Hygiene in the 21st Century Presentation presented to Health Career Teachers at the ACTE AZ 2013 Summer Conference in Tucson, AZ on July 16, 2013 from 8:00 am - 9:30 am.

1. HYGIENE IN THE 21st
CENTURY
Sheri L. Carlino
Dr. Charles P. Gerba
Department of Soil, Water
and Environmental Science
University of Arizona
Tucson, AZ

2. Life in the 21st Century
 Most of our time is spend indoors (80 - 90%)
 More people work in offices than ever before
 We travel more than ever before
 We spend less time cleaning than the last
generation (50% less than 50 years ago)
 We are less clean (e.g. laundry practices)
 We spend more time in public places
 We are more mobile and have more electronic
equipment (e.g. cell phones, ipods)
 We share more common surfaces (fomites) with
more people than ever before in history

3. Challenges in Infection Control
in the 21st Century
 Infectious diseases are the 3rd leading cause of
death in the United States today. They are 1st in
the developing world.
 Continued emergence and re-emergence of
pathogens (SARS, MRSA, bird flu, etc)
 A more susceptible population (aging
population, cancer treatment) – 30 to 40% of
 U. S. population at greater risk of serious
illness and death)

4. Cleaning vs. Hygiene
Cleaning is “the removal of
unwanted matter”
Hygiene is “reducing the risks of
infection”
Good hygiene had more impact
on human health than the
development of vaccines and
antibiotics

5. Did you know??
 80% of all common infections
(colds, flu, diarrhea) can be spread
through the environment
(air, water, food, fomites)
 ~800,000,000 cases of respiratory and
enteric infections per year in the U.S.
 Unmarried males experience one cold per
year and unmarried women 1.3. Couples
with school children experience 2.3 colds
per year each. School children experience
an average of 3.5 colds per year.

6. What are Fomites?
 Inanimate objects involved in the spread of
disease

7. Hand vs. Sneeze

8. Role of fomites in transmission of a disease
Sick person sneezes, coughs and pathogens
falls on fomite or get aerosolized.
Pathogen falls on fomites
e.g. phone, computer
Person picks up pathogen
through contaminated fomite.
Person touches nose or eyes
with Contaminated fingers and
Becomes infected with pathogen.

9. Mouthing Events in Children (per hour)
81 times under two years
42 times two thru five years
A child swallows the about of dirt on six kitchen
floor tiles per day

10. Hand Contact in Adults
 Adults touch their face 15.5 times per
hour
 2.5 eyes
 5 nose
 8 lip

11. Identifying Critical
Control Points
Home/Work/Play/Shopping

12. Coliform Bacteria and E. coli
 Coliform bacteria and
E. coli are found in
feces and their
presence on surfaces
indicates……………..
contamination by
feces and the
potential presence of
disease causing
microorganisms

13. Germs at Home

14. Coliforms in the Home by
Location
-2
-1
0
1
2
3
4
5
6
7
Geometricmeanpercm2orpermL
Bath
Sink
Kitchen
Floor
Bath
Counter
Bath
Floor
Toilet
Seat
Kitchen
Sink
Sponge Cutting
Board

15. The Importance of Cleaning
Tools in the Spread of Germs

16. “Breeders”

17. “Spreaders”

18. • The kitchen is more heavily contaminated than
the bathroom.
• Ordinary cleaning practices do little to reduce
the microbial load.
• Risk of infection could be reduced by greater than
99.99% on cutting boards and kitchen counter-
tops by use of hypochlorite cleaning products.
Germs at Home Summary

19. Bacteria on Shoes
 Shoes worn at least three months
 Total bacteria
 13,600 to 8,000,000 sq cm
 Coliform bacteria
 10 to 72,000 sq cm
 Present on 96% of shoes
 E. coli
 Present on 27% of shoes

20. A Microbial Zoo Living on the
Bottom of your Shoes
 E. coli
 Aeromonas hydrophila
 Klebsiella pneumoniae
 Serratia marscesens
 Pseudomonas fluorescens
 Pseudomonas luteola
 Pantoea spp.

