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Updateon"notouch"room
disinfec3onsystems-uvlights,
hydrogenperoxideandozone
DickZoutman,MD,FRCPCEmeritusProfessor
MedicalMicrobiology&Infec3ousDiseases
QueensUniversity
HostedbyMar3nKiernan
mar3n@webbertraining.com
www.webbertraining.com March14,201
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ConflictOfInterestDisclosure
AninventorofAsep3cSure ChiefMedicalOfficerofMedizoneInterna3onalInc.
ShareholderofMedizoneInterna3onalInc
RapidlyevolvingfieldDatacanbehardtocomebyNotpossibletoincludeALLtechnologiesoutthere
2
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Objec3ves
Attheendofthispresenta3onIhopeyou: WillbeabletodescribethetwotypesofUVlamp
technologies,theircharacteris3csandefficacy
Willbeabletodescribethebasisforthehydrogenperoxidevaporandmisttechnologiesandtheirefficacy
Willbeabletodescribehoweffec3veozonebasedmethodsareasaspacedisinfec3ontechnology
Understandthesynergyofcombiningozoneandhydrogenperoxideasanovelhighleveldisinfec3ontechnologyforhealthcarespacesandotherapplica3ons
Willknowwhattolookforininvitro,invivoandclinicalstudiesofthenewtechnologiesforroomdecontamina3on
anddisinfec3on
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TheProblem
Toomanyhealthcareinfec3ons Needlesssufferingandmortality Despiteinnova3onsandbestefforts Environmentamajorsourceandreservoir Weneedtofindatransforma3onaltechnology!
Justcleaningwherethedotsareisnotgoodenough!
4
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Characteris3csoftheIdealRoom
Disinfec3onSystemHighestpossiblekillofallrelevantorganismsespeciallyC.difficilespores
FastSimpletoperformCosteffec3veCanbesafelydeployedNoenvironmentalresiduesReducesincidenceofhealthcareinfec3onsHighqualitysuppor3vescien3ficevidence
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QualityofEvidenceConcerning
H2O2,UV,O Canbeverymixedsoreaditcri3cally Peerreviewedliteraturebest invitrostudies
Usingtestchambersetc Bacteriaorotherorganismsonvariousmaterials
Steeldiscs/coupons Fabric,carpet,plas3cs,variousbuildingfinishes
Goodcontrolswithmanyreplicates Quan3ta3veCarrierTests(QCT)ProtocolbySpringthorpeandSaaretal Useofasoilload Eachorganismbringsuniquechallenges
6
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invivoTes3ng
Inhospitalrooms,laboratories,variousfieldloca3onsRandomassignmentofrooms/spacesNooverlapofmethods,washout3mesDetailedsurfacecultureprotocolwithlargenumberof
samples Highlystandardized,withdifferentmethods
Supplementedwithmicrobeloadedcouponsinstandardloca3onsintheroom
Alwaysusesporesofsporeformingpathogens egC.difficile,Bacillusspp,Geobacillusspp.etc.
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Interpre3ngResults
Wanttoseeexpressionofdataaslog10kill(orlog10survivor) Kill=star3nginoculum-survivors
Expressedaslog10kill
Usegeometricmeansforlargenumberofsamples Needdozensofreplicatesunderanyonesetofcondi3ons
especiallyforinvitrotes3ng
Surfaceswabs Typicallyexpressedascfu/cm2 Typicallysee10sto100scfu/cm2
Countspecificpathogens Orcountallheterotrophicbacteriaonthesurface
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ClinicalStudies
Beforeandaerstudiesci3ngreduc3onsininfec3ons
RatesofHAIvarysignificantlyover3meBecau3ousintheinterpreta3onoftheseresults
Preferrandomizedandmul3centerdesignideallyDifficulttodoandcostlyCombinedwithsurfaceculturesandloadedcouponsandclinicaloutcomestomakeacomprehensive
evalua3on
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ABitofPhysicsAboutUVLight
Ultravioletgermicidalirradia3on(UVGI) Wavelengthshorterthanthatofvisiblelight
UVA400nmto15nmUVB15nmto280nmUVC280nmto200nm
Theen3reUVspectrumcankillorinac3vatemanydifferentmicroorganisms
UVCenergyprovidesthemostgermicidal 265nmop3mumwavelength
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Suscep3bilityofOrganismstoUVC
FromMar3nSBetal.ASHREJournal.August2008 11
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MercuryVaporLamps
Inmercuryvaporlamps,themercuryvaporisexcitedtocreateUV-C
CreateUVat25.7nm. ThisisclosetotheaveragepeakDNAabsorbedat260-265nm.
