Infection Control Facts: How to Select an Ideal Disinfectant Lee Nesbitt, BMSc Manager, Professional & Technical Services Virox Technologies Inc Phone: x115

 2003: CDN Hospitals notified >900 patients that improper sterilization of equipment may have exposed them to HIV, Hepatitis and other diseases. $150M class action lawsuit filed alleging negligence in failing to meet adequate sterilization standards.  Government ordered a province-wide audit of hospital infection-control practices Healthcare Quarterly Vol. 8, Special Issue October 2005

 Canadian law clearly establishes a positive duty on care providers to inform patients of errors that occur during their care  When care providers realize that patients may have been exposed to infection from equipment, other patients or healthcare workers, a legal obligation may arise to contact patients to warn them of the risk and provide advice regarding appropriate follow-up testing and care.

 The removal of adherent visible soil, blood, protein substances (tissue) and other debris from surfaces by mechanical or manual process  Generally accomplished with water and detergents  Removes or eliminates the reservoirs of potential pathogenic organisms

 Viruses (enveloped)  Bacteria (Gram +ve & Gram -ve)  Fungi  Viruses (non-enveloped)  Mycobacteria  Protozoa  Bacterial Spores Most Susceptible Least Susceptible

Once the device has been defined determine the Disinfection Process Choose the CORRECT Product Consider the Device Classification (According to Spaulding)

Sterilization High Level Disinfection Intermediate Level Disinfection Low Level Disinfection Critical Devices* Semi-Critical Devices Non-Critical Devices *Foot Care Instruments defined as critical according to CCDR Vol. 23S8 (Dec 1997) Infection Control Guidelines: Foot Care by Health Care Providers

 refers to the level of disinfection required when processing noncritical items or some environmental surfaces and kills most vegetative bacteria and some fungi as well as enveloped viruses but not mycobacteria or bacterial spores.

 refers to disinfectant that kills vegetative bacteria, most viruses and most fungi but not resistant bacterial spores.

 refers to a process which destroys vegetative bacteria, mycobacteria, fungi, enveloped and non-enveloped viruses, but not necessarily bacterial spores

 refers to the chemical disinfection process that destroys all forms of microbial life including bacteria, viruses, spores and fungi.

LLDILDHLDChemical Sterilants Enveloped Viruses3 Log / 99.9% 3 Log / 99.9% Vegetative Bacteria 6 Log / % Fungi 5 Log / % 5 Log / % 5 Log / % 5 Log / % Non-Enveloped Viruses 3 Log / 99.9% 3 Log / 99.9% Mycobacteria4 Log / 99.99%6 Log / % Spores6 Log / %

What’s in your bottle?

 Disinfectants are the backbone of Environmental Infection Control  >8000 Products registered in the U.S. & Canada  50% of which are used for Healthcare Infection Control  There are 300 different active chemistries › 14 are in 95% of the disinfectant products › 6 are the most common

 Detergency properties for cleaning  Not Readily Neutralized in Organic or Inorganic Matter  Microorganism Resistance will not develop  Broad-Spectrum & Fast Acting Germicidal Activity

AlcoholsChlorinePhenolicsQUATsAHP Must have good cleaning ability to remove organic soil load on surface. Alcohols are not effective cleaners as they do not contain detergency Properties Chlorine can be inactivated by a soil load and do not contain detergency Properties Phenolics are ineffective cleaners Quaternary Ammonia Compounds are not effective cleaners AHP contains a combination of superior surfactants that are proven effective cleaners in synergy with H2O2 Is effective in a soil load. Testing is done with no soil load. Neutralized by soil. Testing is done with a soil load Testing is generally done without a soil load. Testing is done with a soil load. Will not lead to development of resistant organisms Active ingredient evaporates Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface

