Disinfection Presentation Slide Library - FINAL TO POST

A 3 Prong Infection Control
Strategy for Public Buildings
Based on the School Disinfection Workgroup

National Conference Call
Research and Document Collaboration
2009
Project Coordinated by: Lynn Rose
Training and Documents Written by: Lynn Rose and

Carol Westinghouse, Informed Green Solutions, Inc.
Funded by: the Massachusetts Toxics Use Reduction

1
Institute, University of Massachusetts, Lowell
Workgroup Members
National: Centers for Disease Control and
Prevention and Environmental Protection Agency
Massachusetts: Division of Occupational Safety,
Dept Public Health, MA Nurses Association,
MassCOSH, TURI Surface Solutions Lab
California: Dept of Public Health, California
Childcare Health Program, UCSF
Connecticut: University of Connecticut Health
Center
New England: Informed Green Solutions, Inc. 2
Objectives
http://www.vancouverdad.com/photos/germs1.jpg
 Facilitate adequate infection control while

minimizing the use of toxic cleaning products
and antimicrobial pesticides.
 Protect workers and building occupants from

exposure to hazardous disinfectants.
 Clarify the differences between cleaning and

disinfecting products and processes, and
when each is appropriate. 3
Presentation Overview
 Why be concerned?
 How is disease transmitted?
 How can Facility Managers safely reduce
disease transmission in their buildings?
 Strategies and planning
 Policies and procedures
 Products and equipment
4
 Training and resources
Why reduce use of disinfectants?
Chemical Hazards
 Disinfectants are actually
antimicrobial pesticides, cide = kill
designed to kill microbes.
 Disinfectants do not clean, and
cleaners to do not disinfect.
 The active ingredients of common
disinfectants are among the most
toxic chemicals used in custodial
work.
5
Chemical Exposure Risks
 A single janitorial worker uses, on average, 194
lbs. of chemicals annually, approximately 25% of
which are hazardous substances
 Environmental Working Group tested 21 common

cleaning products used in California schools. They
found 457 chemicals were emitted into the air:
 6 known asthmagens
 11 known, probable or possible cancer-causing
agents
6
 Others - health effects are unknown
Chemical Exposure Risks
 Children are at greater risk than adults when exposed
to toxins because:
 They are exposed at higher levels as they eat more
food, breathe more air, drink more water
 They metabolize and eliminate toxins more slowly
 Their rapidly developing systems are more
sensitive
 Play closer to the ground
 Have significant hand-to-mouth activity
Occupational Hazards
 If not handled properly, some disinfectants
can cause serious injuries:
 Eye damage
 Chemical burns
 Severe skin irritation
 Out of 100 janitors injured each year:
 20% are serious burns to the eyes or skin
 12% are a result of chemical vapors 8
Occupational Asthma
Products # Cases
Note:
Unspecified 104 12% of all Work Related Asthma

cases in 4 states were associated
Bleach 43 with cleaning and disinfectant
Acids, bases, 23 products.
oxidizers
Disinfectants 20
Carpet 17
cleaner
Floor stripper/ 16
wax
Ammonia 14 CA, MA, MI, NJ 1993-1997 9
Rosenman et al 2003 JOEM 45(5):556-63
Children’s Asthma
Students (K-12) with Asthma in
Massachusetts ESHS Programs
120 116.2
115
110 105.8
105
97.7
100
95
90
85
2006- 2007 2007- 2008 2008- 2009
S c h o o l Ye a r
St udent s wit h Ast hma ( per t housand st udent s )
Massachusetts Department of Public Health

10
Data on Student Asthma Rates
Myth Buster: Question
Do you always need to

use disinfect
to control infection?
11
Myth Buster: Answer
No, some alternatives include:
 An all purpose cleaner
and microfiber
 Equipment without
chemicals such as a steam
cleaning machine
12
3 Levels of Microbe Control:
Cleaning Sanitizing Disinfecting

Removing Killing Killing
Microbes Bacteria Microbes
99% 99.9 to 99.999% 99.99%
13
Breaking the Chain of Infection:
“3 Prong Approach ”
1. Personal Strategies
2. Cleaning for Health
3. Targeted Sanitization
a. Hand Hygiene and Disinfection
b. Respiratory Hygiene
d. Social Distancing
c. Cough Etiquette 14
and Isolation
Understanding
the
Chain of Infection
A series of events that need to
occur before a person develops
an infectious disease.
15
What are Microbes?
Dispelling the “Fear Factor”
 Microbes are everywhere in the environment
– in the air, water, soil, plants and animals.
 We can’t live without them.
 Some are good for you, and other

pathogenic” microbes cause infections and
disease, commonly referred to as “germs”.
16
What are Microbes?
 Bacteria* – have their own cell walls, and can live
independently.
 Fungi* – grow on dead and decaying matter.

Common forms are yeast and molds.
 Viruses – live and multiply inside of cells of a living

host, and cannot live independently.
* Spores produced by some types of bacteria and fungi

can live in the environment for months or years.
17
How Are Microbes Transmitted?
Infectious Microbes
Bacteria, Virus,
Susceptible Host Fungi Reservoir
Microbes make host sick Microbes adapt and multiply
(on animate & inanimate objects)
Portal of Entry:
Chain of
Microbes enter new location
(e.g. mucous membranes)
Transmission
Modes of Transmission: Portal of Exit
Microbes are transported to new location Microbes leave
(by animate or inanimate objects) (e.g. sneeze or cough)
Where people come in contact with them
Contact Contact
Respiratory
18
Reservoir
 Microbes live and multiply in a reservoir.
 Microbes prefer:
 Warm, dark environment
 Moisture
 Source of food
19
Droplet Transmission
 Large droplets containing microbes are:

 propelled short distances
(3-6 feet) through the air
from sneezing, talking, and
coughing.
 deposited on a host’s mucous
membranes - eyes, nose or mouth
 Examples:
 flu, cold, strep
20
Photo: 2009 Camfil Farr , http://www.camfilfarr.com/cou_us/industries/care/infection_transfer.cfm

