Reducing Airborne Transmission

Reducing Airborne Transmission

Why UV air filtration units are critical to patient – and caregiver – safety, and how to broach the topic with customers

Amid the COVID-19 pandemic, conversations on how to reduce airborne transmission of pathogen have come

front and center. UV air filtration units are one solution distributor reps can discuss with their customers. In the following Q&A, Alan Kivia, president of Medical Illumination, and Rob Saron, senior vice president, global distribution, Symmetry Surgical, provide insights on the benefits of the technology, its proper uses in different care settings, and how distributor reps can approach accounts about the topic.

Repertoire: How old are UV air filtration units? That is to say, how long have they been around?

The first commercial grade UV-C lamps were developed in the 1930s and were used primarily in hospitals to neutralize viruses, bacteria, and molds. Due to the harmful effects UV-C can have on the skin, they are used only in unoccupied spaces.

UV24 was introduced as VidaShield in April 2016. The product line was acquired by Medical Illumination in April 2019 and was introduced into the distribution market in late 2019.

Repertoire: What improvements have been made to the technology in the ensuing years?

Being able to use UV-C to deactivate airborne pathogens in occupied spaces was made possible by shielding the UV-C in an enclosed irradiation chamber. In such devices, air is brought into the irradiation chamber

through the use of fans where it is exposed to the UV-C in the appropriate dose to destroy the pathogens, while assuring that no harmful rays escape from the fixture. The units should run continuously, turning the air over in the room approximately every 15 minutes. By incorporating the irradiation chamber into ceiling lighting fixtures, the installation and retrofit of existing rooms is easy.

It has also been shown that much of the surface contamination in a facility is due to pathogens settling out of the air. Use of these units has shown to significantly reduce the pathogens found on surfaces within the area. Because the UV-C deactivates molds in the air, odors are often dramatically reduced in the space.

Repertoire: Where are they typically installed? Hospitals (and if so, where in the hospital)? Longterm-care facilities? Outpatient surgery centers?

Units are appropriate in any areas where people gather, in any location where there may be exposure to harmful airborne pathogens, or in any location where individuals with compromised immune systems may be.

In the hospital, studies have shown that the areas with the highest bio-burden are the Emergency Room and the staff changing rooms. Soiled linen closets also are areas where high amounts of airborne pathogens are found. Besides these obvious areas, ICUs, patient recovery areas, nurse stations and corridors around the surgical suite are also prime areas.

Outside of the hospital and surgical center facility, such units are beneficial in cancer treatment centers, compounding pharmacies, dental offices, long term care facilities, assisted living facilities, day care facilities, schools, offices and any other areas where groups may congregate.

Repertoire: How about physician offices? Does it make sense for a physician to have an air filtration unit in exam rooms?

UV-C units not only help to reduce airborne pathogens from transferring between patients, they help to reduce pathogens transferred to the staff. Whenever doctors, nurses, or office staff contract highly contagious diseases, the costs to a practice can be very high due to staff missing work and being unable to treat patients. Any disease contracted at a medical facility can be damaging to the facility’s reputation. Since Medical Illumination acquired this product, it has fairly significantly reduced the distributor’s and thus the end users price.

Repertoire: Who would be the typical decisionmaker(s) to acquire an air filtration unit in:

ʯ The hospital? Infection Control departments and facilities departments ʯ Long-term-care facility? Management and facilities departments ʯ Surgery center? Infection Control departments and facilities departments ʯ Physician office? Office Managers, Physicians, facilities departments

Repertoire: How about the distributor rep, such as those who read Repertoire? What’s their role?

Distributor reps should be on the lookout for opportunities where this technology can help to reduce airborne transmission.

Whenever doctors, nurses, or office staff contract highly contagious diseases, the costs to a practice can be very high due to staff missing work and being unable to treat patients.

Other airborne pathogens such as influenza and MRSA, to name a few, are always a threat, and can stay airborne for much longer periods of time than coronavirus. None the less, having this product cleaning the air we breathe 24/7 can only lead to a healthier work environment. This is good for the physician, the staff and the patients. The culture around this product has changed. A month ago when we would talk about this, doctors considered it a luxury item, unnecessary and superfluous. That has changed in short order, and I believe permanently. They weren’t giving enough attention to how quickly contagious diseases can spread through the air and how they, their staff, and their patients can be exposed when a contagious patient is present. Those risks have been more fully exposed by the pandemic.