Mercurylampsproducecon3nuousUVlight
12
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XenonVaporLamps
PulsingaxenonUVlampPX-UV Resultsinaflashoflightwithabroadspectrumfrom200nmto20nm
Millisecondpulses MoreUV-CwavelengthsareproducedHighintensityofthefastpulsesmaygivePX-UVbeerdisinfec3onefficacy?
1
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Tru-DUnitbyLumalier
FromECRIHealthDevicesMay2011 14
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MercuryUVSystemTru-D
AnautomatedmobileUV-Cunit Tru-D;byLumalier Showntoproducealog10killofvegeta3vebacteria
MRSA,VRE,andA.baumannii 2.4-log10killofC.difficileseededontoFormicasurfacesinexperimentally
contaminatedpa3entroom
RutalaWA,GergenMF,WeberDJ.Roomdecontamina3onwith
UVradia3on.InfectControlHospEpidemiol2010;1:10251029. 15
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Tru-D
Tru-D,Lumalierstudiedinreducingenvironmentalcontamina3onwithvegeta3ve
bacteria MeasuredusingaerobiccolonycountsandC.difficileinoculatedontostainlesssteelcarrier
disks
BoyceJMetal.InfectControlHospEpidemiol2011;2:77742
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Tru-D
Roomdecontamina3onwiththeTru-DUVsystem Reduc3onsinaerobicbacteriaon5high-touch
surfaces.
MeanC.difficilelog10reduc3onsrangedfrom1.8to2.9whencycle3mesof4.2100.1minuteswereused.
Surfacesindirectlineofsightweresignificantlymorelikelytoyieldnega3vecultureresultsaerUV
decontamina3onthanbeforedecontamina3on BoyceJMetal.InfectControlHospEpidemiol
2011;2:77742
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Tru-D Oninoculatedsurfaces Reflecteddoseof22,000Ws/cm2for45minutes KillofC.difficilesporesandMRSAby>2-log10colony
formingunits(CFU)/cm2
KillofVREby>-4log10CFU/cm2 SamelevelofkillofMRSAandVREwasachievedin20
minutesatareflecteddoseof12,000Ws/cm2,
ButkillingofC.difficilesporeswasreducedsignificantly.
NerandzicMM.BMCInfectDis2010;10:197.18
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Tru-DLog10BacterialKill
FromNerandzicMMetal.BMCInfectDis2010;10:19719
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Tru-DSurfaceSwabs
Hightouchsurfacesofabathroom 60,000cm2
C.difficilespores Before:600spores
Aer:24spores MRSAbacteria
Before:1,200 Aer:240
VREbacteria Before:180 Aer:0
FromNerandzicMMetal.BMCInfectDis2010;10:197 20
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Xenex
From:www.xenex.com
PulsedxenonUVlight
21
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XENEXinvitroLabStudy
C.difficilewas1meterfromlamp,MRSAandVRE2metersfromlamp. C.difficile9samples,MRSA&VRE4samples. TheexperimentwasconductedatanindependentmicrobialtesDnglaboratory Modifiedfrom:SDbichM.AbstractpresentedatSHEA/Fi7hDecennialMee;ng2010
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XenexStudyatMDAnderson
JanuarytoMarch2010atMDAndersonCancerCenter,HoustonTx
12roomsextensivelysurfaceculturedatdischargeforVREisola3on Isola3oncleanwithgermicidex0mins. x4minexposurestoXenexlamp Culturestakenbeforecleaning,aercleaningandusingtheXenexlampS@bichetal.InfectControlHospEpidemiol2011;2()
2
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XENEX
S@bichetal.InfectControlHospEpidemiol2011;2()24
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XenexCooleyDickinsonHospitalStudy
140bedacutehospital,NorthamptonMA
January-September2011Xenexused
Uncontrolledobserva3onalstudy 2x7mininroom 1x7mininbathroom
Pre-cleanedwithchlorinebleach(SOPthroughout)
CDIRates 2009:notstated 2010:0.95/1000PtDay 2008-2010Q1-:0.98/1000PtDay 2011(Q1-):0.2/1000PtDay
LevinJetal.IDSA2011Abstract25
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UVLightSummary
Property UV-CLight XenonPulseLight
Source Mercurybulb Xenonbulb
Exposure3me 20-100min 8-12minsover2-doses
Vegeta3vebacterialkill -4log 4-5log
C.difficilesporekill 2-log 4-5log(limiteddata)
Risks UVexposure UVexposure
Toxici3es/ByProducts Mercuryvapor None
ControlledClinicalTrials Yes Noneyet
Costs $124,500capital$1,600forlamps(9000h)
??Lampsx-4months
Other Lineofsighteffect Scantdata,
lineofsighteffect
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H2O2Technologies
Bioquell 0%H2O2solu3on H2O2vapor
Glosair(ASP) 5-6%H2O2solu3on ASP(J&J)acquiredSterinis
in2009
H2O2mist/aerosol VHP(Steris)
5%H2O2solu3on H2O2vapor
27
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SterisVHP1000EDSystem
From:www.steris.com 28
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BioGienie
Hyproxil 6%H2O2withsilverions Hyproxilasaliquidas
4-6log10killofMRSA,Ecoli,P.aeruginosa
NopublisheddataonefficacyasHPvapour
system
hourcycle3me
29
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BioQuellQ-10
www.bioquell.com 0
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Glosair(ASP)
Glosair600 Glosair400
www.aspjj.com 1
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VHP(Steris)AgainstAerobicSpores
PoageT.Appl.Environ.Microbiol.2012,78(12):4169.