Airborne Transmission
Photo: 2009
Camfil Farr ,
http://www.ca
mfilfarr.com/c
ou_us/industri
es/care/infecti
on_transfer.cf
m
 Microbes in airborne droplets:

 Survive from evaporated droplets, and
 Remain in the air for long periods
(hours to days).
 Examples:
21
 measles, TB, chickenpox
Contact Transmission: Indirect Contact
 Transfer of microbes from object to person
 Examples such as MRSA or Norovirus - transmitted
by:
 Touching environmental
surfaces contaminated with
infectious blood or body fluids,
and
 Then touching mucous
membranes (eyes, nose,
mouth) or touching an area
with broken skin. 22
Contact Transmission: Direct Contact
 Transfer of microbes from person to person.

 Examples such as MRSA or Norovirus -
transmitted by:
 Touching infected area or
infectious body fluid on a
person, and
 Then touching mucous
membranes or touching an
area with broken skin. 23
Means of Entry
 Breaks in the skin
 Respiratory tract
 Digestive tract
 Circulatory system
24
Susceptible Host
 Weakened Immune System - body not

able to fight off infection!
25
What Influences the Survival of Microbes
Outside of the Body?
Conditions of
Surrounding Properties of the
Environment Object
Humidity, pH, Porous or
Microbe
temperature, nonporous,
Properties
microbes present, How clean,
Type of microbe
ultraviolet light and type of How much moisture
exposure medium it is
suspended in
Adds up to
microbe Adapted from Stephanie A. Boone* and Charles P.
Gerba, Significance of Fomites in the Spread of
survival on Respiratory and Enteric Viral Disease. Applied and

Environmental Microbiology, March 2007, p. 1687-1696,
Vol. 73, No. 6
object
Breaking
the
Chain of Infection
Breaking any of the links of the chain can

interrupt the transmission of disease.
Example: Influenza 27
The Three Prong Approach
1. Personal Strategies and
Responsibilities
 Prevent transmission
2. Cleaning for Health

 Remove reservoir
3. Targeted Sanitizing/Disinfection
 Remove reservoir 28
Personal Strategies:
Will Respiratory Hygiene and Cough Etiquette Reduce
Flu Transmission?
Yes. The CDC recommends:
 Covering the nose/mouth when coughing
or sneezing, and washing hands after.
 Coughing into the elbow when tissues are
not available.
 Using & disposing of tissues.
 Leaving a 3-6 foot buffer between yourself

and others when coughing or sneezing.
29
CDC Influenza Fact Sheet, http://www.cdc.gov/flu/professionals/pdf/resphygiene.pdf.

Will Self-Isolation and Social Distancing Help Reduce
Flu Transmission?
Yes, and guidelines for sick people from the CDC
include:
 Staying home and away from people until at least
24 hours after they are free of fever (100° F), or
signs of a fever without the use of fever-reducing
medications.
 Limiting contact with others and maintaining a
distance of at least 6 feet from people.
 Wearing a surgical or N95 mask around other
people. 30
Will Hand Hygiene Help Reduce
Flu Transmission?
 Yes, depending on the product and

process used.
 Hand washing with soap and water can

reduce infections by more than 50 % in
some cases!
31
Hand Hygiene: Product Types
 Soap will remove, not kill microbes.
 Anti-bacterial products kill bacteria

and some, but not all viruses.
 Anti-microbial products can kill or

suppress growth of bacteria, viruses or
fungi.
32
Hand Hygiene Products:
Hand Soap
 Soap is available in liquid, bar (not

recommended) and hand wipe forms.
 Soap and warm water remove microbes by

breaking down the oil and dirt that harbors
them, and washing them away.
 The CDC guidelines call for washing hands with

warm water and soap for 15 to 20 seconds to
effectively prevent infection.
33
Anti-bacterial Hand Soap
 Kills bacteria and some, but not
all viruses such as the common
cold, flu, stomach flu and blood
borne pathogens such as HIV
and Hepatitis B and C.
 A Federal Drug Advisory Panel concluded
in 2005 that, for general use, antibacterial
soaps are no more effective than regular
plain soap at removing germs.
Reference: http://www.cdc.gov/Features/HandWashing , August 28, 2008
Anti-bacterial Hand Soap
 The most common ingredients are triclosan and
triclocarban. Triclosan health issues include:
 Can be absorbed
through skin, linked to
liver damage.
 Detected in breast milk,

urine and blood.
 Linked to hormone
disruption.
35
Anti-Microbial Hand Sanitizer
 Product that can kill or suppress growth

of viruses, bacteria or fungi.
 Available in foam, gel or hand wipes.
 Most common ingredient is alcohol,

which comes in 2 forms and different
strengths.
Note: Always replace product in dispenser, never
top off to prevent microbial growth in dispenser. 36
Alcohol Based Sanitizers - Concentrations
Concentration Required to Kill Specific Viruses

Virus Ethyl Isopropyl
Alcohol Alcohol
Influenza A 30% 30%
Norovirus (stomach flu) 62% 95%
Rhinovirus (common cold) 62% 95%
Hepatitis A 62% 95%
Note: 70% Ethyl Alcohol would be better than 62%, but its hard to find.
Alcohol Based Sanitizers - Dangers
 Routes of Exposure for Children

 absorb it through skin
 lick it off their hands
 squirt it into their mouths
38
 Risks
 3 squirts* can raise blood alcohol
level in a toddler to be legally
intoxicated .10, which is
comparable to someone that
size to drinking 120 proof alcohol.
 “Ingesting as little as an ounce or two of this
product could be fatal to a toddler,” says Heidi
Kuhl, health educator, Central NY Poison Control
Center.
* Purell and Germ-X contain 62% Ethyl Alcohol
39
Reference: http://www.snopes.com/medical/toxins/sanitizer.asp
Hand Hygiene:
 Class 1 - Flammable Liquid
 Follow 527 CMR storage guidelines
 State Fire Marshal reissued an Advisory for