21. Shoes and Microbial Transport
 Germ
viewpoint
–Shoes
are made
for walking

22. Left Shoe Right Shoe
1 ft 1,000 110
2 ft 400 10
3 ft 10 20
4 ft 240 90
5 ft 140 30
6 ft 100 640
66,000,000
Bacteria (105)
Virus (107)
68,000,000
23,000,000
27,000,000
21,000,000
15,000,000
61,000,000
27,000,000
11,000,000
17,000,000
4,200,000
2,600,000
Movement of
organisms on
shoes during
walking –
keeping in step
with you

23. Another Brief Run Down of
Bacteria Comparisons
(per square inch)
200,000 – Carpeting
49 –Toilet Seat
1,686 Kitchen counter top
2,546 Kitchen tile floor - home
18,025 Bathroom floor - home

24. Vacuum Cleaners – Meals on Wheels
for Bacteria
 Concentrate bacteria and
food in one place
 E. coli detected on 50%
of brushes from homes
 Bag less: E. coli and
Salmonella growth in
collection container
 Move bacteria and virus
around

25. Why Do Shoes, Carpet and
Vacuums Matter?

27. Exposure from Laundry
 Changes in practices
in the U.S
 Hot water used only
5% of the time. Most
use cold water
 Only 12 minute wash
 Dry for only 3 minutes

28. Feces in the Laundry
 Average pair of
underwear contains
0.1 grams of feces
(1/2 a Southwest
Airlines peanut)
 Salmonella 1010 per
gram of feces

29. 29
Hospital Scrubs
Total Bacteria
Type of scrub
Number of
garments
Average CFU/sq
cm
Unwashed
hospital 18 180
Home-
laundered 26 143
Hospital-
laundered 20 4

30. Hospital Cafeterias
 Bacteria isolated
from tables
 MRSA
 C. difficile
 Enterococcus
 E. coli
 coliforms

31. 31
Household Bath Hand Towels
(442 towels tested)
HPC
Bacteria Coliforms E. coli
Average 9.2E+08 3.9E+05 1.1E+04

32. 46
36
35
29
28
26
14 14
11
10
0
5
10
15
20
25
30
35
40
45
50
%SurfacesPositiveEnvironments Most Contaminated
With Body Fluids

33. 52
OCCURRENCE OF COLIFORMS (%) IN YOUR DENTIST OFFICE
64
70
0
76
67
18
50 22

34. 4
OCCURRENCE OF E. COLI (%) IN YOUR DENTIST OFFICE
20
48
25

35. Microbiology of Automobiles
 Dash board has the
most germs followed
by drink and change
holders
 Most bacteria
detected in cars was
Florida
 Most molds in cars
was detected in
Chicago

36. Bacteria in Offices

38. 0
200
400
600
800
1000
1200
Men Women
Comparison of Bacteria in
Men vs Women Offices
HPCCFU/4sqinAverage

39. Comparison of Offices that Use Disinfectant versus
Offices that Don't Use Disinfectant
1.00E+01
1.00E+02
1.00E+03
1.00E+04
1.00E+05
Don't Use Disinfectant Use Disinfectant
AverageBacteria

41. Impact of Wiping Table Top in Restaurants with
Cleaning Cloths

42. Germs at School

43. Germiest Office Occupations
#1 Elementary School Teachers
#2 Accountants
#3 Bankers
#10 Lawyers

44. Average
Toilet Seat
4.77E+06
1.70E+06
8.60E+05
1.00E+02
1.00E+03
1.00E+04
1.00E+05
1.00E+06
1.00E+07
Cafeteria Table Computer Mouse Desk
TotalBacteria/approximate100cmsq
Top Three Contaminated Sites in All Schools
School Study Grade K thru 12

45. Classrooms
 Areas most contaminated with bacteria
 Pencil sharpener
 Student desk top
 Computer
 Sink in classroom
 Viruses isolated
 Influenza
 Norovirus
 Parainfluenza

46. Impact of Disinfectant Wipes on
Absenteeism -Seattle
 Study
 Two school semesters
 3rd and 4th graders
 Intervention
 Children’s desk wiped with a disinfectant wipe
at the end of each school day
 Results
 50% reduction in absenteeism

47. The Curse of the Cruise Ships

48. Detection of Noroviruses on Fomites –
University of Arizona
 Winter of 2008
 Norovirus most commonly isolated on
• Desk tops (20%)
 Libraries
 Dorm rooms
• Vending machines buttons (5%)

49. Shopping with Germs

50. Coliform Bacteria in Reuseable
Grocery Shopping Bags
51%
Coliforms
49%
Yes
No

51. Reusable Shopping Bags
 E. coli detected in
10% of the bags

53. Grocery Store Touch Screens
(self service)
 100% contain
bacteria (average
13,000)
 Bacteria isolated
 MRSA
 E. coli
 Klebsiella oxytoca
 Coliform bacteria
(65%)

