At this time of year, we are reminded of the risk of contracting colds or flu and cautioned to obtain a flu shot, observe good hand hygiene and cough etiquette. Whether we do or we don’t is one of personal choice, but the risks associated with infection acquisition can have severe consequences not only to others but also to our social and financial infrastructure. Should we forget the lessons learned from the SARS outbreaks in Asia and Canada in 2003 to the more recent MERS-CoV outbreaks in the Middle East and South Korea, we do so at our peril. Succinctly put by Dr. Richard Schabas, Chief of Staff of York Central Hospital, Toronto, “SARS 1 was not avoidable. We were struck by lightning. Everything after that was (avoidable).”
Through the ages, humans have relied on animals. However, our interactions with animals have infected humans with numerous communicable diseases. Exotic animals in a Guangdong market may have given the human race yet another novel infectious disease: severe acute respiratory syndrome, or SARS. Old diseases usually spread slowly. SARS, on the other hand, moved at the speed of a jet airplane. Within days of its arrival in Hong Kong, it had circled the globe, spreading to 37 countries and causing about 1,000 deaths. The 2009 H1N1 Swine flu virus similarly spread rapidly and claimed the lives of 300,000 people worldwide.
Significantly, in each of the SARS and MERS-CoV outbreaks, a large proportion of those infected were hospital staff, including the environmental support workers. These people were largely uneducated in infection prevention and ill trained in appropriate precautions. Robust public health resources are now in place. But the point I am arriving at for you to consider is this. UAE, and Dubai in particular, is a global hub serving virtually every corner of the earth, and with this remarkable achievement it has also inherited the commensurate risk of infection and at worst, the potential for pandemic disease.
The statistics: Dubai airport is projected to receive 88 million passengers this year. A further 26 million passengers pass through Abu Dhabi. The Al Maktoum Airport DWC will become the new world’s largest airport serving 146 million passengers by 2025. Expo 2020 will welcome an estimated 25 million visitors. The Dubai Metro serving Expo 2020 will have the capacity to carry 46,000 passengers an hour. These are staggering numbers. Multiply by two and you have the number of hands that will touch common surfaces, sharing each individual’s bacteria. Coughs and sneezes will contaminate surfaces and shed particulate plumes through the air.
Due to globalisation, growing populations and increased accessibility to international travel, airports and transit systems now need to have a strong prevention mechanism in place and emergency response plan to effectively respond to the event of a pandemic. This responsibility for infection preparedness and response planning and training extends also to the allied tourism facilities and services of hotels and tourist sites. It is quite possible that with the rapidly expanding rate of air travel (forecast to double in the next 15 years), the risks of infection will similarly increase. It is likely that diseases will spread around the world quicker. Aircraft and airports are possible places where infectious individuals may interact with airport staff and passengers.
Risk factors involved
The risk for disease transmission will depend on several factors, such as the disease transmission mode, infectivity and virulence of the pathogens, duration of exposure, applied protective measures as well as vaccination status. Fortunately, the human immune system in healthy individuals is resistant to many forms of infection and standard precautions by the individual can prevent or significantly reduce the likelihood of infection. Personal behaviour measures such as good hand hygiene practice and frequency, cough etiquette and consciously not touching the face will prevent infection.
Organisational measures within high-density, high-usage facilities such as airport lounges, waiting areas, restaurants, sanitary areas, hotels, malls, theatres, recreational parks, public transport require a multi-modal approach to risk mitigation - from public health to facilities management, engineering and environmental support services including cleaning. High density areas should have user access to hand washing and hand sanitiser dispensers as a priority intervention as a front-line preventative measure. Contaminated hands are acknowledged as the principle cause of preventable infection.
The ‘hidden’ microbial challenge
To expand on the magnitude of the challenge of maintaining safe environments, we can identify and apply mitigation measures from lessons learned from Healthcare Associated Infection, i.e. infections that are acquired within the hospital environment, either from direct transmission of indirect via the environment (hand contact with contaminated surfaces, or from the air or water).
Over the past 10 years, there has been a growing body of research evidence that has clearly established the link between the healthcare environment and acquired infection. The evidence highlights the susceptibility for contamination of frequently touched environmental surfaces and that there is a direct correlation between the level of bio-burden found in the environment and the level of contamination of healthcare workers’ hands.
Cleaning and disinfection of healthcare surfaces are therefore of paramount importance, as is the frequency of cleaning, since many of these high frequency touch sites become heavily contaminated within minutes or a few hours after cleaning. The relationship between good hand hygiene practice and environmental cleaning is an equal and opposite equation. We need to focus as much on surface cleaning as we emphasise the importance of hand hygiene.
However, the challenge is more complex than it was first thought. Microorganisms are constantly evolving and can remain viable in the environment for long periods of time (days – months). Add to this the nature of the surface we are attempting to clean and disinfect. Not all surfaces react in the same manner in terms of ‘cleanability’, whereby the efficacy of chemical disinfectants can be compromised by the inherent surface characteristics. In many cases, we are no longer cleaning a flat smooth surface but rather a three-dimensional profile that harbours organic residue and biofilm and inhibits decontamination by traditional cleaning methods.
How do we protect ourselves from the micro-organisms that we cannot see? From the perspective of training cleaning staff, how do we make the invisible, visible? UV fluorescence (black light) ‘illuminates’ organic contamination, ATP (Adenosine Triphosphate) swab method is a rapid detection for organic contamination. However, these techniques are not always practical beyond training and periodic audit applications.
Environmental research has revealed the typical ‘hot spots’ of contamination and this reference provides us with the guidance for prioritising focal points and applying evidence-based materials and competency based training methods to achieve optimal effectiveness and efficiency. The ‘quality’ of cleaning has historically been assessed by visual inspection. While the aesthetic appearance is an important aspect of perceived cleanliness it does not provide assurance that the environment is microbiologically clean and safe.
The cleaning quotient
Cleaning, whilst recognised as an essential service, has not received the necessary investment in staff education, training, technical skills development and material resources essential to keep pace with the dynamic complexity of microbial contamination. Not only in healthcare environments but also common public facilities that service large numbers of people – transport, hospitality, recreational, malls, schools etc. Cleaning and disinfection is a science. The practitioners should be competency trained hygiene technicians. However, all too often, cleaning is viewed as a low skilled occupation. As a consequence, the staff is typically under-valued and rarely recognised as a front-line resource in infection prevention.
Cleaning contract costing typically focuses on square metres and the number of basic cleaning staff required. It may or may not include reference to outcome based on risk to the facility user (e.g. prevention of infection and patient safety). Consequently, the status quo remains whereby the lower bid wins the tender and does not include sufficient funds to incorporate competency based training, desired by infection prevention & control, and application of evidence-based cleaning methods, materials and equipment or timely adoption of emerging hygiene technology.
These are generalised comments and there are always exceptions. But, I take you back to the opening of this commentary, which identifies the UAE and Dubai in particular as an exceptional place in our world. UAE has created a global hub and leads the world in futuristic visioneering and investment in infrastructure and societal resources. As larger numbers of visitors converge, the greater the demand on facilities and resources which need to be maintained to the highest level of hygiene as is practically possible.
Emphasis needs to be placed on planning and developing the skills for preventative measures and developing capability in rapid response resources to meet the challenge of pandemic infection as it emerges in any part of the world. Leadership comes at a price. Prevention is an investment in the future, and our hygiene industry has an exceptional front-line role to play.
About the Author: Michael Rollins is an independent consultant specialising in validation and implementation of healthcare hygiene technology, environmental Infection prevention and integration within patient safety quality improvement initiatives.