Alcohol Based Hand Sanitizers containing
60% - 95% ethanol or isopropanol.
 Posted: SFO website  Fire Prevention  SFO Advisory
40
Hand Hygiene: Product Limits
 Dirt: antimicrobial and alcohol based

products don’t necessarily remove dirt on
hands, which compromises their ability to
kill microbes.
 Proteins: soap is more effective

at removing proteins from hands
than alcohol sanitizers.
41
Do Hand Sanitizers
Replace Hand Washing?
No, hand-washing is the first and most
important step, especially if hands are visibly
soiled.
CDC Recommendations:
When hand washing is not an option (e.g.
school bus or field trip), “alcohol-based hand
cleaners are also effective.”
Sources: 1) City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and 2) Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging Infectious Diseases, by Dr.
Elaine Larson, prof pharmaceutical & therapeutic research, & prof of epidemiology, Columbia Univ School of Nursing 42
Infection Control
Strategy
as part of
A Cleaning for Health Program
43
Cleaning for Health Program
Cleaning that protects public health, without adversely
affecting the staff, building occupants and the
environment.
 A comprehensive program to:
 prevent proliferation of dirt and microbes
 use safe cleaning products and work practices
 Sample strategies include:

 More frequent cleaning of high-touch surfaces
 Cleaning with color coded microfiber mops/cloths
 Using floor/vacuuming equipment with HEPA filters
44
Three Levels of Microbe Control
1. Cleaning 2. Sanitizing 3. Disinfecting
99% 99.9 – 99.999% 99.99%
Level 1: General Surface Cleaning

 Physically remove viruses, fungi and
bacteria and the conditions they need
to survive (e.g. organic matter).
 Accomplished with water, detergent,
and abrasion of the surface.
 Microfiber can enhance this process
by removing up to 99% of microbes.
45
99% 99.9 – 99.999% 99.99%
Level 2. Sanitizing
 Reduces (kills) 99.9% to 99.999% of tested
bacteria to levels considered safe for public health.
 May not have claims for killing viruses or fungi.
 Some products can be both a sanitizer and a

disinfectant, depending on specified concentration.
46
References: Infection Control for Dummies, J. Darrel Hicks, REH, http://www.epa.gov/iaq/glossary.html#S, http://www.epa.gov/iaq/glossary.html#D, and Source:
Cleaning for Health, Inform, Inc, and presentation by Marcie Tidd on Disinfectants, Sanitizers, and Product Labeling, Overview of EPA’s Antimicrobial Registration Process,
Women's Voices for the Earth Conference Call, February 4 th, 2009
Level 2. Sanitizing
 Registered by EPA for use on
porous and nonporous
surfaces:
 Food contact surfaces:
sanitizing rinses for
surfaces such as dishes
and cooking utensils.
 Non-food contact surfaces:
carpet, laundry, toilet bowl,
etc.
47
References: Infection Control for Dummies, J. Darrel Hicks, REH, http://www.epa.gov/iaq/glossary.html#S,

http://www.epa.gov/iaq/glossary.html#D, and Source: Cleaning for Health, Inform, Inc
99% 99.9 – 99.999% 99.99%
Level 3. Disinfecting
 Destroys 99.99% of all forms of

microbial life, but not
necessarily their spores.
 Use on hard nonporous surfaces,

which have higher transmission
rates. 48
Disinfectants: Claims
 All disinfectants do not kill all types

of microbes.
 EPA categorizes & registers products by their
Disinfectant Claims based on what they kill:
Broad
Hospital,
Limited Spectrum,
Medical Use
General
49
 Hospital / Medical Use Disinfectant:

 meets the requirements for a general
disinfectant
 also effective against the
Pseudomonas aeruginosa
 does not necessarily kill TB or HIV
50
 To comply with OSHA BBP

Standard, use:
 a tuberculocide, or
 A product that lists the specific
BBP viruses - HIV and hepatitis B
 For MRSA and other specific

diseases, check the label. 51
Disinfecting:
Consult the Label & EPA’s Website
Listings of EPA’s
registered
antimicrobial
products for
specific diseases:
http://www.epa.go
v/oppad001/chemr
egindex.htm
52
Disinfectants:
Claims for H1N1 and Influenza A
EPA’s position
October 22, 2009
An influenza A virus label

claim is sufficient to support
label claims against 2009 H1N1
influenza A virus.
53
Disinfectants: Selection
Are they ranked for safety?
 EPA Design for the Environment
program is implementing a 2 year pilot
project Safer Product Labeling Program.
 Products restricted to EPA registered
disinfectants.
 Evaluatescritical health and environmental
standards, and is available at:
http://www.epa.gov/dfeprojects/gfcp/. 54
EPA’s Pilot Program
 Identified the following active ingredients as being
least-toxic:
 Accelerated Hydrogen Peroxide
 Lactic Acid
 Citric Acid
 Products with these ingredients will not be approved:

 Quaternary ammonium compounds
 Sodium hypochlorite (bleach)
 Ortho-phenylphenol (2 phenylphenol)
 Thymol 55
 EcoLogo - in Canada does certify
disinfectants. Not all products are
available in the US, or are EPA
registered.
 MA Operational Service Division -

Environmental Preferable Products
Contract FAC 59 provides a fact sheet
on several uncertified antimicrobial
products available through contract
56
vendors.
Health: EPA Toxicity Rating (1-4)
Acute Toxicity Category Signal Word Required

Toxicity
Category I Danger/Poison
Category II Warning
Category III Caution
Category IV Caution
(or none required if all routes are Cat IV)
57
Disinfectant: Selection
Hazardous Options - Bleach
 Hazard Level
 CDC Disinfection Level - Intermediate Level
 EPA Toxicity Category - Category I
 Claims
 most bacteria and some viruses
 registered as effective against HIV, HBV, H1N1
(Influenza A), MRSA, TB
Note: Can’t be stored longer than 3 months for disinfecting.

