Disinfectants in Personal Services Settings

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1 Disinfectants in Personal Services Settings 2014 Ontario Branch Canadian Institute of Public Health Inspectors (CIPHI) Conference Cecilia Alterman, MEd, BES, BASc, CPHI (C) (A) Manager, Control of Infectious Diseases/Infection Control, Toronto Public Health

2 Objectives: By the end of this presentation you should be able to: 1. Understand what makes a disinfectant low, intermediate or high-level 2. Identify when an operator should use a low, intermediate or high-level disinfectant 3. Identify if the appropriate disinfectant is being used with the right item 4. Interpret the appropriate use of a disinfectant label

3 Label Claim Reading the fine print: 1. Not a chemical/disinfectant expert 2. Cleaning is a critical step prior to disinfection 3. Follow manufacturer instructions on concentration, contact time, use (surface/instrument immersion), and expiry dates 4. Assessment to ensure the disinfectant level is appropriate for the item and the organism of concern 5. Mindful of occupational and environmental issues, cost, access and ease of use of a product Please read the fine print carefully Active Ingredient: Fun, we are PHIs after all

4 What makes a disinfectant low, intermediate or high level? The type of microorganisms the disinfectant kills in laboratory tests

5 Low Level Disinfectants Kills lipid viruses (e.g. hepatitis B, hepatitis C and HIV) and vegetative bacteria (Gram + and -) On the label: General or hospital disinfectants", "kills germs, broad spectrum, cleaner/disinfectant, or quaternary ammonium ingredients. Often can purchase product at a grocery or pharmacy store. **Not tuberculocidial, sporicidal** CDC, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 National Collaborating Centre for Environmental Health, Effectiveness of Alternative Antimicrobial Agents for Disinfection, 2011

6 Intermediate Level Disinfection Kills mycobacterium species (e.g. M. bovis or M. terrae*), fungi, non-lipid and lipid viruses, and vegetative bacteria On the label: Tuberculocidial, Tuberculocide, Mycobactericide, Mycobactericidial, or a TB claim. *M. terrae is sometimes used to replace M. tuberculosis in laboratory testing because M. tuberculosis is highly pathogenic and has a slow growth rate Editor: Semour S. Block, Disinfection, Sterilization and Preservation, 2001 CDC, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 National Collaborating Centre for Environmental Health, Effectiveness of Alternative Antimicrobial Agents for Disinfection, 2011

7 High Level Disinfection Kills mycobacteria, fungi, non-lipid, lipid and vegetative bacteria On the label: TB claim and High Level or Chemical Sterilant or Sporicidal claim. - There are HLD that if the contact time is extended are sporicidal - HLD have higher microbial log reductions than ILD

8 When to use a LLD, ILD or HLD? In health care settings, only HLD permitted on semi-critical items. MOHLTC, PSS Infection Prevention and Control Best Practices for Personal Services Settings, 2009 In health care settings, ILD only permitted on non-critical items

9 Assessing the classification of an item, helps to determine the level of disinfection required New items found in PSS all the time

10 Assessing the classification of an item, helps to determine the level of disinfection required Example: Footbaths (pipes or pipeless) non-critical? 1. Assessment of the microorganism that poses an infectious risk for footbath customers 2. Assessment of contact with intact skin

11 Footbaths Classified as Semi-Critical 1. Mycobacterium poses the infectious risk - Dirty screens provide reservoir - Need to eliminate reservoir via thorough cleaning of screens - Requires an ILD to HLD to destroy organism 2. Those that shave, wax or have open sores before using a footbath are at higher risk for infection - Eliminate portal of entry recommend no shaving/waxing/pedicure until after the footbath Emerging Infectious Diseases, April 2005; 11(4): EPA, Recommended Cleaning and Disinfection Procedures for Foot Spa Basins in Salons, Feb 2014.

12 The perfect reservoir for mycobacteria Accumulation of debris in screens

13 Pipeless Footbaths: Current Practice Focus on thorough cleaning of screens between clients Use a disinfectant with a tuberculocidial claim and can be used on hard surfaces or a thorough spray with a solution of bleach and water (2 teaspoons of bleach* with 2 cups of water) (made daily) Shelf life in polyethylene container: Approximately 30 days. * Bleach will be discussed in detail further in the presentation

14 * Bleach will be discussed in detail further in the presentation Footbaths With Pipes: Current Practice Focus on thorough cleaning of screens at the end of each day Fill and run footbath disinfectant with a tuberculocidial claim and can be used on hard surfaces that can be diluted with water or solution of bleach* and water (404 ml bleach to approximately 20 litres of water)

15 Use of Household Bleach in PSS Blood spill contamination on hard surfaces - spills usually minor in PSS and permitted for use in healthcare* Footbath disinfection need to focus on reducing the risk of infection from eliminating the mycobacteria reservoir and portal of entry EPA allows for LLD once screens are cleaned regularly *PIDAC, Best Practices for Environmental Cleaning for Infection Prevention and Control, May 2012

16 Use of Household Bleach in PSS Advantages: Low cost, rapid action, readily available, easy to mix/use Disadvantages: Need thorough cleaning for product to work, solution needs to be made fresh daily, no test strips, corrosive to pipes Concerns: No DIN, only EPA registered as Tuberculocidal, no label claim on how to properly use item, occupational and environmental concerns when large amounts used, stains clothing/furniture

17 Is 5.25% Bleach Tuberculocidal? US Environmental Protection Agency, Office of Pesticide Programs, List B: EPA s Registered Tuberculocide Products Effective Against Mycobacterium tuberculosis April 2014

18 The Future of Household Bleach in PSS 1. Some health units are not allowing bleach to be used in PSS 2. Need consistency in approach 3. Still allow for blood spill contamination on hard surfaces (spills usually minor in PSS)?

