When Will Infection Control Get Real? By: Rella P. Christensen, RDH, PhD

You say it’s 66 pages and not fun to read—and you couldn’t find an executive summary anywhere? Well, it’s really only about 10 pages of actual recommendations. The other 56 pages are introduction, background, and review of some of the science related to infection control. Just because this comes first in the booklet doesn’t mean you can’t flip to page 39 and read the actual recommendations first.

The multiple acronyms bugged you? There’s the PPE to help avoid the need for the PEP, and the OPIM that could contain HAV, HBV, HCV, HDV, and HIV that threaten the DHCP. Don’t worry, after a while you remember what most of them mean.

You know, Doc, you can’t escape it. Putting off reading this booklet is like putting off a confirmatory diagnosis of a dreaded disease. Whether or not you acknowledge it, you have it. Subconsciously you are wondering, does this replace OSHA requirements or add to them? (You already know it doesn’t simplify or subtract from them.) Are you trying to think of a staff person who could figure it out for you, without morphing into Godzilla?

There are at least four major reasons you should not delegate infection control. Instead, appoint a staff person as your administrative assistant to help produce results, but retain the administrative lead yourself. Why?

1. Work related threats to patients and staff are clearly your responsibility.

2. Staff members come and go; the programs delegated to them come and go with them.

3. Infection control costs are substantial, in both time and dollars, and you need to know these costs well to determine your fees and to determine which third-party plans you can and cannot support. (As you know, many third-party plans provide only token reimbursement for infection control, and your infection control costs can exceed the reimbursement for some procedures.)

4. Only you, the owner dentist, have the authority to make final decisions and enforce controversial decisions.

Unfortunately, once again, dentistry has been handed an infection control document with thousands of words dictating procedures and techniques in amazing detail, but giving virtually no information on the relative merits of the many products that make control of infectious microbes possible. There is no use trying to fool ourselves—infection control is a product-dependent discipline. Good techniques and procedures cannot overcome the consequences of facemasks and operating gloves that leak profusely, or disinfectants and antiseptics that have weak kill of bacteria and no kill of viruses. Unfortunately, clinicians cannot use price, visual appearance or company appeal as guides to products that effectively kill or block contaminating microbes, or those products that bolster your immune system to the point it can kill or block invading microbes.

The CDC’s implication that procedures and techniques can do the job without absolutely efficacious products is like sending a soldier into battle with an unloaded weapon. He looks like a soldier, acts like a soldier, but he lacks the firepower to be a soldier. Unfortunately, when deadly strains of microorganisms are encountered by clinicians, consequences can be rapid, deadly, and widespread due to failure of infected people to isolate themselves—as witnessed most recently in the Severe Acute Respiratory Syndrome (SARS) epidemic. After exposure and onset of symptoms, it is too late to worry about why you weren’t more careful.

Let’s “get real” here. The reasons the official documents overflow with lists of procedures and techniques, and ignore the quality level of the necessary products that make infection control happen, are that:

1. None of the groups issuing guidelines, recommendations, and laws performs actual efficacy testing of products, so they have no first-hand data they can trust enough to defend legally, if the need arises. This includes CDC, OSHA, FDA, EPA, ADA, OSAP, and many other respected groups in medicine, nursing, and hospital administration.

2. All of these groups are hopelessly bound by a variety of entanglements that prevent candid reporting of full data on product efficacy––even if they were to test.

3. Infection control product efficacy testing is time consuming, expensive, and often difficult and thankless work that, of necessity, must not be funded or influenced in any way by industry.

So, you can probably see critical information on infection control product efficacy is not likely to be forthcoming from the sources that should be addressing the issue as they write your “guidelines”. Only Clinical Research Associates’ (CRA) non-profit microbiology lab tests the efficacy of all types of infection control products from all over the world, and reports candidly the full data. Sorry to say this folks, but it is true. You can write or call CRA to receive a listing of the few infection control products, of the hundreds tested by CRA, which have demonstrated efficacy and met manufacturer’s claims.

Now that you are aware of a very important and fundamental lack in the CDC document, let’s discuss some notable ways the CDC Recommendations compare with OSHA’s Bloodborne Pathogen document:

1. The CDC Guidelines are recommendations, not law. The OSHA Bloodborne Pathogen document is federal law. However, since these new recommendations come from the CDC and are written specifically to dentistry, they are likely to become the standard of care in legal challenges. So this is a fifth reason, Doc, that you should not delegate the reading of this document to a staff person, and forget it yourself.