Distribution reps should be talking about this product when the PPE subject is being discussed or when doctors are asking about air filtration systems or UV robots.

Repertoire:Among hospital customers, what are the most common objections? How do you respond?

Costs are typically the biggest objection since many units may be necessary to adequately cover a large area. It is important to make the customer aware that these units are considered Engineering Controls that once installed do not require any effort from the medical staff. The continuous reduction of bioburden in the air does not require the units to be managed actively like surface disinfection units that use UV-C. Such units have to be moved from room to room when the rooms are unoccupied, often requiring a dedicated person to manage this operation.

Prior to the coronavirus pandemic, hospitals often felt they were doing enough to manage the quality of the air throughout their facilities by wiping down counters and surface cleaning in combination with robots. Now that we see the effects of what a highly contagious airborne pathogen can do, we realize that more can be done.

Repertoire: What about long-term-care facilities?

Again, the initial costs to purchase and install units throughout the facility. Protecting the patients, staff, visitors, and reputations are the main benefit drivers. For example, if highly contagious flu were to spread throughout a facility, the costs would be very high.

Costs will always be the main objection, with the benefit being the reduced likelihood transmitting airborne pathogens between individuals. However, you do not need to do the whole office or facility at one time.

In long-term-care facilities, there is typically no time when rooms will be unoccupied long enough to do complete disinfection, and even if there were, new pathogens can be introduced the moment someone enters the room.

Prior to the coronavirus pandemic, long-term care facilities often felt they were doing enough to manage

The effectiveness of air filtration units and COVID-19

While the unit has not been specifically tested with COVID-19, and therefore not validated, the white paper shows that other coronavirus removal rates from a single pass through the unit are 100%.

the quality of the air throughout their facilities by surface cleaning and purchasing robots. Now that we see the effects of what a highly contagious airborne pathogen can do, we realize that more can be done.

Repertoire: And physician offices/clinics?

Costs will always be the main objection, with the benefit being the reduced likelihood transmitting airborne pathogens between individuals. However, you do not need to do the whole office or facility at one time. The office could do the waiting room or rooms first and then do exam rooms a few at a time.

Repertoire: Is there a consumables trail? What is it? And if so, would the med/surg distributor carry them? Or would it be an HVAC service provider?

Units require that the intake filter be replaced every 3 months and the UV lamp be replaced once a year. An annual maintenance kit includes one UV lamp and 4 filters. These kits can be put on automatic reorder annually for each unit at a customer’s facility through the med/surg distributor.

Repertoire: Anything else to add that might encourage Repertoire readers to discuss air filtration units with their customers?

Medical facility staff spend an enormous amount of time cleaning and disinfecting their facilities on a daily basis, but the air is often overlooked. In fact, the air in a facility is often the dirtiest right after the surface cleaning process is complete as much of the matter that has been on surfaces, linens, etc. become airborne from the cleaning process. Studies have shown that air purification units using UV-C have reduced hospital acquired infections dramatically once installed.

Frontline Infection Control

Could a healthcare provider’s antiseptic solution itself be a possible source of contamination?

Skin antiseptic products are used to reduce bacterial burden on skin prior to performing invasive medical procedures,

such as injections or surgical incisions. In this role, skin antiseptics, including alcohol, iodine, and chlorhexidine gluconate (CHG), are part of the frontline in infection control. 1,2,3,4,5

As our understanding of factors leading to infection has evolved, so have antiseptics and aseptic technique. The goal of any aseptic procedure is to reduce the risk of contamination by pathogens that are prevalent on the skin and in the environment. Appropriately, it is standard practice to use sterile instrumentation and take great care to prevent contamination from the surrounding environment. However, only recently has the antiseptic solution itself been investigated as a possible source of contamination. 1

Contamination

In a survey, 92% of healthcare providers indicated they were not aware that antiseptic solutions are not sterile. 6 Sterile means free of microorganisms (any microscopic organism such as bacteria), and sterile products are treated with a process during manufacturing to eliminate potential microorganisms.