19 Drug Identification Numbers (DIN) and Natural Product Numbers (NPN) Health Canada does not test products applicants provide required information to support the safety, efficacy and quality of a disinfectant Health Canada assesses and evaluates information and determines if a DIN is granted Health Canada does not regulate the consumer free to choose which product and how it will be used

20 Why is the DIN or NPN important? Let s user know the product is assessed and approved by Health Canada Product must have a label that includes: products recommended use or purpose dosage information medicinal and non-medicinal ingredients Any cautions associated with the product

21 Drug Identification Number (DIN) Look for a DIN or for alcohols, a natural product number (NPN) Current exception: Household Bleach or 5.25% sodium hypochlorite, as per the IPAC BP for PSS, Jan 2009 PIDAC, Best Practices for Environmental Cleaning, May 2012

22 Reading the label: What is the nature of the item to be disinfected? Approved for use on instruments (immersion)? Approved for use on surfaces (wipe/spray)?

23 Reading the label 1. What level of disinfection is this product? 2. How could this disinfectant be used in PSS? 3. How should it not be used? 4. Why is this a good product? 5. What information can t we see from this picture and is important?

Reading the label 1. What level of disinfection is this product? ILD 2. How could this disinfectant be used in PSS? Surfaces, pipeless footbath 3. How should it not be used?

24 Reading the label 1. What level of disinfection is this product? ILD 2. How could this disinfectant be used in PSS? Surfaces, pipeless footbath 3. How should it not be used? Instruments/footbaths with pipes 4. Why is this a good product? DIN, occupational concern, label is clear 5. What information can t we see & is important? Shelf life/expiry date, cost

product with HLD or Chemosterilant* label claim *Recommend a ready-to-use product

25 ILD for the immersion of semicritical instruments in PSS Example: Most common semi-critical item in PSS are manicure and pedicure items Use ILD or HLD HLD use a product with HLD or Chemosterilant* label claim *Recommend a ready-to-use product that can be used as a HLD when the contact time is decreased and has minimal occupational concerns

70% Isopropyl Alcohol in PSS: Advantages 1. Kills blood-borne & Mycobacterium? Yes. 2. NPN? Yes. 3. Readily available? Yes. 4. Easy to use? Yes. 5. Low cost? Yes. 6. Rapid action? Yes (10 minutes) 7.

26 70% Isopropyl Alcohol in PSS: Advantages 1. Kills blood-borne & Mycobacterium? Yes. 2. NPN? Yes. 3. Readily available? Yes. 4. Easy to use? Yes. 5. Low cost? Yes. 6. Rapid action? Yes (10 minutes) 7. Non-toxic? Yes 8. Not corrosive for metal instruments Change weekly or if visibly dirty. Editor: Semour S. Block, Disinfection, Sterilization and Preservation, 2001 CDC, BC Centre for Disease Control, A Guide to Selection and Use of Disinfectants, 2003 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

27 70% Isopropyl Alcohol in PSS: Disadvantages 1. Hard to find large bottles with NPN 2. No label instructions approx minute contact time 3. Item must be cleaned thoroughly 4. Flammable Do the advantages out weigh the disadvantages?

28 Disinfection Chart: Needs Updating Only recommend high level disinfectants for the use on instruments with appropriate label claims Contact times have improved Needs to be revised to include 0.5% stablized/enhanced action formulation

29 The Bottom Line Look for DIN or NPN for alcohol For pipeless footbaths look for a ready-to-use surface disinfectant with a TB claim that can be wiped or sprayed, short contact time For footbaths with pipes look for a hard surface disinfectant with a TB claim that can be mixed with water, non corrosive, short contact time (few, but there are some available) Follow manufacturer instructions ensure safe for surfaces vs. immersion of instruments/items

30 The Bottom Line If using a HLD for the immersion of instruments/items, only use labelled HLD or chemosterilants safe to use as HLD Look for the shelf life/expiry date Products with test strips are recommended and could be used during inspections Start to move operators away from bleach or Continue to allow it to be used as a disinfectant of blood spills; and/or Footbaths?

31 Thank You! Also thanks to Ontario PSS Working Group Public Health Ontario Jason MacDonald, Alberta Health (and thanks for not throwing tomatoes) CIPHI

Cleaning and Disinfection Protocol for Emergency Services Fire, Ambulance, Police, Search & Rescue

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