Brief overview of transmission risks in indoor spaces Current consensus is that SARS-CoV-2 is primarily transmitted via prolonged close contact with an infected person, through respiratory secretions passed in the air, and secondarily due to transmission via contaminated surfaces fomites.

Elimination or substitution Elimination or substitution involves removing the hazard, or separating occupiers from the hazard to eliminate risk of transmission. Measures can include: Closing of public places such as shops, schools, businesses, and facilities or stopping some activities to eliminate or reduce person-to-person interactions.

Replacing services with online or contactless options, limiting, or discouraging activities that result in contact e.

Engineering controls Engineering controls include changes to the physical structure, equipment or layout of a space that reduce risks of transmission. Engineering control measures can include: Changes to the structure or layout of the facility to allow for a minimum of 2 m physical distancing or other measures to keep people apart e.

Use of passive or mechanical means to reduce the concentration of bioaerosols inside and to dilute indoor air with clean outside air e.

Modified infrastructure to reduce the need for and likelihood of touching surfaces e. Administrative controls Administrative controls include changes to how people interact, work, play or socialize in a space to minimize opportunities for close contact and to reduce interactions with shared spaces, items, or surfaces.

Some examples include: Increased messaging by email, websites, or social media before users arrive at a facility, to emphasize appropriate practices and encourage individuals with COVID symptoms to stay home. Physical distancing measures including reducing maximum occupancy, moving activities to larger spaces or outside to reduce potential for transmission via respiratory droplets.

Use of signage and physical or visual cues to encourage one-way foot traffic, maintaining 2 m distancing, and promoting hand hygiene. Enhanced cleaning and disinfection practices ensuring adequate supplies of disinfectant, soap, sanitizer, tissues.

Discouraging practices such as shared food, communal coffee stations. Removing objects in waiting rooms, such as magazines or toys.

Recording contact details of facility users for future contact tracing. Personal protective equipment PPE PPE has traditionally been considered to be an additional control measure when other measures have already been considered and implemented where practical to do so.

PPE control measures for public indoor spaces are limited but can include: Non-medical masks, with or without face shields for use in spaces or situations where physical distancing is difficult to maintain, or when close contact is necessary.

Disposable gloves may be considered for some activities, such as handling of shared objects or cleaning of surfaces or objects. Additional control measures Additional control measures and technologies that can fall within the hierarchy of controls are continually being considered and developed, whether these are new approaches to ventilation, new concepts of design and layout of indoor spaces, new viricidal surfaces and materials, different ways of working or interacting with clients or the public, or new materials or design of PPE.

Ultraviolet Germicidal Irradiation UVGI Description of the technology Ultraviolet germicidal irradiation UVGI has been used for the control of respiratory diseases such as tuberculosis TB in healthcare and other high-risk settings for decades. How it works UVGI can be used in a range of applications that disinfect by irradiating air, surfaces, or objects.

Effectiveness of UVGI against SARS-CoV-2 The literature on the effect of UVGI on coronaviruses indicates that it can be an effective means of treatment, with the structure of coronaviruses enveloped single-stranded RNA viruses being more sensitive to UV-C compared to some other viruses such as double stranded RNA viruses and non-enveloped viruses.

Table 1. Review of UVGI application. UVGI Technology Description Effectiveness as a disinfection strategy In-duct and cooling coil systems UV lamps single or multiple are placed in exhaust or duct work to disinfect air as it passes the UV lamp s or near cooling coils to prevent mould or bacterial growth, and disinfect ambient air passing the lamps.

This technology is most effective when used in buildings with mechanical systems that recirculate air, to reduce the redistribution of infectious viruses. Disinfection efficiency is affected by airflow rates, UV-C dose, and placement of lamps. Lamp efficiency is affected by deposition of dust on lamp surfaces, which can be resolved with an upstream dust filter and routine inspection and maintenance.

Upper room UV lamps single or multiple are mounted on walls or ceilings to disinfect air in the upper part of a room. Has been effective in healthcare environments, homeless shelters, and prisons for reducing transmission of infectious viruses; may also be suitable for locations with heavy footfall or where people gather e.

Disinfection efficiency is affected by the number and location of fixtures, and reflectivity of the walls and ceilings. The devices are most effective when pathogens are in proximity to the lamps and unshielded from UV radiation.

Provides targeted disinfection of air moving between rooms or spaces but can present risks to occupants passing below due to unshielded UV-C irradiation.

May be more suitable for high-risk areas such as intensive care units in healthcare settings. Lower room UV lamps are placed in the lower cm with shielding directing UV towards the floor. Provides targeted disinfection to floor areas, reducing viability of infectious virus that deposits on the floor in high footfall areas such as building entrances.

Can present exposure risks to lower extremities and children. Recirculation or air cleaning units UV lamps housed in mounted or stand-alone units, which may also include air filters, draw room air through the system past UV lamps, and expel cleaner air.

Provides localized air treatment but the effectiveness may depend on the size of room being treated, exposure time within the system, and the rate of air changes due to ventilation. Area disinfection systems Portable or mounted units direct high levels of unshielded UV-C irradiation over a large area for periodic disinfection of walls, floors, tables, chairs, equipment, or surfaces.

Provides effective treatment of air and surfaces depending on intensity and duration of exposure. Shadowed or dirty surfaces or objects may receive less exposure. It is not intended for use when there are occupants in the room and is more suitable for intermittent or routine after-hours disinfection in settings such as healthcare or industry.

Disinfection chambers An enclosed chamber or room, which may include a conveyor or rotation system, to apply high levels of UV-C to objects. This technology has been shown to be effective for disinfecting objects used in a range of applications such as medical equipment, mail, and laundry.