2
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SealingDuctsinaRoom
JimDoyleinwww.stltoday.com/business/ar3clepublishedAugust15,2010
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BioquellEfficacyforCDI
HPVdecontamina3onof5high-incidenceCDIwardsfollowedbyhospital-wide
decontamina3onofroomsvacatedbypa3ents
withC.difficileinfec3on(CDI)
25.6%ofculturesfromsurfacesbeforeHPVdecontamina3onyieldedC.difficile
comparedwith0culturesofsamplesobtainedaerHPVdecontamina3on(P
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BioquellandCDIContd
During9monthinterven3onperiod Onthe5highincidencewardsratesofCDIdroppedfrom2.28vs1.28casesper1,000pa3ent-days(P
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BioquellandMRSA
74%of59swabstakenbeforecleaningyieldedMRSA Aercleaning,allareasremainedcontaminated,with
66%of124swabsyieldingMRSA.
Aertreatmentof6roomswithHPV(Bioquell)only1of85(1.2%)swabsshowedMRSA
notesmallersamplesizeaerexposurehowever 5hourcycle3me 500ppmH2O2(high)
FrenchGLetal.JournalofHospitalInfec3on(2004)57,17
6
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BioquellClinicalStudy
PassareCLetal.ClinInfectDis201;56:27-5
Acquiredanyone
ofMRSA,VRE,
MDRGNBor
Cdiff
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BioquellClinicalStudy
HPVprocesstook1.5-.0hours Theonlyreduc3oninMDROwasthereducedincidenceseenforVREacquisi3ons
53meslesslikelyintheHPVtreatedroomsadjustedIRR,0.2095%CI,.08.52
Nosta3s3callysignificantreduc3oninacquisi3onsofMRSA,C.difficileorMDRgramnega3vebacilli
PassareCLetal.ClinInfectDis201;56:27-5 8
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BioquellClinicalStudy
218(21.0%)ofthe109pa3entroomssampledwerecontaminatedwith1MDRO
HPVdemonstratedreducedbacterialcontamina3onin: roomscontaminatedwithmul3pleMDROs(RR,0.16;P
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SterinisTrial(becomesGlosair)
TeachinghospitalinZonguldak,Turkey
Steeldiscsinoculatedandplacedinmanyloca3onsinpa3entrooms5m
MRSAandA.baumannii AppliedSterinisHPMist 2.5hrcycles
PiskinNetal.AmJInfectControl.2011Nov;9(9):757-62
40
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Tru-DvsBioquellHeadtoHead
500bedhospital 15pa3entroomsat
randomfrom8wards
5hightouchsurfacesculturedforACC
Steeldiscsloadedwith106C.difficilesporesplacedin5areascloseto
hightouchsurfaces BIswith104and106G.stearothermophilus
Results HPV(Bioquell)
9%ACCnega3ve 6log10C.difficilekill 99-100%BIskilled 2.5-hrcycles
UV-C(TRU-D) 52%ACCnega3ve
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HardyKetal.JHospInfect2007;66:60-68
RapidMRSA
regrowthaer
HPV.
Didntgetthemall?
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ComparisonofH2O2Systems
Parameter Glosair(ASP) VHP(Steris) BioGienie BioQuell
H2O2% 5-6% 5% 6% 5%
Dispersion DryMist/
Aerosol
Vapor DryMist/
Aerosol
Vapor
FinalConc
H2O2
50-80ppm ~500ppm ~500ppm
CycleTime ~2-hr 2-8hrs hr 2hr,upto5
hr
C.difficile
log10kill
2-log NodataforC.
difficile.
5-6logfor
Bacillus
NodataforC.
difficile.
