How environment contributed to HAIs during the COVID-19 pandemic in Asia

It is well recognized that MDROs are selected by use of broad-spectrum antibiotics and often have an environmental reservoir that can facilitate rapid spread in critical care units if appropriate interventions are not introduced. ¹ Also, the constant use of gloves and gowns during a severe acute respiratory syndrome (SARS) outbreak led to an increase in transmission of MDROs, particularly methicillin-resistant Staphylococcus aureus. ^{Reference Yap, Gomersall and Fang5} Outbreaks of MDROs can be more difficult to control in middle- and lower-income countries in Asia where infrastructure may not be adequate (eg, suboptimal design of negative-pressure airborne isolation units and inadequate nurse-to-patient ratios). ^{Reference Apisarnthanarak and Weber2} During the COVID-19 pandemic, airborne transmission of some MDR gram-negative pathogens, such as Acinetobacter baumannii, has also been reported. ^{Reference Wong, Lam and Chen6} Evidence of airborne transmission of MDR-A. baumannii supports the view that placing patients in cohorts in enclosed cubicles with partitions and a closed door is preferred if single rooms are not available. ^{Reference Wong, Lam and Chen6} Such conditions require a practical strategy to control MDROs in resource-limited settings. Additional strategies are also needed in situations that do not allow PPE changing easily between cases in the cohort areas. These strategies must feature multimodal approaches that include risk stratification for index patients that may potentially harbor MDROs with isolation in single rooms, an antimicrobial stewardship program for COVID-19 patients, and policies to discontinue COVID-19 precautions as well as a policy to perform robust terminal environmental disinfection. ^{Reference Apisarnthanarak and Weber2} Such strategies, together with full compliance with infection prevention measures, will help limit the transmission of MDROs in COVID-19 cohort areas in critical care units. Antimicrobial stewardship strategies, including inappropriate antibiotic use featuring the combination of procalcitonin and clinical pulmonary infection score (CPIS), have been associated with successfully reducing inappropriate antibiotic use among severely to critically ill COVID-19 patients, for multidrug-resistant organisms, and for invasive fungal infections during the intervention. ^{Reference Sathitakorn, Jantarathaneewat and Weber7,Reference Sathitakorn, Chansirikarnjana and Jantarathaneewat8}

Likewise, hospital construction and renovations activities are never ending, and they are the main cause of healthcare-associated fungal outbreaks including Aspergillus and Zygomycetes, ^{Reference Kanamori, Rutala, Sickbert-Bennett and Weber9} which pose serious threats to immunocompromised hosts, including high-risk patients (eg, COVID-19 pneumonia patients). Implementing an infection control risk assessment (ICRA) for renovation and construction decreases the risk of healthcare-associated fungal outbreaks. However, ICRAs are not typically performed in developing countries, leading to healthcare-associated fungal outbreaks in settings such as ICUs, hematologic wards, and renal transplant units. ^{Reference Kanamori, Rutala, Sickbert-Bennett and Weber9} Although uncommon, healthcare-associated fungal outbreaks must be suspected when 2 or more cases occur over a short period. ^{Reference Sathitakorn, Chaononghin and Katawethiwong3} Early outbreak investigation and identification of the source are likely to play a key role in limiting the spread of healthcare-associated fungal outbreaks. Such strategies, together with a full compliance with recommendations from a multidisciplinary coordination team, will help limit the construction-related fungal infection especially in a COVID-19 ICU.

