Q: What exactly does “Infection Control” mean and why does it matter to environmental health?
A: Infection control includes all the policies, programs, procedures, and – most importantly – practices developed to keep disease from spreading. In other words, infection control keeps germs, or pathogens, from infecting people and making them sick. A pathogen is an organism that causes disease, whether it is a virus, bacteria, or fungus.
The term infection prevention is more commonly used in healthcare settings such as acute care facilities. CDC’s infection control recommendations focus on protecting healthcare workers from infection while making sure patients have the essential care that they need, as well as protecting patients from infection while they’re in the facility, with the goal of keeping the disease from spreading. Project Firstline’s goal is to make sure that the public health workforce and frontline healthcare workers are knowledgeable in infection control, and that they can put their knowledge into action to keep themselves and their communities safe.
Infection control matters to environmental health because of the crucial role that environmental health plays in keeping the environment safe and free of germs. In the community setting, environmental health staff provide advice and compliance assistance on cleaning, disinfection, and sterilization, which are important parts of infection control.
Not only is it important to have a clean environment, but it is also important that environmental health staff do not spread germs from place to place in a facility, or across facilities. We do not want to not serve as a route of transmission by bringing potentially infectious organisms from one setting to another, and we want to keep our environmental health staff safe and protected from infection.
Q: What are the main ways that COVID-19 spreads?
A: The main way that SARS-CoV-2, the virus that causes the disease COVID-19, travels between people is through respiratory droplets. When someone who is infected with the virus breathes out, coughs, or talks, the tiny droplets of water that are carrying the virus can reach people who are close by. Those people can breathe the droplets in, or the droplets can land on their eyes, and they can get infected.
Respiratory droplets spread COVID-19 by traveling between people. In this case, “droplets” does not just mean water that you can see, like big raindrops or splashes in the sink or a pool. These droplets are tiny, and where they come from might surprise you. You might think that when you breathe out, all that comes out is air, right? You do not see anything else. But in fact, our breath contains a lot of water. When you go outside in cold weather and you breathe out, you see your breath, or if you breathe on a mirror, it fogs up. What you are seeing in both these cases is not air. It is all the water in your breath. Those are your respiratory droplets. Most droplets are too small for us to see, and different-sized droplets can travel different distances in the air. Some will go farther than others. It is important to know that even though these droplets come in a lot of different sizes, they are all small enough and light enough that if another person is close by – for example, when we are eating at a table – then that person can breathe in the droplets that we have just breathed out. And when someone is infected with SARS CoV-2, those tiny respiratory droplets have virus particles inside of them. If you breathe in respiratory droplets that are carrying that virus, it can then get onto your nose and into your throat and your lungs. Droplets fall on objects that are nearby, like chairs, tabletops, and clothes. Once the droplets land on something, the virus can survive for at least a little while. It can’t survive long on most surfaces, but it's long enough for you to touch that surface and for the virus to make it onto your hands. The virus can get into your body if you touch your face without cleaning your hands first.
In addition to droplets falling, another important way that virus can get onto surfaces is when an infected person touches their eyes, their nose, or their mouth, which transfers virus particles onto their hands. If they then touch another surface, like the break room door handle or the keyboard, and if another person touches those surfaces and doesn't clean their hands, the virus can be spread to that person. It is important to remember that someone can be infected with the virus and not feel sick. Even though they don’t know they have the virus, they can still spread it to others.
Q: Can SARS-CoV-2 live on surfaces for very long? And if so, are there particular surfaces in restaurants, daycares, and other buildings that should be a higher priority for cleaning and disinfection?
A: Although COVID-19 is mainly spread through respiratory droplets that are breathed in by others, another way you can get sick is if you touch something that has live virus on it and then touch your face without cleaning your hands first. Viruses can get on surfaces when respiratory droplets land on those surfaces. Viruses can also get on surfaces when bodily fluids from an infected person – like spit and snot – get onto things nearby.
In the healthcare setting, routine cleaning, and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects) are appropriate for SARS-CoV-2. Surfaces can be classified by their use and whether they are expected to get dirty. Surfaces like door handles and light switches, which are touched often and by many people, are called “high-touch” surfaces and should be cleaned and disinfected at least daily when visibly soiled. In addition to cleaning, these areas should be disinfected, but this can depend on the frequency of touch and the number of people who are contacting that shared surface.
It is important to establish routine procedures for cleaning and disinfection and to follow them consistently and correctly. For food preparation surfaces, the normal food service standards include using an EPA-approved food contact surface sanitizer and following the recommended contact times and label instructions.
Q: What does the term “Standard Precautions” mean? And how would that apply to me as an inspector working in the field?
A: Standard precautions are infection prevention and control practices that are used for all patient care to protect patients and healthcare workers from infection, and to prevent the spread of infection in healthcare.
One of these core precautions is hand hygiene. In a healthcare setting, this can be either with soap and water or alcohol-based hand sanitizer. For environmental health specialists, a good practice for hand hygiene is washing hands upon the start of an inspection and upon completion of the inspection. When handwashing is not possible, use 60% alcohol-based hand sanitizer at the start of the completion of the inspection.
In a healthcare setting, cleaning, and disinfection of the environment and of equipment and devices, as well as handling textiles and laundry carefully, are also part of standard precautions. Also, there are recommendations for safe injection practices – needle selection, administration technique, and sharps disposal.
Promoting good respiratory hygiene and cough etiquette, which includes “covering your cough” and wearing a mask for source control, is another important part of standard precautions. Most people are familiar these days with personal protective equipment (PPE), which is the equipment that is used to protect us from germs and to keep germs from spreading.
This set of standard precautions is something that is always practiced (or should always be practiced) regardless of where care is being delivered.
Q: What is the difference between cleaning, disinfection, and sterilization?
A: When we use these terms, we are referring to three different processes. Cleaning is the removal of any material or foreign substance from a surface, such as dirt, debris, or smears. Cleaning and disinfection are both very important and keep infections from spreading. When you clean your house, you're getting rid of dust, dirt, grime, and all the other spills, smears, and stuff that happens in everyday lives, but in healthcare, we do the same thing. Cleaning doesn't kill germs, it removes them.
Disinfection is the process that kills germs on surfaces or objects. Disinfection should not come before cleaning. They either happen at the same time using a single product, or cleaning comes first in the two-step process of cleaning and disinfection. Take precautions such as wearing gloves and making sure you have good ventilation while using the product. Do not eat, drink, breathe, or inject cleaning and disinfection products into your body or apply directly to your skin as they can cause serious harm.
All viruses are not the same. That is why it is important to use the right disinfectant. For COVID-19 disinfection, use products on EPA List N: Disinfectants for Coronavirus (COVID-19). If products on the list EPA List N: Disinfectants for Coronavirus (COVID-19) are not available, a bleach solution can be used if appropriate for the surface and will be effective against coronaviruses when properly diluted. Note that most household bleach contains 5%–9% sodium hypochlorite. Do not use a household bleach product if the percentage is not in this range or is not specified, such as some types of laundry bleach or splash-less bleach, as these are not appropriate for disinfection.
The next level beyond disinfection is sterilization. Sterilization destroys or eliminates all forms of microbial life and can be done either physically or through chemical methods, such as immersing an item in a chemical sterilizing agent or by using steam/pressure to sterilize an item. We must be careful about how we are using the terms and the processes of cleaning, disinfection, and sterilization to make sure we are following the best public health guidance.
It is important to note that cleaning should take place before disinfection or sterilization. Some products will clean and disinfect in one step. If a surface or object is not clean before it is disinfected or sterilized, the processes might not work, because they cannot reach the germs under dirt and grime. It is also possible that disinfectant could spread dirt or spills around on a surface, and not kill the germs.
Q: Is hand sanitizer just as effective as handwashing?
A: “Hand hygiene” is the broad term that includes handwashing with soap and water or using alcohol-based hand sanitizer. Hand hygiene is an important part of stopping the spread of SARS-CoV-2.
In a healthcare setting, alcohol-based hand sanitizer and handwashing are both efficacious when using the proper technique, but with repeated use, handwashing is not well tolerated. However, routine hand washing is required in certain settings, such as when the hands are not clean (or visibly soiled, or when there is an exposure to a potential spore-forming pathogen.