5-6logfor
Bacillus
6logforC.
difficile.
6logfor
BacillusControlled
ClinicalTrials
Somesmall ? ? Yes
Cost $65,000?
$50perroom
? ? $44,000capital
Costperroom?
4
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PureOasAn3bacterial
Sharma&Hudson.AmJInfectControl2008;6:559-6. 44
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Ozone&HydrogenPeroxidein
BiologicalSystems An3bodieshavebeenshowntohavecataly3cac3vitythatproducesBOTHH2O2ANO3BUTtheamountproducedofeachissolowthat
neithercouldkillanymicroorganism
Trioxidane(H2O)hasbeendetectedastheextremelyreac3veintermediarymoleculeofthisreac3on
Trioxidaneislethaltoorganismsinminuteamounts!
Nyffeler,Wentworth&Lerneretal.AngewandteChemie
2004,fromScrippsResearchIns3tuteandOxford
University
45
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TheScienceofAsep3cSuresSynergy
O3
H2O2
H2O3
46
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Asep3cSureMicrobiologyTechniques
Thequan3ta3vecarriertest(QCT-2)
standardusedormodified
1cmstainlesssteeldisksasthebacteria
&sporecarriers
47
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InvitroTes3ngSystemforAsep3cSure
Polycarbonatechamber Fullyinstrumentedto
measurecondi3ons
Computercontrolledandrecordedresults
UsedMRSAastestorganismini3allyto
defineop3mal
condi3ons
48
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InvivoTes3ngSystemAsep3cSure
Fans
OGenerator
H2O2Vapourizer
GasMeasurement
Channelsx5
Scrubbers
80PPMOzonePLUS
1%HydrogenPeroxide
21Cand80%Humidity
TestiscsTestiscs
49
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Asep3cSureResults
Organism Ozone
(PPM)
H2O2
(%)
Exposure
(min)
MicrobialKill
(Log10)
MRSA 80 1 15 6.3
VRE 80 1 15 6.2
E.coli 80 1 15 6.5
S.typhimurium 80 1 15 6.1
P.aeruginosa 80 1 15 6.0
L.monocytogenes 80 1 15 6.3
C.difficilespores 80 1 15-30 6.1
B.sub;lisspores 80 1 30 6.1
Mycobacterium
terrae
80 1 30 6.250
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Tes3ngMaterials
Asep3cSuresystemalsoeffec3veon:StainlesssteelPlas3cfromtoiletseatsLaminateCarpe3ngCoonorsynthe3cclothWithandwithoutorganicsoilload
51
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SummaryofAsep3cSure
Firsteveruseofozoneandhydrogenperoxideforhighleveldisinfec3onofclinicalspacesandsurfaces
CapitalizesuponHUGEsynergybetweenozoneandhydrogenperoxideproducingtrioxidane
Veryfast Broadspectrum Consistenthighleveldisinfec3on(6log10=steriliza3on) PenetraDnggasgoeseverywhere Lowdosesofozoneandhydrogenperoxidereducescosts,
risksanddamagetoinfrastructure
Technologyproventobeveryrobustandreliable CapitalCost~$95,000+~$10-20perroom
52
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AmJInfControl2011;9:87-9
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Asep3cSure
54
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Characteris3csoftheIdealRoom
Disinfec3onSystemHighestpossiblekillofallrelevantorganismsespeciallyC.difficilespores
FastSimpletoperformCosteffec3veCanbesafelydeployedNoenvironmentalresiduesReducesincidenceofhealthcareinfec3onsHighqualitysuppor3vescien3ficevidence
55
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TheFinalResult
56
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21 March TB INFECTION CONTROL IN HIGH HIV BURDENED COUNTRIES
Speaker: Virinia Lipke, Centers for Disease Control, Atlanta
09 April (WHO Teleclass)INNOVATION AND NEW INDICATORS IN HAND HYGIENESpeaker: Prof. John Boyce, Yale University
11 April UTILIZING HOSPITAL-TO-HOSPITAL PARTNERSHIPS TO STRENGTHENINFECTION PREVENTION AND CONTROLSpeaker: Dr. Shams B. Syed, World Health Organisation, Geneva
16 April (WHO Teleclass)REVIEW OF THE EUROPEAN UNION SHARPS LEGISLATION
Speaker: Jane Aston, NHS
17 April (WHO Teleclass) CLOSTRIDIUM DIFFICILE IN THE COMMUNITY: FOOD FORTHOUGHTSpeaker: Prof. Tomas Riley, University of Western Australia
18 April LEADERSHIP IN INFECTION PREVENTION AND CONTROL57
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