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A biological hazard, or biohazard, is a biological substance that poses a threat to the health of living organisms, primarily humans. This could include a sample of a microorganism, virus or toxin that can adversely affect human health. A biohazard could also be a substance harmful to other animals.[A]
The term and its associated symbol
are generally used as a warning, so that those potentially exposed to
the substances will know to take precautions. The biohazard symbol was
developed in 1966 by Charles Baldwin, an environmental-health engineer
working for the Dow Chemical Company on the containment products.[1]
It is used in the labeling of biological materials that carry a significant health risk, including viral samples and used hypodermic needles.
Bio hazardous agents are classified for transportation by UN number:[2]
Category A, UN 2814 – Infectious substance, affecting humans: An
infectious substance in a form capable of causing permanent disability
or life-threatening or fatal disease in otherwise healthy humans or
animals when exposure to it occurs.
Category A, UN 2900 – Infectious substance, affecting animals
(only): An infectious substance that is not in a form generally capable
of causing permanent disability or life-threatening or fatal disease in
otherwise healthy humans and animals when exposure to themselves occurs.
Category B, UN 3373 – Biological substance transported for diagnostic or investigative purposes.
Regulated Medical Waste, UN 3291 – Waste or reusable material
derived from medical treatment of an animal or human, or from biomedical
research, which includes the production and testing.
Immediate disposal of used needles into a sharps container is standard procedure.
NHS medics practice using protective equipment used when treating Ebola patients
The United States Centers for Disease Control and Prevention
(CDC) categorizes various diseases in levels of biohazard, Level 1
being minimum risk and Level 4 being extreme risk. Laboratories and
other facilities are categorized as BSL (Biosafety Level) 1–4 or as P1 through P4 for short (Pathogen or Protection Level).
Biohazard Level 1: Bacteria and viruses including Bacillus subtilis, caninehepatitis, Escherichia coli, and varicella (chickenpox),
as well as some cell cultures and non-infectious bacteria. At this
level precautions against the biohazardous materials in question are
minimal, most likely involving gloves and some sort of facial
protection.
Biohazard Level 2: Bacteria and viruses that cause only mild disease to humans, or are difficult to contract via aerosol in a lab setting, such as hepatitis A, B, and C, some influenza A strains, Human respiratory syncytial virus, Lyme disease, salmonella, mumps, measles, scrapie, dengue fever, and HIV.
Routine diagnostic work with clinical specimens can be done safely at
Biosafety Level 2, using Biosafety Level 2 practices and procedures.
Research work (including co-cultivation, virus replication studies, or
manipulations involving concentrated virus) can be done in a BSL-2 (P2) facility, using BSL-3 practices and procedures.
Biohazard Level 4: Viruses that cause severe to fatal disease in humans, and for which vaccines or other treatments are not available, such as Bolivian hemorrhagic fever, Marburg virus, Ebola virus, Lassa fever virus, Crimean–Congo hemorrhagic fever, and other hemorrhagic diseases, as well as Nipah virus.[3]Variola virus (smallpox)
is an agent that is worked with at BSL-4 despite the existence of a
vaccine, as it has been eradicated and thus the general population is no
longer routinely vaccinated. When dealing with biological hazards at
this level, the use of a positive pressure personnel suit
with a segregated air supply is mandatory. The entrance and exit of a
Level Four biolab will contain multiple showers, a vacuum room, an ultraviolet light room, autonomous detection system,
and other safety precautions designed to destroy all traces of the
biohazard. Multiple airlocks are employed and are electronically secured
to prevent doors from both opening at the same time. All air and
water service going to and coming from a Biosafety Level 4
(P4) lab will undergo similar decontamination procedures to eliminate
the possibility of an accidental release. Currently there are no
bacteria classified at this level.
Symbol
For broader coverage of this topic, see Hazard symbol.
