hand sanitizers and surface disinfectants?

    Prof. Dr. Günter Kampf: As the competent authority for biocidal products, the BAuA issued a general decree on March 4th 2020 regarding the approval of biocidal products for hygienic hand disinfection, which has been updated three times since it was first issued. The latest version is dated April 9th 2020. Additionally, a general decree on the approval of certain biocidal products for surface disinfection was issued on April 2nd 2020. These general decrees significantly expand the circle of manufacturers of disinfectants for hand sanitizers and surface disinfectants. These products may only be placed on the market for a maximum of 180 days as the biocidal products do not fulfill the conditions laid down in Regulation 528/2012 for granting an approval in the typical way.

    Is this also the reason why you recommend that healthcare facilities use approved products from the well-known disinfectant manufacturers wherever possible?

    Yes, because the antimicrobial effectiveness of approved, commercially available products for hand sanitizers and surface disinfectants has been extensively tested. Many of these products have been certified by the VAH and the skin compatibility or material compatibility is usually well documented.

    How do we know how effective these products are against SARS-CoV-2?

    Hand sanitizers and surface disinfectants that have a proven efficacy against enveloped viruses and therefore fulfill the “limited virucidal” efficacy spectrum are to be regarded as generally effective against coronaviruses including SARS-CoV-2.

    Recipes for hygienic hand disinfection approved according to the BAuA are also effective against coronaviruses. And yet despite this, you critically evaluate these biocide products for healthcare facilities, why?

    For the majority of biocidal products for hygienic hand disinfection mentioned in the general decree, there is no or only a small amount public evidence of efficacy in the form of expert opinions, even if the active substances themselves are mostly well investigated by the manufacturers or in the scientific literature. Based on published data, half of the 8 biocidal products for hygienic hand disinfection from the general decree issued by the Federal Institute for Occupational Safety and Health do not have sufficiently strong bactericidal and levurocidal efficacy within 30 seconds. Three of the formulations must even be applied with 2 x 3 ml over 2 x 30 seconds, which is twice the application time and twice the application volume if you compare it to the majority of commercially available products. On top of this, four of the alcohol-water mixtures from the general decree do not include skin care substances.

    What consequences do these shortcomings in the formulations have for the practice with regards to the care of patients?

    If these alcohol-water mixtures are frequently used, it is to be expected that employees will suffer from skin irritation. If their skin is irritated, it is less likely that employees will continue to comply with hand hygiene recommendations. This will then increase the patient’s risk of nosocomial infection. Clinics continue to treat critically ill patients whose greatest risk of infection is still bacteria and yeast fungi, and increasingly also multi-resistant bacteria. To prevent the transmission of these germs, employees sanitize their hands up to 60 times per shift. For hand sanitizers to provide reliable antimicrobial effectiveness within 30 seconds as well as having good skin compatibility are of the utmost importance for patient care. In the latest version of the general decree, the biocidal products described above with a lower efficacy within 30 s are therefore only recommended for use outside patient care.

    According to the general decree from the Federal Institute for Occupational Safety and Health, four biocidal products should also be considered for hand disinfection in the care of patients in the event of a shortage?

    These are two alcohol-water mixtures as well as the modified WHO formulations originally developed by the World Health Organization for countries with limited economic resources to locally manufacture products for the care of patients.

    What do you think about biocidal products that are manufactured in accordance with the general decrees from the Federal Institute for Occupational Safety and Health (BAuA) for approval as surface disinfectants?

    Biocide products that are temporarily approved by the Federal Institute for Occupational Safety and Health for surface disinfection are based on 80% v/v ethanol, 0.5% w/w sodium hypochlorite or 2.5% w/w chloramine T.

    According to the general decree, ethanol can only be used on areas of up to 2 m2 and should be effective over a period of 15 minutes. Therefore, this biocidal product is only suitable for small areas. The manufacturer must also ensure that the ethanol does not contain hazardous impurities. Sodium hypochlorite should only be used against enveloped viruses and should only be applied to non-polluted dry surfaces for 30 minutes.

    Aqueous chloramine T solution must also not contain any hazardous impurities and should be effective for over 2 hours. This all means that the practicability and application safety of these three temporarily approved biocidal products must still be critically questioned for routine use on surfaces in the care of patients.

    Prof. Dr. Kampf, thank you for speaking with us.

    In order to eliminate gaps in supply chains for hand sanitizers and surface disinfectants, the Federal Institute for Occupational Safety and Health (BAuA) issued a general decree which has been updated several times. This authorizes pharmacies and companies in the pharmaceutical and chemical industry to manufacture biocide products that can be used as hand sanitizers and surface disinfectants. Specialist for hygiene and environmental medicine, Prof. Dr. Günter Kampf, explains what healthcare facilities should keep in mind.

    In order to eliminate gaps in supply chains for hand sanitizers and surface disinfectants, the Federal Institute for Occupational Safety and Health (BAuA) issued a general decree which ha [...]

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