The idea of contaminated antiseptic solutions goes against common perception because the primary function of an antiseptic is to kill bacteria. Yet, antiseptics are not “self-sterilizing,” and bacteria can persist for prolonged periods of time within antiseptic products. Unfortunately,

numerous outbreaks have occurred worldwide as a result of antiseptics contaminated with persistent bacteria. 1,7 In 2007, a review article summarizing over 50 years of documented patient infections was published. It showed how infections were caused by various contaminated germicides, including patient skin antiseptics and surface disinfectants. 1

In 2010, an outbreak of patient infections occurred as a result of contaminated alcohol prep pads. In 2013, the U.S. Food and Drug Administration (FDA) reported that all commonly used antiseptic categories have been linked to infection-causing contamination. 8 Documented results included: ʯ Bacteremia in 32 cases ʯ Wound infection in five cases and peritonitis in seven cases ʯ Replacements required for indwelling catheters in 14 cases ʯ Sepsis in two cases ʯ Infection of the injection site in 16 cases ʯ Death of five patients due to B. cereus ʯ Product recalls of alcohol prep pads following 40 out of 60 testing positive for B. cereus

Outcomes associated with contaminated antiseptics may be underreported for a range of reasons, including 1 : ʯ Disposal of the contaminated product before infection is discovered ʯ Inconsistent contamination within the same product lot

Manufacturers are not required to sterilize antiseptics so the risk of bacterial contamination continues to exist; however, sterile and nonsterile labeling allows healthcare professionals to make informed decisions. The majority of preoperative skin preparation components (applicators, sponges, ampoules) are sterilized using an ethylene oxide chemical process; however, the solution itself is nonsterile. CHG is a thermally sensitive compound. 9 While heat exposure during terminal sterilization would sterilize the solution, it will also damage its chemical integrity. Thus, any terminal sterilization process must balance the integrity of the CHG molecule (i.e., strength and purity) while achieving thermal exposure conditions necessary for sterilization.

New solutions

Standard belief, among most manufacturers, is that it is impossible and impractical to sterilize CHG-based antiseptics on a scale large enough to fulfill surgical needs in the U.S. 10 Contrary to this thinking, BD (Becton, Dickinson and Company) (NYSE: BDX) researched and developed a patented sterilization process to achieve the temperature control, precision and scale necessary to effectively sterilize CHG.

As antiseptics have evolved to reduce bacterial threats, this new sterilization technology has allowed BD to bring a fully sterile skin preparation option to healthcare providers. BD invested significant resources and research hours to create a patented sterilization process to achieve a minimum sterility assurance level (SAL) of 10-6. 11

“We invested six years of effort, more than 50,000 research and development hours and millions of dollars to develop the only commercially available sterile CHG skin antiseptic, because we knew it was the right thing to do for patient safety,” said Gary M. Cohen, Executive Vice President, Global Health, and President, BD Foundation.

As antiseptics have evolved to reduce bacterial threats, this new sterilization technology has allowed BD to bring a fully sterile skin preparation option to healthcare providers.

BD ChloraPrep™ Patient Preoperative Skin Preparation with sterile solution is the only commercially available patient preoperative skin antiseptic in the U.S. that combines: ʯ FDA-approved dual formulation of 2% chlorhexidine gluconate (CHG) + 70% isopropyl alcohol (IPA) ʯ Packaged in a proprietary one-step, single-use sterile applicator ʯ CHG-based sterile antiseptic solution

The result is BD ChloraPrep™ Patient Preoperative Skin Preparation with sterile solution which builds on the proven history of ChloraPrep™ and its over 4 billion applicators used to date, more than any other 2% CHG/70% IPA skin prep applicator. ChloraPrep™ is supported by more than 50 peer-reviewed publications demonstrating its efficacy in driving patient safety and better clinical outcomes.