Effectiveness is determined by UV-C intensity, exposure time, and shadowing on object surfaces. UV-C wands Hand-held UV devices, which can be battery powered, are used to apply localized UV-C to surfaces or objects that may be difficult to disinfect using traditional approaches.

Effective for disinfection of objects or complex surfaces and has been used for disinfection of mattresses and surfaces in vehicles e.

Additional considerations and precautions Health concerns: Prolonged exposure to UV-C can penetrate the outer surface of human skin and eyes, damaging cells and presenting additional risks to health. Upper room UVGI may provide the most practical option for disinfecting large indoor spaces while shielding occupants from UV-C radiation that could damage human skin and eyes.

This technology is only effective with adequate upward air movement. Other air disinfection systems may be appropriate for certain applications such as in-duct UVGI systems for recirculating air or stand-alone air cleaners or recirculating systems for localized air disinfection in small unventilated spaces.

Mounted or portable area cleaners that provide direct intense UVGI to air and unshielded surfaces may be effective in providing intermittent or after-hours disinfection of an entire space.

This technology is not suitable in occupied rooms or spaces and can present a risk of harmful UV-C exposure. Disinfectant Fogging Systems Description of the technology Fogging technology that disperses fine particles of liquid sanitizers or disinfectants to provide whole-room decontamination has been utilized in the pharmaceutical and food processing industries for decades, and more recently in hospital settings.

Safety precautions As disinfectant fogging may pose inhalation exposure risks to occupants, the indoor space being treated should be vacated prior to treatment. Conclusion It is now widely recognized that the vast majority of COVID outbreaks have been linked to interactions in indoor environments.

Acknowledgements This document benefited from the contributions of Lydia Ma NCCEH , Michele Wiens NCCEH and Tom Kosatsky BCCDC. References National Collaborating Centre for Environmental Health.

An introduction to SARS-CoV-2 [evidence review]. Vancouver, BC: NCCEH; Apr US Centers for Disease Control and Prevention. Coronavirus disease COVID - How COVID spreads. Dietz L, Horve P, Coil D, Fretz M, Wymelenberg K. Qian G, Yang N, Ma AHY, Wang L, Li G, Chen X, et al.

COVID transmission within a family cluster by presymptomatic carriers in China. Clin Infect Dis. Qian H, Miao T, Liu L, Zheng X, Luo D, Li Y. Indoor transmission of SARS-CoV Andrade A, Dominski FH, Pereira ML, de Liz CM, Buonanno G.

Infection risk in gyms during physical exercise. Environ Sci Pollut Res Int. Public Health Agency of Canada. Community-based measures to mitigate the spread of coronavirus disease COVID in Canada.

Ottawa, ON: PHAC; Mar Rivers C, Martin E, Gottlieb S, Watson C, Schoch-Spana M, Mullen L, et al. Public health principles for a phased reopening during covid guidance for governors. Baltimore, MD: John Hopkins Bloomberg School of Public Health, Center for Health Security; Apr Somsen GA, van Rijn C, Kooij S, Bem RA, Bonn D.

Small droplet aerosols in poorly ventilated spaces and SARS-CoV-2 transmission. Lancet Respir Med. Eykelbosh A. Physical barriers for COVID infection prevention and control in commercial settings [blog]. Vancouver, BC: National Collaborating Center for Environmental Health; May O'Keeffe J.

Masking during the COVID pandemic. Vancouver, BC: National Collaborating Centre for Environmental Health; Apr Chen T, Nicol A-M. Reducing COVID transmission through cleaning and disinfection of household surfaces [guidance document].

Hierarchy of controls. British Columbia Public Safety and Emergency Services. Key steps to safely operating your business or organization and reducing COVID transmission. Nardell EA, Nathavitharana RR. Airborne spread of SARS-CoV-2 and a potential role for air disinfection.

Byrns G, Barham B, Yang L, Webster K, Rutherford G, Steiner G, et al. The uses and limitations of a hand-held germicidal ultraviolet wand for surface disinfection. J Occup Environ Hyg. Kowalski W. Ultraviolet germicidal irradiation handbook.

New York, NY: Springer; International Ultraviolet Association. IUVA Fact sheet on UV disinfection for COVID Chevy Chase, MD: IUVA; Mar. Morawska L, Tang JW, Bahnfleth W, Bluyssen PM, Boerstra A, Buonanno G, et al. How can airborne transmission of COVID indoors be minimised?

Environ Int. Simmons S, Carrion R, Alfson K, Staples H, Jinadatha C, Jarvis W, et al. Disinfection effect of pulsed xenon ultraviolet irradiation on SARS-CoV-2 and implications for environmental risk of COVID transmission.

Seyer A, Sanlidag T. Solar ultraviolet radiation sensitivity of SARS-CoV Lancet Microbe. McDevitt JJ, Rudnick SN, Radonovich LJ.

Aerosol susceptibility of influenza virus to UV-C light. Appl Environ Microbiol. Houser KW. Ten racts about UV radiation and COVID American Society of Heating Refrigerating and Air-Conditioning Engineers Inc. ASHRAE Handbook - Heating, ventilating, and air-conditioning systems and equipment SI Edition - Knovel.

Atlanta, GA: ASHRAE; Kujundzic E, Matalkah F, Howard CJ, Hernandez M. UV air cleaners and upper-room air ultraviolet germicidal irradiation for controlling airborne bacteria and fungal spores. Petersson LP, Albrecht U-V, Sedlacek L, Gemein S, Gebel J, Vonberg R-P. Portable UV light as an alternative for decontamination.

Am J Infect Control. Scarpino PV, Jensen NJ, Jensen PA, Ward R. The use of ultraviolet germicidal irradiation UVGI in disinfection of airborne bacteria and rhinoviruses.