58
When diluted, is only effective as a disinfectant for 24 hours.
Hazardous Options - Bleach
(5.25% and 6% Sodium Hypochlorite)
 Health Effects
 Corrosive to eyes and skin
 Respiratory irritant
 Suspected cardiovascular, gastrointestinal or
liver, kidney, central nervous system, respiratory,
and skin or sense organ toxicant
59
Using Bleach Safely
Note: Although the project does not advocate the use

of bleach as there are much safer alternatives, we
provide these guidelines for those who continue to use
bleach.
 The dilution rate will vary depending on the

strength of the original product 5.25% or 6%
and intended uses. Check the label.
60
Using Bleach Safely
 Use different dilutions for specific uses,

such as:
 Sanitizing food surfaces
 Disinfecting non-blood or body fluids,

disinfecting shared sports equipment (mats,
etc.), sinks, etc.
 Disinfecting blood, vomit spills (after

cleaning) 61
Hazardous Options - Phenols
 Hazard Level
 CDC Disinfection Level - Some are
intermediate and some are low level.
Check the label.
 EPA Toxicity Category - Category I or II
 Claims
 Read product label for specific microbes 62
Hazardous Options - Phenol
 Health Effects
 Recognized carcinogens (CA Prop. 65)
 Suspected toxicant - cardiovascular,
developmental, neurological, reproductive,
respiratory, skin, sense organ
 Corrosive to eyes and skin
Absorbed through the skin and by inhalation.
63
Hazardous Options - Quaternary Ammonium Compounds
 Hazard Level
 CDC Disinfection Level - Low Level
 EPA Toxicity Category - Category III
 Claims
 Generally effective against a broad spectrum of
microbes including MRSA and H1N1 (Influenza A),
but not spores
 Read product label for effectiveness against TB
64
Hazardous Options - Quaternary Ammonium Compound
 Health Effects
 Can cause contact dermatitis and nasal irritation.
 Ammonium quaternary compounds* are

respiratory sensitizers and are associated with
asthma.
*Includes: benzalkonium chloride, dodecyl-dimenthyl-benzyl ammonium

chloride and lauryl dimethyl benzyl ammonium chloride.
65
Less Hazardous Options - Accelerated Hydrogen Peroxide
 Claims - as a disinfectant & sanitizer (non-food contact)

 Viruses – e.g., Hep B & C, HIV
 Bacteria – e.g., TB & MRSA
 Fungi – e.g., athletes feet
 Ease of Use
 Rinsing not required, except for
allowable food surfaces
 Hazard Level
 Non flammable, not hazardous Ingredient in
several products.
 Acidic - pH 2.5–3.5 This product is
registered by EPA 66
as a Disinfectant
Sanitizer: Selection
Less Hazardous Options - Ionized Water
Process involves:
1. Charging - a battery applies an
electrical charge to water.
2. Transforming - charged water
passes through an ion exchange
membrane, creating positive and
negative nano-bubbles.
3. Cleaning - activated water now
attracts dirt like a magnet and
lifts it from the surface, enabling
it to be wiped away. 67
Equipment used: Ionator
Disinfectant: Selection Criteria
 EPA registered
 Broad spectrum
 Health - EPA toxicity rating (1-4), select the

relatively non-toxic (4 preferable)
 Storage - stable shelf life, nonflammable
 Ease of Use – whether rinsing is required, short

dwell time, no PPE
 Environmentally preferable
68
Disinfection Application Process:
Selection Criteria
 Using the most appropriate application for

the job.
 Preventing cross contamination.
 Preventing exposure to workers and
occupants.
 Conserving resources.
 Protecting the environment.
69
Disinfection Application Process: Comparison
Criteria Conventional Microfiber Reusable Reusable Disposable Pre-Saturated
Mop and Mop Pads Microfiber Cotton Cloths Cotton or Wipes for
Bucket and Bucket Cloths Paper Towels Surfaces
Effective- Captured Superior – Penetrate Significantly Significantly Significantly
ness at 30% captured into cracks less than less than less than
Captur- microbes in 99% that other microfiber. microfiber. microfiber.
ing, or a hospital microbes in materials Depends on
Killing setting a hospital cannot saturation of
Microbes study. study. reach. wipe and
Solution The type of Increased ability to
must be microfiber fiber surface stay wet on
changed affects area & static the surface.
regularly to efficacy, electric Solution
maintain with 0.13 charge remains
efficacy. denier the enable it to stable in
highest. attract, presence of
capture & the wipe
hold material.
particulates
better.
70
Mop and Mop Pads and Microfiber Cotton Cloths Cotton or Wipes for
Bucket Bucket Cloths Paper Towels Surfaces
Ability to Good Superior - Superior - Good Cotton is Can dry out
Maintain microfiber microfiber better than on surface.
Adequate cloths have cloths have paper, but Although
Contact/ such a high such a high retains less wipes are
Dwell density and density and moisture than designed to
Time to surface area, surface area, microfiber. provide a
Kill they can they can premeasured
Microbes absorb up to 7 absorb up to amount of
times their 7 times their solution, the
weight in weight in possible
water and water and uneven
retain that retain that saturation
moisture. moisture. level in
container may
compromise
this.
71
[i] Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002
[ii] Using Microfiber Mops in Hospitals, Environmental Best Practices for Health Care Facilities, November 2002
Mop and Mop Pads and Microfiber Cotton Cloths Cotton or Wipes for
Bucket Bucket Cloths Paper Towels Surfaces
Cross Solutions must Prevents CC if Prevents CC Can serve as CC may Microbes can
Contaminat- be changed a color coding if changed a breeding occur survive on the
ion (CC)
regularly. system is used regularly and ground for between cloth and can
Advantages and if a new when uses or microbes and towel cause CC.
and
Mop must be
Disadvan- cleaned and mop head is rooms cause CC if dispenser Avoids CC
tages dried or used for new change. not laundered handle and that might
microbes will uses or rooms. Increased and dried dispensers, occur from
colonize on the Since the mop fiber surface before reuse. especially if dipping cloths
fibers. head is not area & static located in back into
A bucket dipped back electric splash zone. solution.
divided for into the charge enable
clean and dirty solution, there it to better
water prevents is no CC of hold
CC when mops solution in microbes.
are dipped bucket. It dries faster
back into Increased than cotton so
solution. fiber surface there is less
Disinfecting area & static chance for
mop is electric charge microbes to
difficult. enable it to proliferate. 72
better hold
microbes.
Developing Protocols
Criteria to Consider
73
Disinfecting: Developing a Protocol
A written procedure should provide guidelines