1 Chang C, Furlong LA. Microbial stowaways in topical antiseptic products. N Eng J Med. 2012;367;23:2170-2173. doi: 10.1056/NEJMp1212680. 2 Poole K. Bacterial stress responses as determinants of antimicrobial resistance. J Antimicrob Chemother. 2012;67:2069–2089. doi:10.1093/jac/dks196. 3 Hijazi K, Mukhopadhya I, Abbott F, et al. Susceptibility to chlorhexidine amongst multidrug-resistant clinical isolates of Staphylococcus epidermidis from bloodstream infections. Int J Antimicrob Agents. 2016;48(1):86-90. Doi 1016/j.ijantimicag.2016.04.015. 4 Tansirichaiya S, Reynolds LJ, Cristarella G, et al. Reduced susceptibility to antiseptics is conferred by heterologous housekeeping genes.Microb Drug Resist. 2017. doi: 10.1089/mdr.2017.0105. 5 Rose H, Baldwin A, Dowson CG, et al. Biocide susceptibility of the Burkholderia cepacia complex. J Antimicrob Chemother. 2009;63(3):502–510. doi:10.1093/jac/dkn540. 6 BD, data on file. 7 Weber DJ, Rutala WA, Sickbert-Bennett EE. Outbreaks associated with contaminated antiseptics and disinfectants. Antimicrob Agents Chemother. 2007;51(12):4217–4224. doi: 10.1128/AAC.00138-07. 8 FDA Drug Safety Communication: FDA requests label changes and single-use packaging for some over-the-counter topical antiseptic products to decrease risk of infection. Food and Drug Administration website. http://www.fda.gov/drugs/drugsafety/ucm374711.htm. Published November 13, 2013. Updated February 29, 2016. Accessed July 31, 2019. 9 Zong Z, Kirsch L. Studies on the instability of chlorhexidine, part I: Kinetics and mechanisms. J Pharm Sci. 2012;101(7):2417–2427. doi: 10.1002/jps.23151. 10 Pyrek KM. Sterility of antiseptic products: FDA investigates, deliberates on potential recommendations. Infection Control Today website. https://brnskll.com/ wpcontent/uploads/2013/12/FDA-investigates-Antiseptics-Sterility-and-potential-recommendations.pdf. Accessed April 20, 2019. 11 Degala, et al. United States Patent 9,078,934. July 14, 2015.

WITH BD CHLORAPREP ™ PATIENT PREOPERATIVE SKIN PREPARATION WITH STERILE SOLUTION AND AN ALL-NEW STERILITY ASSURANCE LEVEL OF 10 –6 .

* Introducing a whole new level of sterility assurance for BD ChloraPrep ™ Patient Preoperative Skin Preparation, the solution that more hospitals count on than any other brand. As pioneers in skin antiseptics, we are raising the performance bar above and beyond FDA skin prep requirements, making our market leading solution even better. Discover the confidence of BD ChloraPrep ™ applicators. Discover the new BD.

*The SAL level indicates there is less than one in a 1,000,000 chance (1000x greater than the minimum requirement) that a sterile ChloraPrep™ applicator containing a sterile solution will contain a single (viable) microorganism following terminal sterilization of the ampules through the new manufacturing process of BD.

Discover peace of mind in your antiseptic solution at bd.com/One-Trust

Opioids

Understanding the opioid epidemic, and how the CDC, states, communities and healthcare providers are working to combat it.

What are opioids?

According to Johns Hopkins Medicine, opioids are a class of drugs naturally found in the opium poppy plant and that work in the brain to produce a variety of effects, including the relief of pain with many of these drugs. Opioids can be prescription medications often referred to as painkillers, or they can be so-called street drugs, such as heroin.

Many prescription opioids are used to block pain signals between the brain and the body and are typically prescribed to treat moderate to severe pain. In addition to controlling pain, opioids can make some people feel relaxed, happy or “high,” and can be addictive. Additional side effects can include slowed breathing, constipation, nausea, confusion and drowsiness.