The biohazard symbol was developed by the Dow Chemical Company in 1966 for their containment products.[1] According to Charles Baldwin,[1]
an environmental-health engineer who contributed to its development:
“We wanted something that was memorable but meaningless, so we could
educate people as to what it means.” In an article he wrote for Science in 1967,[4]
the symbol was presented as the new standard for all biological hazards
(“biohazards”). The article explained that over 40 symbols were drawn
up by Dow artists, and all of the symbols investigated had to meet a
number of criteria:
Striking in form in order to draw immediate attention;
Unique and unambiguous, in order not to be confused with symbols used for other purposes;
Quickly recognizable and easily recalled;
Symmetric, in order to appear identical from all angles of approach;
Acceptable to groups of varying ethnic backgrounds.
The chosen symbol scored the best on nationwide testing for memorability.[5]
The design was first specified in 39 FR 23680 but was dropped in the succeeding amendment. However, various US states adopted the specification for their state code.[6]
Experts
agree that careful cleaning and disinfection of environmental surfaces
are essential elements of effective infection prevention programs.
However, traditional manual cleaning and disinfection practices in
hospitals are often suboptimal. This is often due in part to a variety
of personnel issues that many Environmental Services departments
encounter. Failure to follow manufacturer’s recommendations for
disinfectant use and lack of antimicrobial activity of some
disinfectants against healthcare-associated pathogens may also affect
the efficacy of disinfection practices.
Improved hydrogen
peroxide-based liquid surface disinfectants and a combination product
containing peracetic acid and hydrogen peroxide are effective
alternatives to disinfectants currently in widespread use, and
electrolyzed water (hypochlorous acid) and cold atmospheric pressure
plasma show potential for use in hospitals. Creating “self-disinfecting”
surfaces by coating medical equipment with metals such as copper or
silver, or applying liquid compounds that have persistent antimicrobial
activity surfaces are additional strategies that require further
investigation.
Newer “no-touch” (automated) decontamination
technologies include aerosol and vaporized hydrogen peroxide, mobile
devices that emit continuous ultraviolet (UV-C) light, a pulsed-xenon UV
light system, and use of high-intensity narrow-spectrum (405 nm) light.
These “no-touch” technologies have been shown to reduce bacterial
contamination of surfaces. A micro-condensation hydrogen peroxide system
has been associated in multiple studies with reductions in
healthcare-associated colonization or infection, while there is more
limited evidence of infection reduction by the pulsed-xenon system. A
recently completed prospective, randomized controlled trial of
continuous UV-C light should help determine the extent to which this
technology can reduce healthcare-associated colonization and infections.
In
conclusion, continued efforts to improve traditional manual
disinfection of surfaces are needed. In addition, Environmental Services
departments should consider the use of newer disinfectants and no-touch
decontamination technologies to improve disinfection of surfaces in
healthcare.
Background
In
recent years, there is an increasing consensus that improved cleaning
and disinfection of environmental surfaces is needed in healthcare
facilities [1–4].
Experts generally agree on a number of areas, including the fact that
careful cleaning and/or disinfection of environmental surfaces, daily
and at time of patient discharge, are essential elements of effective
infection prevention programs. Moreover, when disinfectants are used,
they must be used appropriately to achieve the desired effects. However,
there are a number of areas of disagreement and controversy regarding
best practices for cleaning and disinfection of environmental surfaces.
Some experts favor physical removal of microorganisms using only a
detergent solution [3].
Other individuals believe that manual disinfection of surfaces using
currently available disinfectants is adequate, and that newer approaches
to disinfection are not necessary.
The purpose of this article is
to summarize the many factors that affect standard cleaning and
disinfection practices and to discuss modern technologies that can
supplement traditional cleaning and disinfection methods.
Personnel-related issues
Multiple
studies have shown that manual cleaning and disinfection of surfaces in
hospitals is suboptimal. In many facilities, only 40 to 50 % of
surfaces that should be cleaned are wiped by housekeepers [5].
In addition, observational methods combined with use of adenosine
triphosphate (ATP) bioluminescence have shown that individual
housekeeper performance varies considerably [6].
One study found variations among housekeepers in the amount of time
spent cleaning surfaces, the number of wipes used in each room, and the
level of cleanliness achieved [6]. Specialized cleaning teams that included infection control personnel have been shown to reduce C. difficile surface contamination more effectively than routine housekeepers [7]. Personnel turnover among Environmental Services departments is a significant problem [8, 9],
which may reach 30 to 50 % in some facilities. As a result, shortages
in Environmental Services personnel were reported by more than 50 % of
hospitals in a recent survey conducted in the United States [10].