that answer the following questions:
 When and how often it should be done.
 What products and tools should be used.
 How to use and manage products/equipment.
 How to protect oneself and building

occupants. 74
Protocol: Determine when to Clean,
Sanitize or Disinfect
 What is the surface to be managed – porous
or non-porous?
 What is the level of occupant contact with the

surface:
 Minimal – floors, walls, etc.
 Frequent – high touch or high risk
 Are there any regulations requiring

disinfection or sanitization? 75
Protocol: Determine Management of Surfaces
High Touch Surfaces - Touched by a Variety of Hands
CDC Position: “does not believe any additional

disinfection of environmental surfaces beyond the
recommended routine cleaning is required.”
Project Recommendation: clean more

frequently during the day with a
microfiber cloth and third-party
certified* all-purpose cleaner.
* Certification: a third party (e.g. Green Seal and EcoLogo) gives written
assurance that a product or service conforms to specified requirements.
76
 Restroom examples:
 Faucet handles, toilet handles, towel
dispensers, hand driers.
 Break Room and Cafeteria examples:

 Coffee pots, microwave doors,
refrigerator doors
 Vending machines
 Water fountains
77
 Office examples:
 Shared desks or work areas
 Shared computer mice and
keyboards
 Fax machines, copiers, printers
78
 Custodial examples:
 Shared cleaning equipment.
 Product containers and
dispensers in custodial closets.
 Public Ways examples:

 Doorknobs, elevator buttons,
light switches, door push bars,
handrails. 79
Protocols: Determine Management of Surfaces -
High Risk Areas
 Some surfaces in the following locations may

require disinfecting:
 Shower and locker rooms
 Rest rooms
 Nurse’s office
 SPED
 Preschool 80
Protocol: Determine Management of
Non-Contact Surfaces - Floors
 Routine disinfection of floors is not

supported by epidemiology, unless there is
a Bloodborne Pathogens (BBP) spill or as
required in certain areas of athletic
facilities.
 Clean floors with a microfiber
mopping system and a 3rd party
certified floor care product.
81
Protocols:
Ensuring Product Effectiveness
 Water Hardness:
 Some disinfectants can be neutralized in hard
water. The label on quats may specify its
effectiveness in hard water.
 Temperature:
 Can degrade product during storage.
 Can enhance or reduce product effectiveness
during use.
 Product Concentration:
 Less concentrated than directed will not be 82
effective.
Protocols:
 Type and amount of microbes:
 Product must have ingredients registered by EPA
to kill target microbes.
 Shelf-life of disinfectant:
 Diluted products have shorter shelf life.
 Length of time solution sits in bucket and
number of times used:
 Efficacy can be reduced, and microbes can
reproduce. 83
Protocols:
 Contact time (AKA – kill or dwell time):
Product must stay wet. Times varies for each product.
 Material on the surface:

Cleaning product residues, protein and dirt can interfere
with disinfectant activity.
 Compatibility of product and surfaces:

Incompatible materials can damage surface.
 Physical configuration of the object (e.g. crevices):

Difficult to remove debris or ensure disinfectant comes in
contact with all areas of a surface. 84
Protocol: Dispensing Disinfectants
Diluting Product:
 Measure concentrates before adding them to the
dilution tank.
 Follow dilution rate instructions exactly for
specific uses as products are tested and only
guaranteed at specific concentrations. More is
not necessarily better, it can be more hazardous.
85
Required information on labels of secondary containers:

 Brand name of the product or the name as listed
on the MSDS.
 Hazard warnings:
 Health Hazard – including affects on target organs
(heart, liver, kidneys, nervous system, etc).
 Physical Hazard – flammable, corrosive, reactive
Health
Flammability HMIS Labels - an “at a glance” warning to alert workers of the 86
Reactivity
PPE
degree of hazard, particularly for those who do not speak English.
Sample Label on Secondary Bottle
CLOROX LIQUID BLEACH
WARNING: STRONG OXIDIZER!
STORE IN A COOL, DRY PLACE.
DO NOT GET IN EYES OR ON SKIN.
DO NOT MIX W/OTHER HOUSEHOLD CHEMICALS.
ACUTE: CAUSES SEVERE BUT TEMPORARY EYE INJURY.
MAY IRRITATE SKIN.
MAY CAUSE NAUSEA & VOMITING IF INGESTED.
EXPOSURE TO VAPOR OR MIST MAY IRRITATE NOSE, THROAT & LUNGS.
87
Recommend adding date prepared, and dilution rate.
Protocol:
Preventing Cross Contamination
Cross Contamination:
 Is the transfer of infectious
microbes from one surface,
object or person to
another.
 Involves understanding Chain of Infection:
 where microbes live and multiply, and
 how they are transferred to a new location. 88
Protocol:
Sources of Cross-Contamination:
 Used cloth or mop head,
especially if left soaking in dirty
solutions.
 Solutions of disinfectants,
prepared in a dirty container,
stored for long periods of time, or
prepared incorrectly.
89
 Contaminated hands or gloves.