55. E. coli Isolation from Shopping
Carts
 Maine 80%
 Atlanta 79%
 Chicago 70%
 Tucson 0%
 Los Angeles 10%
 Recent study has associated Salmonella
and Campylobacter infections in children
and placement in shopping carts

56. Going to the Toilet with
Germs

57. Everybody uses the toilet
 Average time in the
aircraft restroom for
adults
 Men
 106 seconds
 Women
 154 seconds

58. Aerosols are Produced during
Toilet Flushing
 Fecal bacteria and
viruses are ejected
from the toilet during
flushing.
 The droplets settle
out in the restroom
contaminating the
restroom with fecal
microorganisms

59. Commodeograph
 Water sensitive paper held over toilet seat when
flushed. Purple spots represent water droplets.

60. E.coli Detected in Droplets
 Perti dishes held over
toilet when flushed.
 Dark spots are
colonies of E. coli.

63. Refillable Liquid Bulk Soap
Dispensers
 25% are contaminated with millions of
bacteria per milliliter
 Coliform bacteria was found in 22% of
samples
 No bacterial contamination was found
in soap dispensed from
sealed systems

64. No bacterial
contamination
was found in
soap dispensed
from sealed
systems

65. Traveling with Germs

66. Bus Travel increases Risk of
Respiratory Infections
 The more you ride
a bus the more
likely you will get a
cold (6 times more
likely)
 Troko et al 2011
BMC Infectious
Diseases

67. Seat – Bacteria/mold growing
on Petri Dish

68. Airplane Trays
 MRSA – positive on
four different flights
 Norovirus isolated on
one flight

69. Vehicle Bacteria per 100 sq. cm.
Commuter
Train
117,000
Bus 83,176
Airplane 3,127
Family Car 5,220
Toilet Seat 186
ANOTHER COMPARISON TO THE TOILET SEAT!!!

71. Virus Spread between Hotel
Rooms
 Virus added to one
person hand or
bathroom counter top
 Sample next series of
rooms after maids
clean and conference
room at end of day,
tested for virus.
 Conference attendees
hands

72. Results
 Virus detected
 Next four rooms cleaned by the maid
 On surfaces (table tops) in the conference
room
 On 1/3 of the conference attendees hands
 On the coffee pot handle
of the breakfast area

73. Occurrence of fecal bacteria
on the hand (United States)
Preparing a meal Greatest
Children after playing
Doing the laundry Least
Person exiting a toilet

74. Hand Washing
Tucson, Arizona
95% of people say they wash their hands
after using a public washroom
67% actually wash their hands
33% of those use soap
16% really wash long enough

75. Stopping the Spread of
Germs

76. Reducing Risk of Infection from
Fomites
 Hand washing
 30 to 50 % reduction in illness
 Alcohol gel sanitizers
 30 to 50% reduction
 Disinfection of fomite surfaces
 50% reduction
 Use of bleach and hot water in laundering
 reduces risk of transmission

77. How fast does a virus move in
an office building?
 Added a virus to
the entrance door
handle of an office
building with 80
persons
 Collect samples
after 4 and 7 hours
from fomites and
hands

78. First place virus
detected is the
coffee break room

79. Virus detection on office workers
hands/fomites after times indicated

80. Results
 • The number of people with viruses on
their hands was reduced in half (50%).
The occurrence of viruses in communal
work areas was reduced by more than
80% after four hours and by 70%-100%
after seven hours

81. Hand sanitizers
Just as good as hand washing
for bacteria and viruses. New
formulations more active
against norovirus.
However, not effective against
spores like C. difficile.
Proper hand washing is effective in
removal of spores.

82. UV light at the Tap
Point of
dispense
purification
keeps the tap
free from
contamination

83. Antimicrobials
 Disinfectants
 Chlorine
• In use for more than 100 years
• Wastewater treatment plant in Tucson, AZ uses more
chlorine in one day than a household uses in 10,000 years
• Usually >99.999% reduction in target organisms
 Quats
• In use for more than 70 years
 Some increase in tolerance by some bacteria, but still
effective at normal use applications
 Sanitizers
 Usually >99.9% of target organisms

84. The Future
Self-Sanitizing Surfaces
 Copper
 Silver
 Titanium Dioxide

85. Summary
 Fomites will continue play a major role in
disease transmission now and into the
future
 Good hygiene is not cleaning more, but
smarter with a targeted use of
disinfectants and cleaning tools
 Germ exposure is more likely increasing
not decreasing
 No long term immunity for common
infections
 PROPER HANDWASHING

86. Questions?