Among housekeepers and nursing personnel, there is often confusion
about who is responsible for cleaning various surfaces and equipment [11, 12].
Issues related to disinfection protocols and practices
In
addition to the above personnel-related issues, there are many other
factors that can potentially have adverse effects on the efficacy of
traditional cleaning and disinfection practices. The type of surface
being cleaned or disinfected can affect the completeness with which
bacteria are removed. For example, Ali et al. found that the type of
material from which bed rails were made affected how well they could be
cleaned by microfiber cloths, and that bacteria were removed more
effectively by antibacterial wipes than by microfiber [13].
Disinfectants may be applied using inadequate contact times. Failure of
housekeepers to use an adequate number of wipes per room can result in
poor cleaning of surfaces [6].
Use of wipes without sufficient antimicrobial activity against target
pathogens can result in poor disinfection of surfaces and can lead to
spread of pathogens from one surface to another [14, 15].
Binding of quaternary ammonium disinfectants to cloths made of cotton
or wipes containing substantial amounts of cellulose may reduce the
antimicrobial efficacy of the disinfectant [16, 17].
At least one laboratory-based study has shown that detergent wipes have
variable ability to remove pathogens from surfaces, and may in fact
transfer pathogens between surfaces [18].
Inappropriate
over-dilution of disinfectant solutions by housekeepers or by
malfunctioning automated dilution systems may result in applying
disinfectants using inappropriately low concentrations [9, 17].
For example, an investigation of housekeeping practices at a large
teaching hospital included an audit of 33 automated disinfectant
dispensing stations that mix concentrated disinfectant with water to
yield a desired in-use quaternary ammonium concentration of 800 ppm [17].
Quaternary ammonium concentrations of solutions dispensed were tested
using commercially-available test strips. The audit revealed that
several dispensing stations yielded solutions with less than 200 ppm,
approximately 50 % of stations delivered solutions with 200 to 400 ppm.
An investigation revealed several flaws in the dispensing system.
Inexpensive test strips and more complicated titration kits are
available to monitor quaternary ammonium concentrations of
disinfectants.
Contamination of disinfectant solutions can occur, particularly if recommendations for their use are not followed [19–21].
For example, Kampf et al. recently reported that 28 buckets from 9
hospitals contained surface-active disinfectants (e.g., quarternary
ammomium solutions) that were contaminated with Achromobacter or Serratia strains [21].
Buckets and roles of wipes had not been handled according to
manufacturer recommendations. In studies that involved culturing
high-touch surfaces in patient rooms before and shortly after
housekeepers had performed routine cleaning, we found that cultures
obtained from several surfaces in one room after cleaning yielded large
numbers of Serratia and smaller numbers of Achromobacter which were not present before cleaning [Fig. 1] [20]. The housekeeper’s bucket of quaternary ammonium-based disinfectant contained 9.3 × 104 CFUs/ml of gram-negative bacilli (mostly Serratia marcescens and fewer numbers of Achromobacter xylosoxidans). Pulsed-field gel electrophoresis demonstrated that Serratia
isolates recovered from the disinfectant were the same strains as those
recovered from surfaces in the patient room. Genome sequencing of one
of the Serratia strains by collaborating investigators revealed that it contained four different qac
resistance genes that permitted the organism to grow and survive in the
disinfectant (unpublished data). If disinfectant contamination is
suspected, a sample of the product can be used to inoculate a broth
medium or solid agar containing neutralizers effective against the
active agent(s) in the disinfectant solution.
Fig. 1
Numerous studies have found that standard
manual cleaning or disinfection of surfaces can reduce, but often does
not eliminate, important pathogens such as C. difficile, staphylococci including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multi-drug-resistant Acinetobacter [7, 22–28].
Failure to adequately disinfect patient rooms at the time of hospital
discharge contributes to the increased risk of acquisition of resistant
pathogens among patients admitted to a room where the prior room
occupant was colonized or infected with a multidrug-resistant pathogen [29–31].