Protocol:
 Allow laundered mop

heads and cloths to dry
before re-use.
 Replace cloths and mop

heads each time a bucket
of disinfectant is emptied
and replaced. 90
Protocol:
Tools, Equipment and Supplies to Prevent

Cross Contamination from:
 Surface to surface – change

cloths or mop heads when
moving to a new surface
(e.g. toilet to sink). Color
coded microfiber systems
help with this. 91
Protocol:
 Personal Protection:
wear and change
gloves and wash
hands between
tasks.
 Custodial Closets:
clean equipment
after use. 92
Protocol: Pre-Cleaning
Why?
 Soil and organic matter can reduce
effectiveness of disinfectant by:
 Providing shelter for the
microbes to hide.
 Absorbing ingredients.
Disinfectants need to be in
contact with microbes to kill
them! http://www.goductpro.co
m/images/microbes.gif
 Changing the chemical nature of

93
the disinfectant.
Why?
 Biofilm can form when
microbes develop a protective
matrix on wet surfaces over
time.
 Disinfectants cannot penetrate them to kill
microbes.
 Biofilm needs to be physically abraded or penetrated
by the use of steam vapor device to reach microbes .
94
Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
Key locations for a biofilm to form are in

areas that are wet on a regular basis:
 Plumbing facilities such as under rims of

toilets and urinals, in sinks, in distribution
pipes, etc.
 Wet areas that surround
them such as backsplashes,
drain areas, etc. 95
Protocol:
Separating Pre-cleaning & Disinfecting Tasks
 Disinfectant/Cleaner Products:
 There are 2 types of products
registered by EPA to clean and
disinfect.
 They contain a disinfectant and a
detergent.
96
Protocol:
1. One Step Cleaner/Disinfectants
 Workonly on surfaces with a moderate

amount of organic soil.
 Labeled as a one-step cleaner/disinfectant:

“effective in the presence of 5% body
fluids”
97
Protocol:
2. Two Step Cleaner/Disinfectant
 Products that are not “effective in the

presence of 5% body fluids”.
 Labeled and used as a two step process.
98
References: Infection Control for Dummies, J. Darrel Hicks, REH, and What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
Protocol:
 All other disinfectants require surfaces to be

pre-cleaned using a detergent.
 We recommend using two different types of

products to reduce the use of hazardous
ingredients:
 One nontoxic one to clean
 A disinfectant to disinfect
References: Infection Control for Dummies, J. Darrel Hicks, REH, What Microbes Are We Killing? Testing and Classifying Disinfectants, by Allen Rathey, The Housekeeping Channel
99
Protocol: Disinfecting
 Allow time for disinfectants to react with the
microbes to kill them (AKA - dwell, contact or
kill time): follow directions for time required
for the disinfectant to be wet on the surface.
 Reduce quantity: use the smallest possible
amount of disinfectant as recommended.
 Rinse: rinse high-touch areas, if required on
the label. Any residue may be hazardous
when it comes in contact with skin. 100
Protocol: Disinfecting
Protect Workers & Building Occupants:
 Direct workers to spray product on

cloth when possible, not into the air.
 Require adequate ventilation. The HVAC system

should be operating while disinfecting is conducted.
 Schedule use of disinfectants when there are the

fewest occupants, e.g. tasks conducted once daily.
101
Protocol: Worker Safety
Require use of Personal Protective Equipment:
 Non Latex Gloves

 Resistant to chemicals
(check label for type)
 Prevent allergic reactions
 Facial Protection (if needed)

 Chemically Resistant Masks/Goggles (safety glasses
with side piece) 102
 Disposable face shield

Protocol: Worker Safety
Always wear chemically resistant gloves!
If…. Then….
You could be splashed Goggles or safety glasses,
in the face? and a mask or a disposable
face shield is required
You could be splashed An apron is required
on your body?
If you could step in it Booties are required
and track it around? 103
Protocol:
Designating Roles & Responsibilities
 Restrict the use of disinfectants to

trained and approved staff for:
 Targeted disinfecting and sanitizing.
 Regulated disinfecting and
sanitizing.
 Events – BBP, body fluids and
infectious disease outbreaks (when
required).
104
Policy and Procedures:
Providing Guidance and Resources
All staff using disinfectants & sanitizers need:
 Training.
 Clear guidance on when, where
and how to use and handle.
 Labeled containers of approved
products.
 Chemical storage equipment.
105
 Personal Protective Equipment.

Equipment: Microfiber
Infection Control Attributes
 Requires Less Chemicals: reduces need for

disinfectants for most cleaning tasks since the
fiber removes a high % of organic matter.
 Controls Cross-Contamination:
by color coding & changing mop
pads after each room.
 Prevents Aersolization of Dust: The fibers have a

static electric charge that attracts dust and holds it
when dry dusting. (Dust can transmit microbes.)
106
 Minimizes Microbial Growth: dries more quickly,

which helps to prevent microbe growth inside fiber.
 Captures Microbes: more effective than cotton.
Use of microfiber mops in UC Davis Medical

Center 2002 hospital study found 99% reduction
in bacteria versus only 30% reduction using a
conventional wet mop system.
107
Source: EPA Fact Sheet, November 2002 - Using Microfiber Mops in Hospitals
 Absorption Ability: The increased surface area of
the fibers and their shape enable them to absorb up
to 7-8 times their weight in liquid, reducing
conditions for microbe survival.
108
Photo: http://media.primetimesolutions.net/themes/shopmicrofiber.com/images/microfiberCleansBetter.gif
Equipment: Facility
Minimize Occupant Exposure
 Bathroom
 Hands free towel dispenser or hand dryer
 Hands free soap dispenser
 Hands free faucet and toilet controls
 Hands free trash can
 Office and Public Areas