J Aerosol Sci. Walker CM, Ko G. Effect of ultraviolet germicidal irradiation on viral aerosols. Environ Sci Tech. Atci F, Cetin YE, Avci M, Aydin O. Evaluation of in-duct UV-C lamp array on air disinfection: a numerical analysis. Sci Technol Built Environ. Blázquez E, Rodríguez C, Ródenas J, Navarro N, Riquelme C, Rosell R, et al.

Evaluation of the effectiveness of the SurePure Turbulator ultraviolet-C irradiation equipment on inactivation of different enveloped and non-enveloped viruses inoculated in commercially collected liquid animal plasma.

PLoS ONE. Heßling M, Hönes K, Vatter P, Lingenfelder C. Ultraviolet irradiation doses for coronavirus inactivation — review and analysis of coronavirus photoinactivation studies. GMS Hyg Infect Control. Bianco A, Biasin M, Pareschi G, Cavalleri A, Cavatorta C, Fenizia C, et al.

UV-C irradiation is highly effective in inactivating and inhibiting SARS-CoV-2 replication. Decontamination and reuse of filtering facepiece respirators. Schulz-Stübner S, Kosa R, Henker J, Mattner F, Friedrich A.

Infect Control Hosp Epidemiol. Leung KCP, Ko TCS. Improper use of germicidal range ultraviolet lamp for household disinfection leading to phototoxicity in COVID suspects.

Liao L, Xiao W, Zhao M, Yu X, Wang H, Wang Q, et al. Can N95 respirators be reused after disinfection? How many times? ACS Nano. Buonanno G, Stabile L, Morawska L. Estimation of airborne viral emission: Quanta emission rate of SARS-CoV-2 for infection risk assessment.

Welch D, Buonanno M, Grilj V, Shuryak I, Crickmore C, Bigelow AW, et al. Far-UVC light: a new tool to control the spread of airborne-mediated microbial diseases.

Sci Rep. American Society of Heating Refrigeration and Air-Conditioning Engineers. Ultraviolet air and surface treatment. Chapter ASHRAE Handbook HVAC Applications. Robertson JT. Electrostatic technology for surface disinfection in healthcare facilities. Infect Control.

Castaño N, Cordts S, Jalil MK, Zhang K, Koppaka S, Paul R, et al. Fomite transmission and disinfection strategies for SARS-CoV-2 and related viruses.

Patel MK, Ghanshyam C. Fundamentals of electrostatic spraying: Basic concepts and engineering practices. Hershey, PA: IGI Global; Lyons SM, Harrison MA, Law SE.

Electrostatic application of antimicrobial sprays to sanitize food handling and processing surfaces for enhanced food safety. J Physics Conf Series. Clorox Company. Cadnum J, Livingston S, Sankar Chittoor Mana T, Jencson A, Redmond S, Donskey C. Evaluation of a novel sporicidal spray disinfectant for decontamination of surfaces in healthcare.

Open Forum Infect Dis. Archer J, Karnik M, Touati A, Aslett D, Abdel-Hady A. Evaluation of electrostatic sprayers for use in a personnel decontamination line protocol for biological contamination incident response operations.

Washington, DC: U. Environmental Protection Agency; Oct. Report No. Ganesh V, Hettiarachchy NS, Ravichandran M, Johnson MG, Griffis CL, Martin EM, et al. Electrostatic sprays of food-grade acids and plant extracts are more effective than conventional sprays in decontaminating salmonella typhimurium on spinach.

J Food Sci. Jiang W, Etienne X, Li K, Shen C. Comparison of the efficacy of electrostatic versus conventional sprayer with commercial antimicrobials to inactivate Salmonella, Listeria monocytogenes, and Campylobacter jejuni for eggs and economic feasibility analysis.

J Food Prot. Bolton S, Kotwal G, Harrison MA, Law SE, Harrison J, Cannon JL. Sanitizer efficacy against murine norovirus, a surrogate for human norovirus, on stainless steel surfaces when using three application methods.

National Environment Agency. Advisory on surface cleaning and disinfection for COVID Health Canada. Hard surface disinfectants and hand sanitizers: list of hard-surface disinfectants for use against coronavirus COVID Hard surface disinfectants and hand sanitizers COVID : disinfectants and hand sanitizers accepted under COVID interim measure.

Kelleher SR. US Environmental Protection Agency. Can I apply a product using a method that is not specified in the directions for use? Gray R. Covid How long does the coronavirus last on surfaces?

Electrostatic sprayers and disinfectant use [technical bulletin]. Fort Mill, US: Diversey; Boyce JM. New approaches to decontamination of rooms after patients are discharged. Webb JD. A fast track to zero environmental pathogens using novel ionized hydrogen peroxide technology.

Kimball S, Bodurtha P, Gudgin Dickson EF. A roadmap for investigation and validation of dry fogging as a decontamination technology. Ottawa, ON: Defence Research and Development Canada; Hayrapetyan H, Nederhoff L, Vollebregt M, Mastwijk H, Groot MN. Inactivation kinetics of Geobacillus stearothermophilus spores by a peracetic acid or hydrogen peroxide fog in comparison to the liquid form.

Int J Food Microbiol. Masotti F, Cattaneo S, Stuknytė M, De Noni I. Airborne contamination in the food industry: an update on monitoring and disinfection techniques of air.

Use protective gloves and other PPE e. Disinfect areas contaminated with blood spills using an EPA-registered tuberculocidal agent, a registered germicide on the EPA Lists D and E i.

Disinfectant Fogging. Recommendations for Disinfectant fogging: by ID number and category. Recommendation Category 6. Do not perform disinfectant fogging for routine purposes in patient-care areas.