Monitoring housekeeping practices
In
order to improve standard cleaning and disinfection practices, it is
recommended that the practices of housekeepers be monitored and that
they receive feedback regarding their performance. However, monitoring
of housekeeper performance is often not performed as frequently as
needed, if at all [10]. Recently, fluorescent marking systems (Fig. 2) and ATP bioluminescence assays (Fig. 3) have proven useful for evaluating cleaning practices and providing housekeepers with feedback [32, 33].
Unfortunately, such objective means of monitoring the adequacy of
cleaning/disinfection practices are not routinely used in many
facilities [10].
Perhaps the lack of monitoring of housekeepers is due in part to the
fact that monitoring activities can be time-consuming and must be
conducted on an ongoing basis in order to be effective [34].
Fig. 2Fig. 3
Given the multitude of challenges to
achieving and maintaining adequate cleaning and disinfection in
healthcare facilities, there is a need to consider the use of modern
technologies designed to improve disinfection of surfaces in hospitals.
New technologies fall into several categories, including: (A) new liquid
surface disinfectants, (B) improved methods for applying disinfectants,
(C) self-disinfecting surfaces, (D) light-activated photosensitizers,
and (E) no-touch (automated) technologies.
New liquid disinfectants
New
disinfectants that are currently available or under development include
improved hydrogen peroxide liquid disinfectants, peracetic
acid-hydrogen peroxide combination, electrolyzed water, cold atmospheric
pressure plasma, and polymeric guanidine. Several improved hydrogen
peroxide disinfectants have been shown to be effective one-step
cleaner/disinfectant agents that significantly reduce bacterial levels
on surfaces [35–38].
In one study, use of a product containing 0.5 % (weight/volume)
improved hydrogen peroxide was associated with fewer
healthcare-associated infections when compared to an existing cleaning
product, although all potential confounding variables were not analyzed [38].
Improved hydrogen peroxide liquid disinfectants can also be used to
reduce contamination by multidrug-resistant pathogens on soft surfaces
such as bedside curtains [14, 39].
Several of the improved hydrogen peroxide disinfectants also have
activity against norovirus surrogate viruses, although they are not as
potent as sodium hypochlorite (bleach) solutions [40].
These newer disinfectants have Environmental Protection Agency (EPA)
safety rating of category IV (housekeepers do not need to wear any
personal protective equipment while using these products).
A new
sporicidal disinfectant that contains both peracetic acid and hydrogen
peroxide has been shown to reduce bacterial levels on surfaces to a
greater degree than a quaternary ammonium disinfectant in one study, and
reduced contamination by C.difficile, MRSA, and VRE as effectively as sodium hypochlorite in another study [41, 42].
The product has a smell similar to vinegar that may be of concern when
it is initially introduced. The combination product gives hospitals a
potential alternative to sodium hypochlorite when a sporicidal
disinfectant is needed.
Electrolyzed water (hypochlorous acid) disinfectant is produced by passing current through a solution of water and salt [43–45].
This promising disinfectant was shown to reduce bacterial levels on
surfaces near patients to greater degree than a quaternary ammonium
disinfectant in one study [43]. In another study, an electrolyzed water disinfectant significantly reduced MRSA, VRE and C. difficile spores in in-vitro experiments, and significantly reduced aerobic bacteria and C. difficile spores when sprayed onto medical equipment [44].
Spraying equipment was simple, required only approximately 15 s per
application, and could be left to dry without wiping. One group of
investigators found that electrolyzed water effectively reduced the
number of aerobic bacteria (including staphylococci) on near-patient
surfaces, but for reasons not well understood, appeared to allow
regrowth of staphylococci within 24 h of application [45].
Further studies of this phenomenon are warranted. Electrolyzed water
has the advantage of not leaving any toxic residues on surfaces. Issues
related to stability of such products and logistic issues related to its
use require additional study.
Cold-air atmospheric pressure
plasma systems are being investigated for possible use as surface
disinfectants in healthcare facilities [46–48].
In laboratory studies, the reactive oxygen species generated by these
systems have bactericidal activity against a variety of pathogens, with
variable activity against C. difficile spores [48].