2. The CDC Recommendations give very specific instructions on topics OSHA touches only by inference, or not at all. Take a moment to scan the three columns in Table 1 to see some interesting parts of the CDC Recommendations that are the same as OSHA’s Bloodborne Pathogen (BBP) document; similar to OSHA’s BBP, but expanded; and new and not covered in OSHA’s BBP document. This table is not comprehensive. It simply lists some items I found interesting or noteworthy. An upcoming issue of the CRA Newsletter will provide you with a comprehensive listing of the similarities and differences between OSHA’s and CDC’s content.

There are three problems with the CDC recommendations, which will be very misleading to clinicians— misleading to the point of being dangerous.

1. Inaccurate information on disinfectants.
Clinicians are lead to believe that a TB kill claim assures kill of all other pathogens, including viruses, but not spores. This is untrue. The information presented in the figure on page 64 in Appendix A of the guidelines is simply not accurate. Tests performed by CRA in triplicate on over 140 different disinfectants from around the world using EPA’s quantitative tuberculocidal (TB) test* show there is not a reliable correlation between TB and virus kill. Yet this CDC document, and CDC and EPA classifications of disinfectants, seem to be based entirely on TB kill capability, and assumes virus kill will occur if TB is killed. Below is a partial list of current disinfectant brands where CRA data show adequate kill of the TB bacteria, but not of a commonly used nonlipid test virus (poliovirus)**, as long as no bioburden is present:

Amcide Aseptiphene 128 Asepti-phene RTU Bi-Arrest Bi-Arrest II Biocide Coe Spray Coe Spray “The Pump” Discide Ultra Wipes Ectru FD 320 FD 322 Formal Spray Generic Isopropyl Alcohol

Iodofive Iodophore Lysol I.C. Cleaner Madacide-FD Procide Spray Professional Amphyl (1:200) Professional Amphyl (3:100) Sporicidin Sporicidin Wipes Super Sani Cloth Viraguard Towelettes Virahol Vital Defense-D Wescodyne

Then, there are the products that have the opposite incomplete kill profile—where they do not kill TB, but they do kill the poliovirus. Current brand names include:

BBJ Disinfectant Lysol I.C. Foaming Cleaner Lysol I.C. Ready to Use Cleaner

SUV Virkon

Of the 140 disinfectants tested so far by CRA, only the following 22 (16%) killed both TB and poliovirus, as long as no bioburden was present:

Bactol Blue Biosurf Birex SE Cavicide Citrace Citrex Clorox Disinfecting Spray Clorox 1:2 Clorox 1:5 Clorox 1:10 Clorox 1:100

Exspor G2 Germxtra (Canada) Glen 20 (Australia) Lysol Brand II Sprays Lysol Spray Canadian Microstat 2 Sep-T-Ban Surfex-E Viralex with T36 Xinix Concentrate

If you think the above information is shocking, because only 22 of over 140 products could kill both the test organisms, you will be dismayed to learn these results are from the most permissive testing, which is in the absence of any bioburden challenges.

All but six of the 140 disinfectants tested (4%) failed to kill adequately in the presence of the body’s complex protein bioburdens such as blood and saliva. Unfortunately, microorganisms come to you, the clinician, mixed intimately with the complex proteins of body fluids. Therefore, CRA has stated repeatedly and vehemently for years that disinfectants used in healthcare settings should be required to have robust kill in the presence of heavy challenges of fresh human body fluids. And of over 140 disinfectants tested, the six that met this criterion were:

A. Lysol Brand II Sprays, Germxtra (available in Canada), and Glen 20 (available in Australia). All three have high ethyl alcohol formulations.

B. Exspor, plus Clorox mixed 1:2 (one part Clorox with one part water) up to Clorox mixed 1:5 to dilute its odor, bleaching and damaging potentials. All of these have chlorine-based formulations.