Environmental Fogging [December ] Clarification Statement: CDC and HICPAC have recommendations in both Guidelines for Environmental Infection Control in Health-Care Facilities and the Guideline for Disinfection and Sterilization in Healthcare Facilities that state that the CDC does not support disinfectant fogging.

High-Level Disinfection of Endoscopes. Recommendations for High-level disinfection of endoscopes: by ID number and category. Recommendation Category 7. To detect damaged endoscopes, test each flexible endoscope for leaks as part of each reprocessing cycle.

Remove from clinical use any instrument that fails the leak test, and repair this instrument. Immediately after use, meticulously clean the endoscope with an enzymatic cleaner that is compatible with the endoscope.

Cleaning is necessary before both automated and manual disinfection. Disconnect and disassemble endoscopic components e.

Steam sterilize these components if they are heat stable. Flush and brush all accessible channels to remove all organic e. Clean the external surfaces and accessories of the devices by using a soft cloth or sponge or brushes.

Continue brushing until no debris appears on the brush. Use cleaning brushes appropriate for the size of the endoscope channel or port e. Cleaning items e. Discard enzymatic cleaners or detergents after each use because they are not microbicidal and, therefore, will not retard microbial growth.

Process endoscopes e. High-level disinfection of arthroscopes, laparoscopes, and cystoscope should be followed by a sterile water rinse. Phase out endoscopes that are critical items e. Replace these endoscopes with steam sterilizable instruments when feasible.

Mechanically clean reusable accessories inserted into endoscopes e. Use ultrasonic cleaning of reusable endoscopic accessories to remove soil and organic material from hard-to-clean areas. Process endoscopes and accessories that contact mucous membranes as semicritical items, and use at least high-level disinfection after use on each patient.

Use an FDA-cleared sterilant or high-level disinfectant for sterilization or high-level disinfection Table 1. Extend exposure times beyond the minimum effective time for disinfecting semicritical patient-care equipment cautiously and conservatively because extended exposure to a high-level disinfectant is more likely to damage delicate and intricate instruments such as flexible endoscopes.

The exposure times vary among the Food and Drug Administration FDA -cleared high-level disinfectants Table 2. Federal regulations are to follow the FDA-cleared label claim for high-level disinfectants. Management of Equipment and Surfaces in Dentistry. Recommendations for Management of equipment and surfaces in dentistry: by ID number and category.

Recommendation Category 8. Dental instruments that penetrate soft tissue or bone e. In addition, after each use, sterilize dental instruments that are not intended to penetrate oral soft tissue or bone e. Clean and, at a minimum, high-level disinfect heat-sensitive semicritical items.

Noncritical clinical contact surfaces, such as uncovered operatory surfaces e. Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care, that are likely to become contaminated with blood or body substances, or that are difficult to clean.

Change these coverings when they are visibly soiled, when they become damaged, and on a routine basis e. Disinfect protected surfaces at the end of the day or if visibly soiled.

Processing Patient-Care Equipment Contaminated with Bloodborne Pathogens HBV, Hepatitis C Virus, HIV , Antibiotic-Resistant Bacteria e. Recommendations for Processing contaminated patient-care equipment: by ID number and category. Recommendation Category 9.

Use standard sterilization and disinfection procedures for patient-care equipment as recommended in this guideline , because these procedures are adequate to sterilize or disinfect instruments or devices contaminated with blood or other body fluids from persons infected with bloodborne pathogens or emerging pathogens, with the exception of prions.

No changes in these procedures for cleaning, disinfecting, or sterilizing are necessary for removing bloodborne and emerging pathogens other than prions. Disinfection Strategies for Other Semicritical Devices. Recommendations for Disinfection strategies for other semicritical devices: by ID number and category.

Recommendation Category Even if probe covers have been used, clean and high-level disinfect other semicritical devices such as rectal probes, vaginal probes, and cryosurgical probes with a product that is not toxic to staff, patients, probes, and retrieved germ cells if applicable. Use a high-level disinfectant at the FDA-cleared exposure time.

See Recommendation 7p for exceptions. IB When probe covers are available, use a probe cover or condom to reduce the level of microbial contamination. II Do not use a lower category of disinfection or cease to follow the appropriate disinfectant recommendations when using probe covers because these sheaths and condoms can fail.

After high-level disinfection, rinse all items. Use sterile water, filtered water or tapwater followed by an alcohol rinse for semicritical equipment that will have contact with mucous membranes of the upper respiratory tract e. II There is no recommendation to use sterile or filtered water rather than tapwater for rinsing semicritical equipment that contact the mucous membranes of the rectum e.

Unresolved issue None of these listed disinfectant products are FDA-cleared high-level disinfectants. Disinfection by Healthcare Personnel in Ambulatory Care and Home Care. Recommendations for Disinfection by healthcare personnel in ambulatory care and home care: by ID number and category.

Follow the same classification scheme described above i. When performing care in the home, clean and disinfect reusable objects that touch mucous membranes e. Clean noncritical items that would not be shared between patients e.

Microbial Contamination of Disinfectants. Recommendations for Microbial contamination of disinfectants: by ID number and category.

Flash Sterilization. Recommendations for Flash sterilization: by ID number and category. Do not flash sterilize implanted surgical devices unless doing so is unavoidable. Do not use flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time.

When using flash sterilization, make sure the following parameters are met: clean the item before placing it in the sterilizing container that are FDA cleared for use with flash sterilization or tray; prevent exogenous contamination of the item during transport from the sterilizer to the patient; and monitor sterilizer function with mechanical, chemical, and biologic monitors.

When necessary, use flash sterilization for patient-care items that will be used immediately e. When necessary, use flash sterilization for processing patient-care items that cannot be packaged, sterilized, and stored before use.