Selected emerging infectious diseases and germicide susceptibility

SARS-CoV-2 can survive on surfaces for minutes to hours, but contaminated surfaces have only rarely been linked to transmission. ^{Reference Kanamori, Weber and Rutala10} Contaminated elevator buttons were hypothesized via indirect transmission to lead to outbreaks in a mall and in an apartment building. SARS-CoV-2 has been demonstrated in multiple studies to survive on a variety of surfaces (ie, steel, plastics, paper, disposable hospital gowns, wood, glass) for minutes to days; survival was better at low temperature and humidity. SARS-CoV-2 RNA has been detected in a mean of ∼15% of hospital room samples. Despite the frequent finding of SARS-CoV-2 contamination, viable virus was not commonly detected. ^{Reference Kanamori, Weber and Rutala10} SARS-CoV-2 is susceptible to alcohol hand disinfectant agents (ie, ethanol, 60%–90%; isopropanol, ∼75%), which are rapidly effective (ie, 15 seconds) in eliminating >3-log₁₀ SARS-CoV-2 from skin. Povidone-iodine (0.23%-7.5%) is also effective in inactivating SARS-CoV-2 strains in 15 seconds. SARS-CoV-2 is inactivated by sodium hypochlorite and by hydrogen peroxide (0.5%) in 1 minute. SARS-CoV-2 is also inactivated by quaternary ammonium compounds in 30 seconds to several minutes. Disinfectant cloths are also effective in eliminating SARS-CoV-2 in 2 minutes. The environmental survival and germicide susceptibilities of SARS-CoV-2, Middle Eastern respiratory syndrome coronavirus, and Ebola virus have been reviewed. ^{Reference Weber, Sickbert-Bennett, Kanamori and Rutala11} All 3 viruses may survive for hours on environmental surfaces, and because all are enveloped viruses, they are susceptible to standard antiseptics (eg, alcohol) and disinfectants (eg, hypochlorite). Specific germicides that have demonstrated effectiveness against coronavirus are listed by the US Environmental Protection Agency and against Ebola. ^{Reference Weber, Sickbert-Bennett, Kanamori and Rutala11}

Selecting appropriate disinfectant is key to effective healthcare environment disinfection. Some emerging infectious diseases such as Candida auris and monkeypox (mpox) may require further understanding on principle of disinfection in healthcare environment as well as more evidence-based on the proper disinfectant. C. auris is most commonly transmitted via direct contact (patient to patient) and indirect contact (contaminated environment such as sharing the same hospital room or being admitted to a room previously occupied by a MDRO colonized or infected patient). ^{Reference Weber, Sickbert-Bennett, Kanamori and Rutala11} Widespread contamination of the surface environment has been reported. In laboratory tests, C auris has been demonstrated to persist for days on environmental surfaces and linens. C. auris is susceptible to sterilants and chemicals used for high-level disinfectants. ^{Reference Weber, Sickbert-Bennett, Kanamori and Rutala11,Reference Weber, Rutala and Sickbert-Bennett12} Effective low-level disinfectants (used to decontaminate environmental surfaces) have included 70% isopropyl alcohol, 1:10 dilution of 5.25% sodium hypochlorite, 0.5% to 1.4% hydrogen, 0.5% quaternary ammonium compound, and 55% isopropyl alcohol and other products. Alcohols are the antiseptic of choice for hand hygiene based on in vitro testing. The US EPA has published a list of germicides active against C. auris. ^{Reference Weber, Sickbert-Bennett, Kanamori and Rutala11,Reference Weber, Rutala and Sickbert-Bennett12} For mpox, environmental contamination in household or hospital rooms occupied by patients with mpox as assessed by PCR was common, but demonstration of viable virus was less common. There are no published studies of the survival of mpox virus, but based on studies of other pox viruses (eg, variola, vaccinia), prolonged survival is expected (ie, weeks to months). Similarly, there are no published studies on the susceptibility of mpox virus to disinfectants, but based on studies of other pox viruses, mpox virus is likely susceptible to sodium hypochlorite (0.636% active chlorine), quaternary ammonium combined with chlorhexidine, and quaternary ammonium combined with glutaraldehyde. Ethanol (50%–70%) and isopropyl (40%–50%) are likely effective with a 1-minute contact time.

Improvement of air and water quality in Asia Pacific: What is needed?