Much more experience with cold-air atmospheric pressure plasma systems
is needed to determine the practicality, efficacy and safety of using
such systems in hospital settings. A novel nebulized solution of
polymeric guanidine has been shown in one study to have antimicrobial
activity against several healthcare-associated pathogens, and may
warrant further investigation [49].
New methods for applying disinfectants
Microfiber
cloths or mops and ultramicrofiber cloths are among the relatively
newer methods for applying liquid disinfectants to surfaces [50–54].
Some studies have shown increased cleaning efficacy of microfiber or
ultramicrofiber cloths compared to standard cotton cloth or mops [51, 55]. However, it appears that all microfiber wipes are not equally effective [50]. Furthermore, if not used properly, there is some evidence that they may actually spread bacteria to other surfaces [53, 54].
When using microfiber cloths or mops, is important to know that the
durability of these products is adversely affected by hypochlorite and
high temperatures used during laundering and drying, and that their
performance may decrease after multiple washings. One of the advantages
of microfiber over cotton cloths is that microfiber is less likely than
cotton cloths to bind quaternary ammonium disinfectants [16, 17].
However, presently, it is not clear how much the lower binding of
microfiber cloths to quaternary ammonium disinfectants effects
eradication of bacteria from contaminated surfaces. Additional studies
are needed to better define the relative advantages and disadvantages of
applying surface disinfectants with microfiber, cotton cloths and
spunlace non-woven disposable wipes.
Self-disinfecting surfaces
Creating
“self-disinfecting surfaces” by coating surfaces with heavy metals such
as copper or silver that have innate antimicrobial properties or
applying to surfaces compounds that retain their antimicrobial activity
for weeks or months has received some attention as a new strategy for
disinfecting or preventing the growth of bacteria on surfaces in
hospitals [56, 57].
Silver binds strongly with disulfide and sulfhydryl groups present in
proteins of microbial cell walls, leading to cell death [56].
The antimicrobial activity of copper may be due primarily to its
ability to form reactive oxygen radicals that damage nucleic acid and
proteins [56]. Impregnating equipment surfaces with copper alloys has been shown to reduce bacterial contamination of surfaces [58–60],
and in one study, coating several surfaces in hospital rooms with
copper alloy was associated with reduction in incidence of HAIs [60].
Further studies of the long-term antimicrobial potency, practicality
and cost-effectiveness of copper-coated surfaces are needed. Privacy
curtains impregnated with silver have been shown to reduce or delay
contamination of curtains with potential pathogens [61, 62].
Organosilane
compounds are comprised of a surfactant plus an antimicrobial substance
such as a quaternary ammonium moiety. These compounds are designed to
minimize bacterial contamination of surfaces by maintaining their
antimicrobial activity on surfaces for weeks or months. To date, the
ability of these compounds to prevent contamination of surfaces for
prolonged time periods is unclear. One study that applied compounds to
surfaces using microfiber cloths failed to demonstrate continuing
antimicrobial activity, where as two other studies using different
application methods reported persistent antimicrobial activity of
varying levels for differing time periods [63–65].
Further evaluation of organosilane-type compounds using a variety of
application methods appears warranted. Polyhexamethylene biguanide
disinfectant was found to reduce bacterial levels on surfaces for at
least 24 h after application in one study [66].
Light-activated photosensitizers
A
few studies have explored the potential of applying of light-activated
photosensitizers such as nanosized titanium dioxide to surfaces and
using UV light to generate reactive oxygen species that can disinfect
surfaces [67–70].
Activated titanium dioxide has been shown to have varying antimicrobial
activity, with the relative susceptibility of agents against pathogens.
Research on the use of light-activated photosensitizers is in early
stages, and much more information about the feasibility and safety of
using this strategy is needed.
Aerosolized
hydrogen peroxide systems that utilize 3 to 7 % hydrogen peroxide with
or without the addition of silver ions have been evaluated by several
investigators [25, 73–79].
Aerosols (which are not vapor) generally have particle sizes ranging
from 2 to 12 μ, are injected into a room, followed by passive aeration.