Methods of Sterilization. Recommendations for Methods of sterilization: by ID number and category. Steam is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture. IA Cool steam- or heat-sterilized items before they are handled or used in the operative setting.

Follow the sterilization times, temperatures, and other operating parameters e. Use low-temperature sterilization technologies e. Completely aerate surgical and medical items that have been sterilized in the EtO sterilizer e.

Sterilization using the peracetic acid immersion system can be used to sterilize heat-sensitive immersible medical and surgical items. Critical items that have been sterilized by the peracetic acid immersion process must be used immediately i. Dry-heat sterilization e.

Because narrow-lumen devices provide a challenge to all low-temperature sterilization technologies and direct contact is necessary for the sterilant to be effective, ensure that the sterilant has direct contact with contaminated surfaces e.

Recommendations for Packaging: by ID number and category. Ensure that packaging materials are compatible with the sterilization process and have received FDA [k] clearance.

Ensure that packaging is sufficiently strong to resist punctures and tears to provide a barrier to microorganisms and moisture. Monitoring of Sterilizers.

Recommendations for Monitoring of sterilizers: by ID number and category. Use mechanical, chemical, and biologic monitors to ensure the effectiveness of the sterilization process. Monitor each load with mechanical e. If the internal chemical indicator is visible, an external indicator is not needed.

Do not use processed items if the mechanical e. Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an FDA-cleared commercial preparation of spores e.

After a single positive biologic indicator used with a method other than steam sterilization, treat as nonsterile all items that have been processed in that sterilizer, dating from the sterilization cycle having the last negative biologic indicator to the next cycle showing satisfactory biologic indicator results.

These nonsterile items should be retrieved if possible and reprocessed. After a positive biologic indicator with steam sterilization, objects other than implantable objects do not need to be recalled because of a single positive spore test unless the sterilizer or the sterilization procedure is defective as determined by maintenance personnel or inappropriate cycle settings.

If additional spore tests remain positive, consider the items nonsterile and recall and reprocess the items from the implicated load s. Use biologic indicators for every load containing implantable items and quarantine items, whenever possible, until the biologic indicator is negative.

Load Configuration. Recommendations for Load configuration: by ID number and category. Place items correctly and loosely into the basket, shelf, or cart of the sterilizer so as not to impede the penetration of the sterilant.

Storage of Sterile Items. Recommendations for Storage of sterile items: by ID number and category. Ensure the sterile storage area is a well-ventilated area that provides protection against dust, moisture, insects, and temperature and humidity extremes.

Store sterile items so the packaging is not compromised e. Label sterilized items with a load number that indicates the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date.

The shelf life of a packaged sterile item depends on the quality of the wrapper, the storage conditions, the conditions during transport, the amount of handling, and other events moisture that compromise the integrity of the package. If event-related storage of sterile items is used, then packaged sterile items can be used indefinitely unless the packaging is compromised see recommendations f and g below.

Evaluate packages before use for loss of integrity e. The pack can be used unless the integrity of the packaging is compromised. If the integrity of the packaging is compromised e.

If time-related storage of sterile items is used, label the pack at the time of sterilization with an expiration date. Once this date expires, reprocess the pack.

Quality Control. Recommendations for Quality control: by ID number and category. Compare the reprocessing instructions e. Conduct infection control rounds periodically e. Document all deviations from policy. All stakeholders should identify what corrective actions will be implemented.

Include the following in a quality control program for sterilized items: a sterilizer maintenance contract with records of service; a system of process monitoring; air-removal testing for prevacuum steam sterilizers; visual inspection of packaging materials; and traceability of load contents.

For each sterilization cycle, record the type of sterilizer and cycle used; the load identification number; the load contents; the exposure parameters e. Retain sterilization records mechanical, chemical, and biological for a time period that complies with standards e.

II, IC Prepare and package items to be sterilized so that sterility can be achieved and maintained to the point of use. Consult the Association for the Advancement of Medical Instrumentation or the manufacturers of surgical instruments, sterilizers, and container systems for guidelines for the density of wrapped packages.

Periodically review policies and procedures for sterilization. Reuse of Single-Use Medical Devices. Recommendations for Reuse of single-use medical devices: by ID number and category. Adhere to the FDA enforcement document for single-use devices reprocessed by hospitals.

FDA considers the hospital that reprocesses a single-use device as the manufacturer of the device and regulates the hospital using the same standards by which it regulates the original equipment manufacturer. II, IC. Page last reviewed: May 24, Content source: Centers for Disease Control and Prevention , National Center for Emerging and Zoonotic Infectious Diseases NCEZID , Division of Healthcare Quality Promotion DHQP.

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UMass Lowell Students in the Lab. Protect Health by Adhering to these Disinfecting Safety Measures To help prevent the spread of viruses like SARS-CoV2 it is important to clean and disinfect hard surfaces such as countertops, faucet handles, doorknobs and anything else that is frequently touched.

This page was updated, Monday January 09 New: TURI Quats Fact Sheet. Latest Guidance on Disinfection. During an outbreak of infection or an unusual increase in the incidence of a particular organism, enhanced routine cleaning minimum twice daily is recommended.

Depending on the type of outbreak in the healthcare facility, certain areas will require more frequent cleaning and disinfection, e. sanitary areas during an outbreak of gastrointestinal infection.

This may be required in the following circumstances:. For patients requiring isolation or if there is significant body fluid contamination: Clean first then disinfect with ppm chlorine releasing agent. Check clean only.

If there is any soiling then wash with detergent and water, rinse and dry using disposable cloth. Store dry refer to manufacturers instructions. If there is not a bedpan washer on the unit use disposable pans discarded directly into macerator.