 No-touch trash cans
 Sneeze guards
Note shields between public and
employee behind counter
109
Equipment: Custodial
Minimize Occupant Exposure
Examples:
 Steam Cleaners and

Steam Vapor Cleaners
 No Touch Cleaning
Equipment
http://www.anaguard.com/images/kai_equipment.png
110
Equipment:
Ventilation to Reduce Exposure
During outbreaks transmitted through airborne
transmission, increasing ACH can reduce
airborne microbes.
An example, note
that increasing
ACH from 6 to 15
will 'clean' the air
to a 99% removal
rate in 18 minutes
as opposed to 46.
111
Reference: SARS & Air Filter Recommendations
http://www.filterair.info/articles/article.cfm/ArticleID/D4EB5EEC-ACCD-4AF7-
BB92BD9B3DFE9581
Facility Manager
Roles and Responsibilities
Flu Example
112
What role do Facility Managers play?
 Reducing Transmission:
 Risks to staff from their

work.
 Risks between staff,

building occupants and
the public.
113
How could a flu outbreak affect my
workplace and workforce?
 Absenteeism – could affect up to 40 % of
workforce during pandemic peak periods.
 Change in demand for custodial services –
may increase with additional infection
control tasks.
 Change in patterns of building use - the
public may come in at off-peak hours.
 Interrupted supply/delivery - shipments of
114
items maybe delayed or cancelled.
What is involved in fulfilling these
responsibilities?
 Developing Policies:
 Cleaning and Disinfecting
for Infection Control
 Absenteeism
 Stockpiling and providing items to occupants:

 Soap, tissue, hand sanitizer
 Cleaning supplies, microfiber cloths
115
 PPE
What is involved in fulfilling these
responsibilities?
Providing training on:
 Job related transmission routes & exposure risks.
 Exposure Prevention
 Protective behaviors (e.g. cough
etiquette, hand hygiene)
 Protective supplies (PPE)
 Work practices
 Cleaning and disinfection plans to be followed

during outbreaks.
116
Summary: Breaking the Chain of Infection
117
Additional Resources
 MA Operational Services Division
Environmentally Preferable Products
Program
http://www.mass.gov/ - type in EPP
 EPP FAC 59 Contract
 FAC59 Criteria for Disinfectants, Sanitizers
and Mold/Mildew Remediation
118
Additional Resources
 Cleaning Product Certification Organizations
 Green Seal - http://www.greenseal.org/

 EcoLogo - http://www.terrachoice-
certified.com/en/index.asp
 Green Cleaning - www.greencleaningnetwork.org
 Center for a New American Dream,

Responsible Purchasing Network
http://www.newdream.org/work/rpn.php
119
Resources: Project Handbook for Schools
Disinfection Overview Selection of Products, Dispensing Equipment
• Definitions and Application Systems
• The Science of Disinfection and Infection • Selecting Products for Infection Control:
Control Decision Making Flow Chart
• Comparing Disinfectants: Comparison Chart for
Development of Protocols EPA Registered Hard Surface Disinfectants
• Writing a Procedure for Disinfection • Using the Disinfectant Label Information to
• Choosing the Right Level of Microbe Control Make Informed Decisions
• Managing Surfaces for Infection Control • Using Information from Hazardous Materials
• Dispensing Disinfectants Rating Systems for Product Selection
• Labeling Secondary Containers • Using Information from Material Safety Data
• Pre-Cleaning Surfaces and Using Disinfectant Sheets for Product Selection
Cleaners • Selecting the Disinfectant Application System
• Identifying Factors that Compromise • Choosing Between Concentrated Products and
Disinfectant Efficacy Ready To Use Products
• Preventing Cross Contamination • Selecting and Installing Product Dispensing
• Storing Disinfectants Systems
• Disposing of Wastes
• Taking Precautions
• Assigning Roles and Responsibilities, and
Educating School Staff
120
Resources: Project Handbook for Schools
Safe Use Practices Classroom, Nurse and Custodial Guidelines
• Using Bleach (Sodium Hypochlorite) and Posters
• Hazard Overview of Bleach • Sample Classroom Policies
• Protocol for Safe Use of Bleach • Cleaning Surfaces for Infection Control for
• Using Disinfectants School Custodians – Poster
• Sample School Nurse Polices
Infection Control Practices
• Cleaning for Healthy Schools: Best Practices Resources
• Understanding Hand Hygiene: Products and • Organizations
Practices • Green Product Certification and Labeling:
• Cleaning Up Blood and Body Fluid Spills:
Protocol Poster Appendices
• Blood Spill Kit: Sample Memo with List of • Selecting Greener Disinfectants
Kit Items • Program Planning Handout: Cleaning for
Healthy Schools and Infection Control
Equipment for Infection Control • Interpreting the Disinfectant Label:
• Using Devices to Eliminate Chemical Use: • Interpreting Information From Hazardous
Ionator, Steam Technology and Hands-Free Materials Rating Systems: NFPA /HMIS
Technology • EPA's Toxicity Categories
• Using Microfiber Mops and Cloths for • Selecting Disinfectants for Hard Surfaces:
Infection Control • Regulatory Categories
• Using Ventilation to Reduce Microbe • Cleaning for Health: Program Components
121
Populations • Using Ventilation for Microbe Control
Project Contact Information
 Lynn Rose, Project Coordinator
lynnfaith@comcast.net
1-413-774-6540
 Carol Westinghouse, President