These systems have been shown to significantly reduce bacteria,
generally a 4 log10 reduction of spores, although in several
studies spores were not completely eradicated. One system has a
sporicidal claim from the EPA in the United States. In one study, use of
the aerosolized hydrogen peroxide system was associated with a
reduction in C. difficile infection, and possible reduction of MRSA acquisition in a second study [25].
Like many other strategies in infection control, there are currently no
randomized controlled trials of the efficacy of these systems in
preventing health-care-associated infections.
Hydrogen peroxide vapor
A
“dry gas” vaporized hydrogen peroxide system that utilizes 30 %
hydrogen peroxide has been shown to be effective against a variety of
pathogens, including Mycobacterium tuberculosis, Mycoplasma, Acinetobacter, C. difficile, Bacillus anthracis, viruses, and prions [80–83].
In before/after studies, dry gas vaporized hydrogen peroxide system,
when combined with other infection control measures, appears to have
contributed to control of outbreaks of Acinetobacter in a long-term care facility and in two intensive care units in a hospital [84–86]. However, long cycle times have made it difficult to implement this system in healthcare facilities.
A
micro-condensation hydrogen peroxide vapor system, which utilizes 35 %
hydrogen peroxide, is effective in eradicating important pathogens
including MRSA, VRE, C. difficile, Klebsiella, Acinetobacter, Serratia, Mycobacterium tuberculosis, fungi, and viruses. Laboratory-based and in-hospital studies documented significant reductions (often 106 log10) of a number of these pathogens, with 92 to 100 % reduction of pathogens on surfaces [23, 83, 87–93].
In before/after trials, when used in conjunction with other measures,
the micro-condensation hydrogen peroxide vapor system appears to have
contributed to control of outbreaks caused by MRSA, multi drug-resistant
Gram-negative bacteria, and C. difficile [78, 87, 94–99].
A prospective, controlled trial performed by Passaretti et al.
demonstrated significant reduction in the risk of acquiring
multidrug-resistant organisms (MDROs), especially VRE [30].
It has also been used to decontaminate the packaging of unused medical
supplies removed from isolation rooms, instead of discarding such items [100].
This system has also been used to decontaminate rooms previously
occupied by patients with the Lassa fever and Ebola virus infection [101, 102].
Despite the demonstrated ability of this system to eradicate nosocomial
pathogens from surfaces, concerns over its cost and room
turn-around-times have hampered adoption of this technology in
healthcare settings. At least one study found that the
micro-condensation hydrogen peroxide system can be implemented in
hospitals when census levels are relatively high [103].
Recent improvements in the efficiency of the system permit more rapid
turn-around-times than earlier equipment, which may lead to wider
adoption. To date, there are no randomized, controlled trials
establishing the impact of the micro-condensation hydrogen peroxide
system on reduction of healthcare-associated infections. Other vapor- or
aerosol-based no-touch disinfection technologies that have been
described, but whose adoption appears to be limited include gaseous
ozone, chlorine dioxide gas, and saturated steam systems [104–109].
Ultraviolet light devices
Automated
mobile ultraviolet light devices that continuously emit UV-C in the
range of 254 nm can be placed in patient rooms after patient discharge
and terminal cleaning has been performed. A number of these devices can
be set to kill vegetative bacteria or to kill spores. These systems
often reduce the VRE and MRSA by four or more log10, and C. difficile by 1–3 log10 [110–118].
In one comparative trial, a continuous UV-C light system resulted in
lower log reductions than a micro-condensation hydrogen peroxide vapor
system [119].
Advantages of the mobile, continuous UV-C light devices include their
ease of use, minimal need for special training of environmental services
personnel, and unlike hydrogen peroxide vapor systems, the ability to
utilize the devices without having to seal room vents or doors.
Recently, a prospective, multicenter randomized controlled trial
comparing a mobile continuous UV-C light system with standard and other
enhanced surface disinfection methods has been completed [120]. Results of the trial should be published in the near future.
A
pulsed-xenon device, which does not use mercury bulbs to produce UV
light, emits light in the 200–320 nm range. It has been shown to
significantly reduce pathogens in patient rooms [121–127].