In a community setting such as a food facility inspection when handwashing is not possible, choose hand sanitizers with at least 60% alcohol (often listed on the label as ethanol, ethyl alcohol, isopropanol, or 2-propanol). Avoid alcohol-based hand sanitizers that are not approved by the Food and Drug Administration (FDA)external icon. Properly apply alcohol-based sanitizer by rubbing the gel over all surfaces of your hands and fingers until your hands are dry.
Q: I am required to wear a mask when I’m out doing inspections. Can I wear the same mask all day?
A: Wearing a cloth mask or medical face mask that fits your face well is an important part of stopping the spread of COVID-19. These masks are source control, covering your nose and mouth to block the respiratory droplets that come out when you talk or breathe. The masks also can offer some protection for you against respiratory droplets that others are breathing out, and that carry virus if someone is infected with SARS-CoV-2.
It’s important to avoid touching your mask when you’re wearing it. It’s also important to clean your hands, either with soap and water or alcohol-based hand sanitizer before you put it on and after you take it off.
You can wear the same mask throughout your day, but if it gets dirty or wet, you need a new one. CDC has additional tips for masking: How to Safely Wear and Take Off a Cloth Face Covering | CDC It’s also important to remember the other precautions to take when you’re in public spaces (addressed below).
Q: When I meet people to conduct inspections, what are some general precautions I should be taking?
A: There are a couple of core recommendations to follow whenever you are in public. First, wearing a mask that fits you well – that fits snugly around your cheeks and chin – is still recommended when in public, regardless of whether you have had the COVID-19 vaccine.
Secondly, keeping physical distance from people who are not in your household is important to keep the virus from spreading.
Additionally, it is important to be conscientious and diligent about cleaning your hands frequently, and especially after you’ve been in a public place or have coughed or sneezed, either by washing your hands with soap and water or by using alcohol-based hand sanitizer. Lastly, it is important to be aware of how you are feeling. If you are feeling sick – if you start feeling symptoms such as a fever, cough, or shortness of breath – don’t report to work, and speak to your doctor.
Q: Environmental Health has been asked to take a lot on. We are working with schools, daycares, restaurants, shelters, jails, nursing homes, and other businesses. Information continues to change, and it can be overwhelming. Where is the best place to find the most up-to-date information?
A: Look at the recommendations made by CDC and Project Firstline. New information and products are coming out to address some of these emerging topics.
I would end by saying that this is a stressful time for all of us, but we have the basic foundational principles of infection prevention and control to rely on. We can continue to conduct business in a way that is as safe as possible and make sure we are promoting adherence to all the public health recommendations.
Additional Project Firstline Resources:
- NEHA Project Firstline Environmental Health Q&A Session
- CDC Inside Infection Control Training Videos
- Review the Project Firstline Facilitator Toolkit Guide and participant resources
Tim Landers, Ph.D. RN CNP CIC FAAN
Dr. Landers currently serves as Nurse Scientist at Nationwide Children's Hospital in Columbus, Ohio. He previously served as Associate Professor at the College of Nursing at The Ohio State University in Columbus, Ohio. His research work at Ohio State focuses on evidence-based infection prevention strategies. His work has addressed patient-centered hand hygiene, hospital-associated pneumonia prevention, and human to animal transmission of antimicrobial-resistant pathogens. Dr. Landers has served as a member, Vice-Chair, and Chair of the APIC Research Committee. He has the lead author of APIC's Hand Hygiene Implementation guide and was one of the lead authors of the APIC Mega Survey. Internationally, Dr. Landers spent a year working on evidence-based infection prevention strategies in Ethiopia and has lectured in Australia, Kenya, and Canada on patient-centered hand hygiene and oral care. This perspective helped him to see the enormous impact APIC can have on the broader global community. Dr. Landers earned his Ph.D. in Epidemiology from Ohio State University, his Master of Science in Nursing Degree from Pace University in New York City, a Master of Arts in Theology from LaSalle University in Philadelphia, Pennsylvania, and his Bachelor of Science in Nursing degree from Binghamton University, New York. He has been certified in infection control since 1996 and has earned the FAAN designation.