The epidemic by the numbers

According to the Centers for Disease Control & Prevention, from 1999–2018, almost 450,000 people died from an overdose involving any opioid, including prescription and illicit opioids. 1 The number of drug overdose deaths decreased by 4% from 2017 to 2018, but the number of drug overdose deaths was still four times higher in 2018 than in 1999. 2 Nearly 70% of the 67,367 deaths in 2018 involved an opioid. From 2017 to 2018, there were significant changes in opioid-involved death rates: ʯ Opioid-involved death rates decreased by 2%. ʯ Prescription opioid-involved death rates decreased by 13.5%. ʯ Heroin-involved death rates decreased by 4%. ʯ Synthetic opioid-involved death rates (excluding methadone) increased by 10%.

This rise in opioid overdose deaths can be outlined in three distinct waves, the CDC said: 1. The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999. 3 2. The second wave began in 2010, with rapid increases in overdose deaths involving heroin. 4 3. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl. 5,6,7 “The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine,” the CDC said. 8

Combating the epidemic through collaboration

Collaboration is essential for success in preventing opioid overdose deaths, according to the CDC. Its work focuses on: ʯ Monitoring trends to better understand and respond to the epidemic. ʯ Advancing research by collecting and analyzing data on opioid-related overdoses and improving data quality to better identify areas that need assistance and to evaluate prevention efforts. ʯ Building state, local and tribal capacity by equipping states with resources, improving data collection, and supporting use of evidence-based strategies. ʯ Supporting providers, healthcare systems, and payers with data, tools, and guidance for evidencebased decision-making to improve opioid prescribing and patient safety. ʯ Partnering with public safety officials and community organizations, including law enforcement, to address the growing illicit opioid problem. ʯ Increasing public awareness about prescription opioid misuse and overdose and to make safe choices about opioids.

The CDC has built the Overdose Data to Action (OD2A), a 3-year cooperative agreement through which CDC funds health departments in 47 states, Washington DC, two territories, and 16 cities and counties for surveillance and prevention efforts. Funds awarded as part of this agreement will support state, territorial, county, and city health departments in obtaining high quality, more comprehensive, and timelier data on overdose morbidity and mortality and using those data to inform prevention and response efforts.

Recipients will be able to do a number of surveillance activities to monitor and gather data about the scope and nature of the overdose problem under the new cooperative agreement: ʯ Collect and disseminate emergency department data on suspected overdoses categorized as “all drug,” “all opioid,” “heroin,” and “all stimulant.” ʯ Collect and disseminate descriptions of drug overdose death circumstances using death certificates, toxicology reports, and medical examiner/coroner reports. ʯ Implement innovative surveillance activities to support interventions. These activities help increase comprehensiveness of surveillance data and allow jurisdictions to tailor their surveillance efforts to specific needs.

For more information, visit:www.cdc.gov/drugoverdose/ epidemic/index.html.

References

1. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. Available at http://wonder.cdc.gov. 2. Wilson N, Kariisa M, Seth P, et al. Drug and Opioid-Involved Overdose Deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020;69:290-297. 3. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR

MorbMortal Wkly Rep. 2011 Nov 4; 60(43):1487-1492. 4. Rudd RA, Paulozzi LJ, Bauer MJ, Burleson RW, Carlson RE, Dao D, Davis JW, Dudek J, Eichler BA, Fernandes JC, Fondario A. Increases in heroin overdose deaths—28 states, 2010 to 2012. MMWR MorbMortal Wkly Rep. 2014 Oct 3; 63(39):849. 5. Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths—27 states, 2013–2014.

MMWR MorbMortal Wkly Rep. 2016; 65:837–43. 6. O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR MorbMortal Wkly Rep. 2017; 66:897–903. 7. O’Donnell JK, Halpin J, Mattson CL, Goldberger BA, Gladden RM. Deaths involving fentanyl, fentanyl analogs, and U-47700—10 states, July–December 2016.

MMWR Morb Mortal Wkly Rep. 2017; 66:1197–202. 8. Drug Enforcement Administration. 2019 National Drug Threat Assessment. Drug Enforcement Administration Strategic Intelligence Section, U.S. Department of Justice. Published December 2019. Accessed March 17, 2020 from https://www.dea.gov/sites/default/files/2020-01/2019-NDTA-final-01-14-2020_Low_ Web-DIR-007-20_2019.pdfpdf iconexternal icon