Carriers are washed in the bedpan washer. Disinfect with ppm chlorine releasing agent or chlorine dioxide solution if soiled. Disinfect bedpan carrier after each use with ppm chlorine releasing agent or a chlorine dioxide solution if patient has diarrhoea or gastro-enteritis, e.

Holders and storage racks should be disinfected periodically using ppm available chlorine or a chlorine dioxide solution to limit the accumulation of C difficile.

Wash the outside of Bedpan Washer daily with detergent and water. Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled. For shared equipment: Disinfect after each patient use. If there is soiling with body fluids clean with a detergent and water prior to disinfection.

Single Patient use BP cuff must be used for patients in isolation, patients with alert organisms or patients in high risk areas such as ICU, Renal, SCBU etc. Washing bowls - wash with detergent and water cream cleanser may be required for scum removal , rinse and dry.

Store dry; inverted and tilted forward. Individual wash bowls should be available for each bed-space to ensure a dedicated bowl for each patient. Single Patient Use accessories should be washed between use with general detergent and water, rinse and dry.

Refer to manufacturer instructions for disinfection of these items. In Theatre use single use disposable brushes or packed sterile for individual use and returned to CSSD. For patients with enteric infections Campylobacter, Salmonella, C difficile etc rinse after use in toilet with ppm available chlorine or a chlorine dioxide solution.

Toilet brushes used for such cases should be disposed of after patient discharge or on cessation of isolation. Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled or used by a patient in isolation. Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled; or used on a patient in isolation.

Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled or used by a person with known infection. Pay particular attention to arm rests and under the rim; clean from top to bottom taking care to get into all edges.

If possible disassemble commode for full daily clean and disinfection. For any patient with diarrhoea or for any infected case, wash and then disinfect using 1,ppm available chlorine or a chlorine dioxide solution, rinse and dry. Flat top keyboards or keyboard covers should be considered for high risk areas e.

Theatre, ICU, SCBU. Daily clean with general detergent and water and disinfected using a chlorine releasing agent or a chlorine dioxide solution as required e. if visibly stained with blood or bodily fluids. If patient is isolated disposables are NOT usually required unless there is doubt over functionality of dish washer; ensure dishes are placed directly into dishwasher.

Curtains and screens considered at risk of contamination from infected patients should be changed after patients discharge or cessation of isolation. Clean with detergent and water or detergent wipe; rinse and leave dry refer to manufacturer instructions. Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled or used by a patient who is isolated.

Water impermeable cover: Wash with detergent solution and dry. Do not soak or disinfect unnecessarily as this may compromise the impermeability of the cover. Water permeable cover: Disinfect with ppm available chlorine or a chlorine dioxide solution.

If contaminated with blood or infected body fluids refer to manufacturer instructions. Weekly: Wash inside and outside include trays, racks around door seals using warm water and detergent with disposable cloth and dry refer to manufacturer instructions.

Disinfect with ppm chlorine releasing agent or a chlorine dioxide solution if soiled or in an area where a patient is isolated. Hoist frame - clean with detergent and water or detergent wipe, ensuring full removal of contamination or body fluids, rinse and dry.

Daily or after each use: clean using detergent and water or detergent wipe; rinse and dry. refer to manufacturer instructions. After infected cases or soiling, first clean then wipe inside with hypochlorite ppm, rinse and dry by leaving open and switched on for hours.

Laryngoscope is needed for emergency situations- those on emergency resuscitation trolleys should be kept within the packaging to minimize contamination. When the laryngoscope is opened and checked it should then be placed inside the loose packaging to protect it from environmental contamination.

Local risk assessment should dictate frequency of change of unused blades. Wash with detergent and water, rinse and dry using disposable cloth. Then disinfect with 1,ppm available chlorine or a chlorine dioxide solution, rinse and dry. Detachable mop heads should be laundered daily using washing machine with appropriate detergent.

Dry in a tumble dryer. Follow with disinfection using ppm available chlorine or a chlorine dioxide solution in isolation areas. If soiled with body fluids follow cleaning with disinfection using ppm chlorine releasing agent or a chlorine dioxide solution, rinse and dry.

Sluice and dirty utility rooms should be disinfected periodically using ppm available chlorine or a chlorine dioxide solution to limit the accumulation of C diff. A stethoscope must be dedicated to an individual patient for those in isolation with a known infection.

Clean electronic hand piece after each use per manufacturer instructions. After infected case disinfect with ppm available chlorine or a chlorine dioxide solution and rinse. Wash weekly or when soiled.

If appropriate refer to manufacturer instructions. If contaminated with blood or body fluids clean and then disinfect surface with an alcohol wipe or ppm available chlorine, rinse and dry. Clean trolley with detergent and water or detergent wipe daily.

Low level :- Visible soiling should be removed immediately by thoroughly washing with detergent and water. Skip to main content. Cleaning Cleaning with warm water and detergent is a process that removes visual dirt and contamination and in most cases is effective for decontaminating both equipment and the environment.

Disinfection Disinfection is a process that reduces the number of microorganisms to a level at which they do not present a risk to patients or clients. Cleaning and disinfection of the environment Routine General Cleaning?

Enhanced Cleaning? Terminal Cleaning? Single patient use if headphones enter the ear canal. If external ear contact only — change covers and clean with GPD; rinse and dry.

Surface disinfect with hard surface wipe. Clean with detergent and water or detergent wipe; rinse and dry. Clean with disinfectant or wipe with a disinfectant wipe after each use.

Daily Check clean only. Weekly For long stay patients wash with detergent and water or detergent wipe weekly.

This document is a rapid review of literature to answer the following questions:. Disclaimer: The information provided here is for the purpose of addressing a specific inquiry related to an environmental health issue.