The manufacturer recommends placing device in 3 locations in a room
with 5–7 min cycles (shorter than with some continuous UV-C systems).
While a few studies utilizing the device reported reductions in C. difficile infection [122, 127], a more recent 8-month study in a large institution found no significant reduction in C. difficile infection rates hospital-wide or on four units with high C. difficile infection rates [128]. One carefully-performed trial which compared the pulsed-xenon system with a continuous UV-C light device found that log10 reductions of pathogens achieved with the pulsed-xenon system were lower than with the continuous UV-C light device [129]. Additional evaluation of the pulsed-xenon UV system by independent investigators is needed.
High-intensity narrow-spectrum light
High-intensity
narrow-spectrum (HINS) light, which is visible violet-blue light in the
range of 405 nm has been tested as a means of disinfecting air and
surfaces and hospital rooms. This technology targets intracellular
porphyrins that absorb the light and produce reactive oxygen species [130–132].
Its antimicrobial efficacy is lower than UV-C light, but it can be used
in areas occupied by patients. In one study, continuous HINS light
showed a 27 to 75 % reduction in surface contamination by staphylococci
compared to control areas [131]. Further investigation of this technology, including its level of activity against C. difficile, appears warranted.
Photocatalytic disinfection
An
enclosed air purifying system designed for use by NASA utilizes
UV-activated titanium dioxide photocatalytic reactions to oxidize
volatile organic compounds and airborne microorganisms. Since
aerosolization of pathogens such as S. aureus and C. difficile
during patient care activities is known to occur, there may be some
interest in using such systems in patient rooms to reduce airborne
bacteria may settle onto environmental surfaces [133].
Given
the increasing interest in the above-mentioned new technologies for
cleaning and disinfection of environmental surfaces, the Agency for
Healthcare Research and Quality (AHRQ) recently commissioned an expert
panel to review data regarding these modern technologies. The panel
concluded that there is a relative lack of comparative studies
addressing the relative effectiveness of various cleaning, disinfecting
and monitoring strategies, and that future studies are needed that
directly compare newer disinfecting and monitoring methods to one
another and with traditional methods [4].
Conclusions
In
conclusion, manual cleaning and disinfection of environmental surfaces
in healthcare facilities (daily and at patient discharge) are essential
elements of infection prevention programs. Because many factors make it
difficult to achieve high rates of effective disinfection on a routine
and sustained basis, continued efforts to improve the quality and
consistency of traditional cleaning and disinfection practices are
needed. Given the many challenges in achieving desired levels of surface
disinfection, adoption of modern technologies is indicated to
supplement traditional methods. Further research into the efficacy and
cost-effectiveness of newer technologies, and when to best apply them,
is needed. As additional data become available, it is likely that newer
liquid disinfectants and some no-touch room decontamination systems will
be more widely adopted to supplement traditional cleaning and
disinfection practices.