But CDC tells you none of this. In fact they say, “The choice of specific cleaning or disinfecting agents is largely a matter of judgment, guided by product label claims and instructions and government regulations.” The problem here is label information is not necessarily correct, and often not even clinically doable. For example, how do you maintain liquid disinfectant on vertical surfaces in your operatory for ten minutes? What about basing your judgment on the reason you buy and use a disinfectant in the first place—its proven ability to kill microbes! Where do you secure kill data that are reliable, rather than driven by marketing? The truth is, if strictly honest kill data were actually provided to you, most companies that sell disinfectants would go out of business or be forced to find or develop new potent formulations. As it is, from a number of sources, you are led to believe disinfectants have similar kill. Based on this misinformation, you search for those that smell pleasant, don’t disturb your surfaces, and have nice salespeople, instead of seeking the products that have fast, broad-spectrum kill in the presence of bioburden. So, if a virulent virus, like the SARS virus, emerges suddenly and comes your way, you will be caught unprepared.

2. Illogical sequence recommending cleaning before disinfecting.
For years, CRA has been trying to warn clinicians that cleaning before disinfection and sterilization is dangerous and not scientifically sound. One of the major principles of infection control is DO NOT TOUCH CONTAMINATED ITEMS. Yet the CDC document repeatedly recommends cleaning first, which encourages clinicians to handle items immediately following patient treatment, when infectious organisms are most likely to be viable. Getting stuck by a contaminated instrument introduces another person’s bodily fluids directly into your bloodstream. Think about this. I am appalled that experts in infection control continue to recommend the “clean before you disinfect” sequence.

Clinicians, TURN IT AROUND—disinfect before you clean. The unsound practice of clean first then disinfect has been recommended for years to try to overcome the inability of most disinfectants and sterilization processes to penetrate bioburden and kill the organisms within it. Today there are better ways. We have high ethyl alcohol disinfectants that kill in the presence of bioburden and should be spread liberally to lower microbe counts before cleanup begins. We have washer-disinfector machines that can be loaded using tongs, thus avoiding all contact between the cleanup person and contaminated instruments. Sterilization follows treatment in the washer-disinfector.

3. Low and high performing concepts are mixed indiscriminately, implying equal performance.
Hand hygiene recommendations include “non-antimicrobial soap, antimicrobial soap, and alcohol-based hand rubs”. CRA studies using the glove juice test*** show statistical differences in microbe reduction on hands treated in these three different ways. In addition, the type, concentration, and amount of alcohol rub dispensed onto the hands make a substantial difference in numbers and types of microbes affected. High ethyl alcohol preparations have had significantly better performance than isopropyl alcohol formulations, and they kill viruses which isopropyl alcohol fails to inactivate. So the “alcohol-based” products do not perform equally well. Gel carrying agents and the density of foam-dispensed preparations have also been significant factors in performance. If the CDC’s recommendations were to be truly helpful to clinicians, the options suggested need to be ranked in order of antimicrobial potential, along with a listing of the pros and cons of each product. But CDC cannot do this because they do not test. They say this vital area of product efficacy is “beyond the scope” of their document. The same problems exist as their document discusses facemasks versus face shields, antimicrobial active ingredients, and many other products.

I do not know if the CDC staff that prepared the recommendations is aware of the problems mentioned above. I can see a lot of time, effort, and money have been expended to produce these guidelines and mail them to clinicians throughout the U.S. I believe the omission of product efficacy information and the three problems listed above represent serious lacks in this important document of which clinicians need to be aware.

Clinicians need a government owned and well supported testing lab where all products used in infection control are tested, ranked, and categorized so clinicians know exactly what they are buying. The present system protects the infection control industry instead of the clinicians and their patients!

Let’s “get real”! One of these days a new virus strain will engulf the earth, and we will be caught unprepared, wishing we had been more focused on practical essentials and less concerned with politics.

Rella P. Christensen, PhD co-founded Clinical Research Associates (CRA). She received a Bachelor of Science in dental hygiene from the University of Southern California, and practiced dental hygiene for more than 20 years. She also worked as a dental laboratory technician for three years. She founded the bachelor degree dental hygiene program at the University of Colorado, and served as its first director. She returned to school in 1980 to earn a PhD in physiology, with an emphasis on microbiology, from Brigham Young University. Following that, she completed a post-graduate course in anaerobic microbiology at Virginia Polytech State University.

She is a member of the Academy of Esthetic Dentistry, the International and American Associations for Dental Research, and the American Society of Microbiology. As a non-dentist, she has been inducted into the Academy of General Dentistry as an Honorary Fellow, and into both the Academy of Dentistry International as an Honorary Member, and the International College of Dentists.