This is not a comprehensive evidence review. The information offered here does not supersede federal, provincial, or local guidance or regulations. A search was conducted in EBSCOhost databases and Google Scholar with variations of the following keywords: disinfect OR disinfectant OR disinfection OR clean OR cleaning OR cleaner ; asthma OR respiratory OR chronic OR health effects OR health impacts ; sodium hypochlorite OR bleach OR quaternary ; domestic OR home OR house OR occupational OR work.

A search for relevant regulations and grey literature was also conducted in Google Search Engine using variations of the above keywords. Only English language articles were included. A perusal of the title and abstract was performed before the article was included for review.

The COVID pandemic brought to light the importance of cleaning and disinfecting homes and public settings. With increased surface cleaning and use of hand sanitizers and disinfection products, there is concern over the risk of misuse and over-exposure to these products.

Canadian data showed that between March to June , telephone calls to poison information centres about exposures to hand sanitizers, disinfectants, bleach, chlorine gas, and chloramine gas have increased compared to the same time periods in In Canada, surface disinfectants are governed by the Food and Drug Act and evaluated by Health Canada before being assigned a Drug Identification Number DIN.

A comprehensive evaluation of the potential chronic health impacts from exposure to non-food contact disinfectants is not mandatory in Canada.

There are several main classes of active ingredients used in disinfectants: bleach, quaternary ammonium compounds, peroxides, chlorine dioxide, citric acid, ethanol, hydrochloric acid, hypochlorous acid, lactic acid, phenols, sodium chlorite, and thymol.

Adverse health impacts from exposure to disinfectants can be categorized into acute adverse reactions and chronic health impacts. Acute reactions may be a result of misuse and overuse of disinfectants. Chronic health impacts may be due to long-term exposure to certain chemicals used in disinfectants, whether separately or in combination.

According to data from US poison information centres, a sharp increase in total number of calls regarding accidental exposures to cleaners and disinfectants was recorded in March compared to March Misuse of disinfectants includes the improper preparation of disinfectant solutions, and the improper mixing of sodium chlorite with other products containing ammonia or acids.

Users may be exposed to an excessive concentration of the disinfectant, or dangerous by-products, as a result of chemical reactions caused by improper mixing of products.

Sodium hypochlorite reacts with ammonia, which may be found in cleaning products, glass and window cleaners, urine potentially in diaper pails, cat litter boxes , and interior and exterior paints, to produce chloramine gases.

Mixing sodium hypochlorite with hot water also produces chlorine gas. Exposure to low-levels of chlorine gas may cause symptoms including cough, shortness of breath, burning and watery eyes, and runny nose.

Overuse of disinfectants includes the excessive use of disinfectants over the recommended frequency, which may lead to overexposure and acute adverse reactions, as well as chronic health impacts as discussed in the following section.

Cleaning agents are often used in conjunction with disinfectant products. Many of these products contain several ingredients e. This may pose challenges when examining the association between long-term exposure to an individual active ingredient and adverse health outcomes.

Health outcomes such as asthma and rhinitis may also be due to exposure to chemical by-products, such as chloramines and chloroform a known carcinogen , from improperly mixed products.

A review of epidemiological studies found that there is some evidence of association between exposures to spray disinfectants and asthma symptoms among both professional and non-professional users.

A systematic review of 24 epidemiological studies found that occupational exposure to cleaning and disinfectant products is associated with an increase in the risk of asthma and rhinitis.

Studies examining the association between domestic use of disinfectants and adverse health effects in adults is limited. A survey of elderly adults found that weekly use of irritating cleaning products, including bleach and ammonia, exhibits a dose-response relationship with asthma symptoms. Establishing a causal association between exposure and adverse health outcomes is challenging as many studies often group cleaning and disinfectant products together.

The use of questionnaires in most studies may be prone to recall bias in the survey respondents. Increased use of household disinfectants containing bleach and hydrogen peroxide was found to alter the gut microbiota of infants at months of age.

Conversely, another study found that cleaning with bleach at least once a week in homes seemed to have a protective effect against the development of asthma in children, possibly due to more effective reduction of indoor allergens and other microbial agents in homes.

Some possible reasons may be due to differences in frequency of disinfectant use, presence of other indoor contaminants, and recall bias in study participants as many studies relied on questionnaires for data collection, among other reasons.

There are a variety of ways to apply disinfectants. These methods range from manual application with trigger spray bottles to more technologically advanced techniques such as large mechanical sprayers, electrostatic sprayers, and foggers. The technique used depends on many factors, including the type of setting, target surfaces, the intended purpose, size of room or number of surfaces to be treated, and presence of other occupants.

Manufacturers of disinfectant products are required to provide clear usage and safety instructions to maximize the effectiveness of disinfection while minimizing harm to users and occupants. As disinfectants have shown to be associated with adverse respiratory health impacts, application of disinfectants via sprays may facilitate respiratory exposure to airborne particles.

Many factors including aerosol size, shape, density, surface characteristics, and evaporation rate dictate how long aerosols stay airborne and where the aerosols eventually deposit in the respiratory tract.

Electrostatic sprayers and disinfectant foggers typically produce smaller droplets compared to handheld trigger sprayers. For a general overview of these types of sprayers, refer to the NCCEH document COVID in indoor environments — Air and surface disinfection measures. Electrostatic sprayers such as the Clorox Total System Electrostatic Sprayer produce droplets ranging from µm, while fogging systems may produce droplets as small as µm depending on the process used.

The use of a disinfectant fogging machine to disinfect ambulances led to complaints of nausea, migraines, headaches, and eye and skin irritation. Surface disinfection is only one of a number of interventions that reduces the transmission risk of pathogenic microorganisms such as SARS-CoV Personal practices such as proper hand hygiene, physical distancing, and wearing face coverings are important non-pharmaceutical interventions to reduce transmission risk, particularly when they are used in combination.