AlcoholsChlorinePhenolicsQUATsAHP Vegetative Bacteria YES 3 min to 10 min YES 10 min YES 5 min to 10 min YES 3min to 10 min YES 30 sec to 20 min Enveloped Viruses YES 3 min to 10 min YES 10 min YES 3 min to 10 min YES 3 min to 10 min YES 1 min to 5 min FungiYES 3 min to 10 min YES 10 min YES 3 min to 10 min YES 3 min to 10 min YES 3 min to 5 min Non- Enveloped Viruses NOYES 10 min YES / NO Product Specific Review label 3 min to 10 min NOYES 1 min to 5 min MycobacteriaYES 3 min to 10 min YES 10 min YES 3 min to 10 min ONLY WITH SOLVENT OR ALCOHOL 3 min – 10 min YES 1 min to 5 min Bacterial Spores NOYES 10 min NO YES 10 min

OPAGluteraldehydeAHP FungiYES 10 min YES 20 min – 45 min YES 5 min – 20 min MycobacteriaYES 10 min YES 20 min – 45 min YES 5 min – 20 min Bacterial SporesYES 32 hours YES 8 – 12 hours YES 20 min – 6 hours

 Safe to Transport & Easy to Store Improper storage of disinfectants may lead to explosions or fires  Long Shelf Life Improper or prolonged storage of disinfectants may lead to growth of bacteria in them  Non-Corrosive & Material Compatible Using the wrong type or level of disinfectant may cause corrosion or other damage to expensive items such as flexible endoscopes

AlcoholsChlorinePhenolicsQUATsAHP Does not have storage limitations FlammableHighly reactive with other chemicals creating toxic by-products Toxicity poses risk for water and food contamination. Cannot be used around children Caution with products that contain solvents or alcohols Non- flammable or combustible Realistic Shelf life and stabilty Readily evaporates decreasing concentration Readily degrades once open, diluted product must be made fresh daily Relatively stable in both concentration and Use Dilution Stable in concentrate and Use Dilution Compatible with a wide variety of surfaces and materials Concerns with plastics and glues Concerns with stainless steel and fabric materials Concerns with residue build up on vinyl Concerns with residue build up or Quat burn on some flooring and vinyl Concerns with prolonged exposure to copper and brass

OPAGluteraldehydeAHP Does not have storage limitations Non-flammable or combustible Do not store at elevated temperatures and keep away from ignition sources. Non-flammable or combustible Realistic Shelf life and stability Shelf life decreases to 75 days once bottle is opened Once activated shelf life rapidly decreases Shelf life does not decrease once opened Compatible with a wide variety of surfaces and materials Concerns with plastics and glues Concerns with residue build up on vinyl Concerns with prolonged exposure to copper and brass

 Non-Toxic to humans & animals  Non-Allergenic & non-sensitizing  Non-Hormone disruption Certain microbicidal chemicals or their breakdown products can disrupt hormone function in humans & animals  Safe for the User and Patient Exposure to cleaner & disinfectant vapours may cause respiratory sensitization Improperly rinsed endoscopes or other devices may release residues of disinfectants into body cavity

AlcoholsChlorinePhenolicsQUATsAHP Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality Creates high levels of VOCs through reactions with surface and soil load Contain VOCs; Toxicity poses risk for water and food contamination Contain VOCs;Contains no VOCs Does not contain hormone disrupting or carcinogenic chemicals Does not contain APEs / NPEs Highly reactive creating toxic / carcinogenic by-products Phenolic Compounds have been found to be carcinogenic Many formulations contain APEs / NPEs Does not contain APEs/NPEs ; is not carcinogenic Will not lead to development of resistant organisms Active ingredient evaporates Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface

OPAGluteraldehydeAHP Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality Contain VOCs; Requires special ventilation Contains no VOCs Adverse Reactions to Residues left on surfaces after reprocessing Residues have lead to anaphylactic reactions Anaphylactic reactions to both vapours and residues No Active Residue left on surface Will not lead to development of resistant organisms Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface

 Environmentally sound (Biodegradable) Environmentally-stable sanitizers & disinfectants can contaminate food or water (groundwater & surface water)  No Active Residual Chemistry  Good Air Quality Free of any pungent smell No Volatile Organic Compounds (VOCs) Use of gaseous or volatile products may negatively affect indoor air quality Fragrance Free

AlcoholsChlorinePhenolicsQUATsAHP Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality Creates high levels of VOCs through reactions with surface and soil load Contain VOCs; Toxicity poses risk for water and food contamination Contain VOCs; often contain hormone disruptors Contains no VOCs and no hormone disruptors Will not lead to development of resistant organisms Active ingredient evaporates Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface Carries EcoLogo or Green Seal Certification Does not meet certification criteria Only1 product meets Canada’s EcoLogo criteria Received certifications by EcoLogo and Green Seal

OPAGluteraldehydeAHP Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality Contain VOCs; requires special ventilation Contains no VOCs; does not require special ventilation Restrictions to Disposal Restrictions in disposal Can be disposed into municipal waste water

 Clearly outlines the requirements of what must be included on a label Name of Product & Manufacturer DIN must be on the main panel Active Ingredients Intended Use Net contents Lot Number & Expiry Date Precautionary symbols and cautionary statements

 Label requirements continued: Claims Area or Site of Use Directions for Use Specific directions for preparing in-use dilution including ratios or metric units Reference to level of hardness of product diluent at time of testing Pre-cleaning or cleaning requirements Contact Times Temperature Stability of diluted or in-use product

 Label requirements continued: Rinse procedures Directions for Use for intended use against bloodborne pathogens Reference to PPE Directions for disposal of infectious waste

Remember:  Match Product with Protocol › Surfaces vs Instruments  Cleaning = 1 st step  Disinfection = 2 nd step  Contact Time is MANDATORY!

Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, Health Canada. Dec 1998, Vol 24S8 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care, Health Canada. July 1999, Vol 25S4 Guidelines for Environmental Infection Control in Healthcare Facilities, CDC. MMWR June 2003, Vol 52, No RR-10 Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings, PIDAC, May 2006

Block S. Disinfection. Sterilization, and Preservation, 5 th Ed Mayhall CG. Hospital Epidemiology and Infection Control, 3 rd Ed. Philadelphia. Lippincott Williams & Wilkins, 2004: Cokendolpher JC & Haukos JF. The Practical Applications of Disinfection and Sterilization in Health Care Facilities, Chicago. American Hospital Association, 1996: Rutala WA. APIC Guideline for Selection and Use of Disinfectants AJIC 1990:17(2)

Bessems E. The effect of practical conditions on the efficacy of disinfectants. Int Biodeter & Biodeg 1998: Crawford L et al. A Comparison of Commonly Used Surface Disinfectants: Alcohol-, Phenol-, Chlorine- and Quat Disinfectants. at2.html at2.html Russel AD. Glutaraldehyde: Current Status and Uses. Inf Con & Hosp Epi 1994;15 (11) Rutala WA. Sporicidal Activity of Chemical Sterilants Used in Hospitals. Inf Con & Hosp Epi 1993; 14(12)

Rutala WA & Weber DJ. The benefits of surface disinfection. AJIC 2004;32(4) Woldkoff P et al. Risk in cleaning: chemical and physical exposure. Sci of Total Env 1995:215: Sattar SA. Current issues in testing, selection and use of microbicides in infection control: a critical review. AICJ 2004;9(3): Health Canada. Therapeutic Products Programme Guidelines: Disinfectant Drugs. Fall 1999

 Degussa, Hydrogen Peroxide: Properties, Handling and Application  Hugo, Inhibition and destruction of the microbial cell  Ascenzi, Handbook of disinfectants and antiseptics  CCDR Supplement, Vol 23S8 (Dec 1997), Infection Control Guidelines: Foot Care by Health Care Providers. aspc.gc.ca/publicat/ccdr- rmtc/97vol23/23s8/fcindexe.htmlhttp:// aspc.gc.ca/publicat/ccdr- rmtc/97vol23/23s8/fcindexe.html