Prevention must be prioritised while we wait for a clearer picture
As
many countries face new stay-at-home restrictions to curb the spread of
covid-19, there are concerns that rates of suicide may increase—or have
already increased.12 Several factors underpin these concerns, including a deterioration in population mental health,3 a higher prevalence of reported thoughts and behaviours of self-harmamong people with covid-19,4 problems accessing mental health services,4 and evidence suggesting that previous epidemics such as SARS (2003) were associated with a rise in deaths by suicide.5
Widely
reported studies modelling the effect of the covid-19 pandemic on
suicide rates predicted increases ranging from 1% to 145%,6
largely reflecting variation in underlying assumptions. Particular
emphasis has been given to the effect of the pandemic on children and
young people. Numerous surveys have highlighted that their mental health
has been disproportionately affected, relative to older adults,37 and some suggest an increase in suicidal thoughts and self-harm.8
Supposition,
however, is no replacement for evidence. Timely data on rates of
suicide are vital, and for some months we have been tracking and
reviewing relevant studies for a living systematic review.6
The first version in June found no robust epidemiological studies with
suicide as an outcome, but several studies reporting suicide trends have
emerged more recently. Overall, the literature on the effect of
covid-19 on suicide should be interpreted with caution. Most of the
available publications are preprints, letters (neither is peer
reviewed),91011 or commentaries using news reports of deaths by suicide as the data source.12
Nevertheless,
a reasonably consistent picture is beginning to emerge from high income
countries. Reports suggest either no rise in suicide rates
(Massachusetts, USA11; Victoria, Australia13; England14) or a fall (Japan,9 Norway15)
in the early months of the pandemic. The picture is much less clear in
low income countries, where the safety nets available in better
resourced settings may be lacking. News reports of police data from
Nepal suggest a rise in suicides,12 whereas an analysis of data from Peru suggests the opposite.10
Any
change in the risk of suicide associated with covid-19 is likely to be
dynamic. The 20% decrease in Japan early in the pandemic seemed to
reverse in August, when a 7.7% rise was reported.9
Evidence from previous epidemics suggests a short term decrease in
suicide can occur initially—possibly linked to a “honeymoon period” or
“pulling together” phenomenon.5
Trends in certain groups may be hidden when looking at overall rates,
and the National Child Mortality Database has identified a concerning
signal that deaths by suicide among under 18s may have increased during
the first phase of lockdown in the UK.16
Preventive action
We
must remain alert to emerging risk factors for suicide but also
recognise how known risk factors may be exacerbated—and existing trends
and inequalities entrenched—by the pandemic. In 2019, suicide rates
among men in England and Wales were the highest since 2000, and although
suicide in young people is relatively rare, rates have been rising in
10-24 year olds since 2010.17
Tackling
known risk factors that are likely to be exacerbated by the pandemic is
crucial. These include depression, post-traumatic stress disorder,
hopelessness, feelings of entrapment and burdensomeness, substance
misuse, loneliness, domestic violence, child neglect or abuse,
unemployment, and other financial insecurity.15
Appropriate services must be made available for people in crisis and those with new or existing mental health problems.14
Of greatest concern, is the effect of economic damage from the
pandemic. One study reported that after the 2008 economic crisis, rates
of suicide increased in two thirds of the 54 countries studied,
particularly among men and in countries with higher job losses.18
Appropriate
safety nets must be put in place or strengthened for people facing
financial hardship, along with active labour market policies to help
people who are unemployed obtain work.Responsible media
reporting also has a role: promoting the importance of mental health
support, signposting sources of help, reporting stories of hope and
recovery, and avoiding alarmist and speculative headlines that may
heighten risk of suicide.1920
It
is still too early to say what the ultimate effect of the pandemic will
be on suicide rates. Data so far provide some reassurance, but the
overall picture is complex. The pandemic has had variable effects
globally, within countries and across communities, so a universal effect
on suicide rates is unlikely. The impact on suicide will vary over time
and differ according to national gross domestic product and individual
characteristics such as socioeconomic position, ethnicity, and mental
health.
One guiding principle, however, is that suicide
is preventable, and action should be taken now to protect people’s
mental health. We must remain vigilant and responsive, sharing evidence
early and internationally (such as in the International Covid-19 Suicide
Prevention Research Collaboration21) in these evolving uncertain times.
Footnotes
Competing interests: The BMJ
has judged that there are no disqualifying financial ties to commercial
companies. The authors declare the following other interests: AJ chairs
the Welsh government’s National Advisory Group on Suicide and Self-harm
Prevention. DG is a member of the National Suicide Prevention Strategy
Advisory Group (England) and Samaritans policy and research committee.
LA is co-chair of the National Suicide Prevention Strategy Advisory
Group (England).
Provenance and peer review: Commissioned; not externally peer reviewed.
This
article is made freely available for use in accordance with BMJ’s
website terms and conditions for the duration of the covid-19 pandemic
or until otherwise determined by BMJ. You may use, download and print
the article for any lawful, non-commercial purpose (including text and
data mining) provided that all copyright notices and trade marks are
retained.https://bmj.com/coronavirus/usage
COVID-19 Suicide Prevention Research Collaboration
. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry2020;7:468-71. doi:10.1016/S2215-0366(20)30171-1 pmid:32330430CrossRefPubMedGoogle Scholar
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