Respiratory droplets and aerosols are recognized as the primary transmission route of SARS-CoV Therefore, the health risks of overexposure to potentially harmful disinfectants should be balanced with the need to prevent viral transmission.

Some studies have found a dose-response relationship between disinfectant exposure and asthma incidence. The BC Centre for Disease Control recommends disinfecting high-touch surfaces once every few days if no one in the household has COVID or symptoms of illness.

Prior to implementing a routine disinfection policy, a proper risk assessment should take the following into consideration: Several recommendations have been suggested in the literature to reduce health risks from disinfectant exposure and improve respiratory health: 12,37— There are organizations in Canada and the US that act as third-party certifiers to identify cleaning and disinfectant products that may be less hazardous to health and more environmentally friendly.

Surface disinfection is one of the interventions that is frequently recommended to reduce the risk of SARS-CoV-2 transmission. However, reports of acute health effects due to misuse and overexposure to disinfectants have been on the rise since early While businesses and facilities strive to implement more stringent cleaning and disinfection policies, some public health practitioners have raised concerns about the potential of disinfectants to increase the risk of asthma and wheezing.

As such, there is merit for public health practitioners to provide clear recommendations about appropriate and safe cleaning and disinfection practices that would protect people from potentially harmful disinfectants while reducing the transmission risk of SARS-CoV The author would like to acknowledge Lydia Ma NCCEH for review of this document and valuable feedback, and Michele Wiens for assistance with referencing.

Home Resources A rapid review of disinfectant chemical exposures and health effects during the COVID pandemic. A rapid review of disinfectant chemical exposures and health effects during the COVID pandemic. Author s. Health impacts of disinfectants Oct 26 final in template.

pdf Diseases, vectors, and pests. Other topics. personal protective equipment. children's health. Posted by NCCEH. Table of Contents. Primary inquiry A public health practitioner raised a question about the misuse and overuse of disinfectants as a result of heightened concerns about SARS-CoV-2 transmission via environmental surfaces, and the potential for acute and chronic health impacts due to the use of certain disinfectant products.

This document is a rapid review of literature to answer the following questions: What are the potential health effects associated with exposure to disinfectants? Are there safer substitutions for common disinfectants that have lower risks of long-term adverse health effects?

Methods A search was conducted in EBSCOhost databases and Google Scholar with variations of the following keywords: disinfect OR disinfectant OR disinfection OR clean OR cleaning OR cleaner ; asthma OR respiratory OR chronic OR health effects OR health impacts ; sodium hypochlorite OR bleach OR quaternary ; domestic OR home OR house OR occupational OR work.

Introduction The COVID pandemic brought to light the importance of cleaning and disinfecting homes and public settings. What are the potential acute and chronic health risks of disinfectants?

Acute health impacts According to data from US poison information centres, a sharp increase in total number of calls regarding accidental exposures to cleaners and disinfectants was recorded in March compared to March Chronic health impacts Cleaning agents are often used in conjunction with disinfectant products.

Indoor exposures in children Increased use of household disinfectants containing bleach and hydrogen peroxide was found to alter the gut microbiota of infants at months of age. Does the application method influence the risk of adverse health outcomes?

Summary Surface disinfection is one of the interventions that is frequently recommended to reduce the risk of SARS-CoV-2 transmission.

Acknowledgements The author would like to acknowledge Lydia Ma NCCEH for review of this document and valuable feedback, and Michele Wiens for assistance with referencing. References Yasseen A, Weiss D, Remer S, Dobbin N, MacNeill M, Bogeljic B, Leong D, Wan V, Mosher L, Bélair G, Thompson M, Button B, Hardy J, Perwaiz S, Smith A, Wootton R.

At-a-glance — Increases in exposure calls related to selected cleaners and disinfectants at the onset of the COVID pandemic: data from Canadian poison centres. Ottawa, ON: PHAC. Chang A, Schnall A, Law R, Bronstein A, Marraffa J, Spiller H, et al.

Cleaning and disinfectant chemical exposures and temporal associations with COVID — National Poison Data System, United States, January 1, —March 31, Morb Mortal Wkly Rep MMWR.

Health Canada. Drug Identification Number DIN. Ottawa, ON: Health Canada. Guidance documents on disinfectants: summary. Guidance document: disinfectant drugs Guidance document: safety and efficacy requirements for surface disinfectant drugs.

Green cleaning, sanitizing, and disinfecting: a curriculum for early care and education. San Francisco, CA: University of California, San Francisco School of Nursing; The preferred method of control is elimination of the chemical through engineering controls or substitution or relocation of the worker.

The following overview of the performance characteristics of each provides users with sufficient information to select an appropriate disinfectant for any item and use it in the most efficient way.

Skip directly to site content Skip directly to page options Skip directly to A-Z link. Infection Control. Section Navigation. Facebook Twitter LinkedIn Syndicate. Disinfection Guideline for Disinfection and Sterilization in Healthcare Facilities Minus Related Pages.

On This Page. Methods of Disinfection. Chemical Disinfectants Alcohol Chlorine and chlorine compounds Formaldehyde Glutaraldehyde Hydrogen peroxide Iodophors Ortho-phthalaldehyde OPA Peracetic acid Peracetic acid and hydrogen peroxide Phenolics Quaternary ammonium compounds Miscellaneous Inactivating Agents Other germicides Metals as microbicides Ultraviolet radiation Pasteurization Flushing- and washer-disinfectors Regulatory Framework for Disinfectants and Sterilants.

Page last reviewed: September 18, Content source: Centers for Disease Control and Prevention , National Center for Emerging and Zoonotic Infectious Diseases NCEZID , Division of Healthcare Quality Promotion DHQP.

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