Informed Green Solutions, Inc.
westies@ecoisp.com
informedgreensolutions.org
1-802-626-8643
 Joy Onasch, Community Program Manager

Toxics Use Reduction Institute
joy@turi.org
http://www.turi.org/community 122
1-978-934-4343
References
1. Infection Control Best Practices for Laundry and Housekeeping
Professionals, Nicole Kenny, B.Sc., Virox Technology, Inc
2. A Guide to Selection and Use of Disinfectants, BC Centre for
Disease Control, 2003
3. Taking the Mystery Out of Chemical Disinfection, Nicole Kenny,
B.Sc., Director of Professional and Technical Services, Virox
Technology, Inc
4. Infection Control for Dummies, J. Darrel Hicks, REH,
5. What Microbes Are We Killing? Testing and Classifying
Disinfectants, by Allen Rathey, The Housekeeping Channel
6. Indoor Air Chemistry: Cleaning Agents, Ozone and Toxic Air
Contaminants, Final Report, Prepared for the California Air
Resources Board and CA EPA 123
References
1. Cleaning for Health, Inform, Inc
2. City of Ottawa FAQs about Alcohol-Based Hand Sanitizers and
3. Hygiene of the Skin: When Is Clean Too Clean? CDC Emerging
Infectious Diseases, by Dr. Elaine Larson, prof pharmaceutical,
therapeutic research & epidemiology, Columbia Univ School of
Nursing
4. 1Didier Pittet, “Clean hands reduce the burden of disease,” The
Lancet, www.thelancet.com, Vol. 366, July 16 2005, pgs 185 – 187.
5. www.flu.gov
6. CDC - http://www.cdc.gov/h1n1flu/guidance/exclusion.htm,
7. CDC - http://www.socialdistancing.org/determining-your-social-
distance-group-plan/
124
Self Isolation
Poster
Source: CDC
Preparation
for Home Stay
Checklist:
http://healthvermo
nt.gov/panflu/famil
y_checklist.aspx 125
Hand Washing Guidelines
 Wet your hands with warm running
water and apply liquid soap.
 Rub hands together to make a lather

and scrub all surfaces for 20 seconds.
 Rinse hands in running water.
 Dry your hands using a paper towel or

air dryer.
 Use paper towel to turn off faucet.

 1Didier Pittet, “Clean hands reduce the burden of disease,” The Lancet, www.thelancet.com, Vol. 366, July 16 2005, pgs
185 – 187.
126
126
Combination
Poster:
Respiratory
Etiquette and
Handwashing
http://organizedwis
dom.com/Special:O
W_Special_Nugget/
HandwashingPoster
_Engl_Spanish-
2006_1_copy.pdf/26
9/363068 127
Cough Etiquette
Posters & Flyers

available from the
CDC
Website
in many languages
http://www.cdc.gov/fl
u/protect/covercough.
htm
128
Alcohol Based Hand Sanitizer
Available as foam rubs, gels, or wipes.
To be most effective,
a dime-size dollop of
alcohol gel should be
rubbed into the hands
for 30 seconds.
If hands are dry after

only 10-15 seconds, it is
likely that not enough
sanitizer was used.
Reference: http://edis.ifas.ufl.edu/fy732 129

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A 3 Prong Infection Control

Strategy for Public Buildings

Based on the School Disinfection Workgroup

Training and Documents Written by: Lynn Rose and

Funded by: the Massachusetts Toxics Use Reduction

 Facilitate adequate infection control while

 Protect workers and building occupants from

 Clarify the differences between cleaning and

 Environmental Working Group tested 21 common

Unspecified 104 12% of all Work Related Asthma

St udent s wit h Ast hma ( per t housand st udent s )

Massachusetts Department of Public Health

Do you always need to

Cleaning Sanitizing Disinfecting

 We can’t live without them.

 Some are good for you, and other

 Fungi* – grow on dead and decaying matter.

 Viruses – live and multiply inside of cells of a living

* Spores produced by some types of bacteria and fungi

 Microbes live and multiply in a reservoir.

 Warm, dark environment

 Large droplets containing microbes are:

Photo: 2009 Camfil Farr , http://www.camfilfarr.com/cou_us/industries/care/infection_transfer.cfm

 Microbes in airborne droplets:

 Transfer of microbes from person to person.

 Breaks in the skin

 Weakened Immune System - body not

survival on Respiratory and Enteric Viral Disease. Applied and

Breaking any of the links of the chain can

2. Cleaning for Health

 Leaving a 3-6 foot buffer between yourself

CDC Influenza Fact Sheet, http://www.cdc.gov/flu/professionals/pdf/resphygiene.pdf.

 Yes, depending on the product and

 Hand washing with soap and water can

 Soap will remove, not kill microbes.

 Anti-bacterial products kill bacteria

 Anti-microbial products can kill or

 Soap is available in liquid, bar (not

 Soap and warm water remove microbes by

 The CDC guidelines call for washing hands with

 Detected in breast milk,

 Product that can kill or suppress growth

 Most common ingredient is alcohol,

Concentration Required to Kill Specific Viruses

 Routes of Exposure for Children

 Class 1 - Flammable Liquid

 Follow 527 CMR storage guidelines

 State Fire Marshal reissued an Advisory for

 Dirt: antimicrobial and alcohol based

 Proteins: soap is more effective

 Sample strategies include:

Level 1: General Surface Cleaning

 May not have claims for killing viruses or fungi.

 Some products can be both a sanitizer and a

References: Infection Control for Dummies, J. Darrel Hicks, REH, http://www.epa.gov/iaq/glossary.html#S,

 Destroys 99.99% of all forms of

 Use on hard nonporous surfaces,

 All disinfectants do not kill all types

 Hospital / Medical Use Disinfectant:

 To comply with OSHA BBP

 For MRSA and other specific

An influenza A virus label

 Products with these ingredients will not be approved: